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This resource has been developed by Trillium Health Centre’s Diabetes Management Program in partnership with the Diabetes Programs of Credit Valley Hospital and Halton Health Care. Your physician can refer you to these centres for further education and support.

Trillium Health Centre Diabetes Management Centre 416-521-4081 Credit Valley Hospital Diabetes Care Centre 905-813-1576 East Mississauga CHC 905-602-4082 Halton Diabetes Program: Oakville 905-338-4437, Georgetown 905-873-0111 ext 8502, Milton 905-878-2383 x 7410 LMC Endocrinology Centre 905-337-0040

Supported by an unrestricted educational grant from sanofi-aventis Canada Inc.

Teaching Guide for Starting Insulin Name:


GETTING STARTED ON INSULIN This booklet is a guide to help you begin to use insulin to control your diabetes. It will answer some basic questions about food, exercise, blood sugar testing and the use of insulin. It is not intended to replace the education required to use insulin safely and effectively, but is designed to support it. It is important to follow up with your family doctor and get referred to a diabetes program in your area. Diabetes programs are staffed by nurses, dietitians and other health care professionals who specialize in diabetes care to provide support and education to ensure a successful transition to insulin.

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WHAT IS TYPE 2 DIABETES AND WHY DO I NEED INSULIN? 1. Much of the food you eat gets broken down into glucose in your stomach and goes into your blood (glucose and sugar mean the same thing) 2. The pancreas releases insulin into the bloodstream as the amount of sugar in your blood rises 3. The insulin sticks to the sugar and takes it from the bloodstream to the cells of your body to be used as fuel or energy 4. Every cell in your body uses this sugar for energy – like a car uses gasoline When you have type 2 diabetes, your body does not make enough insulin, or your body cannot use the insulin properly. If insulin is not taking the sugar from the bloodstream to the cells of your body, the sugar starts to build up in the bloodstream. If your blood sugar levels remain high, then your doctor may tell you that you need to take insulin to help bring your sugar level down into a normal range. To maintain good blood sugar control you will need to take insulin, maybe medications, as well as look closely at food choices and increase physical activity. 2


BLOOD SUGAR MONITORING Blood sugar monitoring is very important because it shows you how well your food, physical activity and insulin are working to keep your blood sugars in control. You cannot “feel” if your blood sugars are in control. Therefore, if you don’t test your blood sugar, you won’t know what it is.

When and how often do I test? It is recommended that you test your blood sugars at the following times and record the results in your logbook:

For bedtime insulin injections and diabetes pills • Before breakfast • 2 hours after one meal (vary the meals) • Before bed

ALSO… be sure to test your blood sugar • Before driving • Whenever you suspect you are having a low blood sugar • Before and after exercise • When you have consumed alcohol

Increase your blood sugar testing if: • Your blood sugars are frequently out of target range (you are having high or low blood sugars) • You become ill • You have made changes to your food choices, activity level or insulin dose This way, you will know if changes need to be made to your food, activity or insulin dose

For two or more insulin injections per day • Before breakfast • Before lunch • Before dinner • Before bedtime

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What is Good Blood Sugar Control? The following target ranges for blood sugar are recommended, but you should speak with your doctor or diabetes educator for your individualized blood sugar targets: TIME

TARGET RANGE

Before breakfast

4.0 to 7.0

Before lunch

4.0 to 7.0

Before dinner

4.0 to 7.0

2 hours after meals

5.0 to 10.0

Before bed

8.0 to 10.0

INDIVIDUALIZED TARGET (mmol/L)

It is recommended that an Evening Snack be taken if blood sugars before bed are less than 8.0 mmol/L… • If your blood sugars are between 6.0 -8.0 mmol/L, take 1 carbohydrate serving (15 grams) and some protein • If your blood sugars are between 4.0-6.0 mmol/L, take 2 carbohydrate servings (30 g) and some protein

HEALTHY EATING FOR PEOPLE ON INSULIN Healthy eating means paying attention to when and how often you eat. • Have 3 meals daily at regular times • Meals should be 4-6 hours apart. For example, if breakfast is at 8 am, lunch could be at 12 noon and dinner could be at 6 pm • Plan to have a morning or afternoon snack if there are more than 5 hours between your meals • Bedtime snacks are especially important to reduce the possibility of a low blood sugar overnight. See evening snack guidelines on the previous page. Eating healthy means including a variety of foods that contain Carbohydrate, Protein, and Fat, but you must watch how much of these foods you eat and how often.

Example: 1 Carbohydrate Serving + Protein (choose 1 of...) • 1 slice of bread and peanut butter OR • 7 small crackers and cheese 2 Carbohydrate Servings + Protein (choose 1 of...) • 1 slice of bread with peanut butter and 1 cup of milk OR • 2 slices of bread with cold cuts or cheese OR • 2 slices bread and peanut butter

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CARBOHYDRATE foods raise your

blood sugar levels. Carbohydrate is found in foods that contain natural or added sugars, and starches. You need carbohydrate foods for your main source of energy. Choose 2-3 fruits, 2-3 cups of low fat milk/yogurt daily and have some starch (such as bread, pasta, rice, potato, roti, cereal) with each meal. Do not avoid carbohydrates, learn to choose moderate portions instead. Consistent amounts of carbohydrate at consistent times will help to work with your insulin to result in good blood sugar control.

Foods that contain Carbohydrates include: Choose More Often

• Whole Grain

Breads & Cereals • Pasta, Rice, & Grains • Beans, Peas, & Lentils (dahls) • Vegetables (including starchy vegetables if desired such as potato, yam, corn) • Milk , Yogurt & Soy Drinks • Fruit • Meat substitutes made with beans or lentils

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Choose Less Often • Juice & Sweetened Drinks •B  aked Goods: Muffins, Cakes & Pies • Table Sugar, Honey, Syrup & Molasses •C  andy & Chocolate • Ice Cream & Frozen Yogurt •M  any “No Sugar Added” Products

PROTEIN has a minimal effect on blood sugar

levels. Protein foods help build and maintain all body tissues. Large amounts of protein can cause weight gain and increase your risk for heart disease. You need 2-3 servings of protein per day. For main meals, choose a portion about the size of a deck of cards, or the palm of your hand and thickness of your baby finger.

Foods that contain Protein include: • Meat (choose lean cuts) • Poultry (choose skinless) • Fish & Shellfish • Peanut Butter • Soy Products i.e. tofu • Eggs (2-4 per week) • Cheese (choose low fat – milk fat less than 20%)

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FAT has a minimal effect on blood sugar

levels. It is necessary for growth and protection of vital organs. Large amounts of fat can easily cause weight gain and increase your risk for heart disease. Choose unsaturated fats or lower fat versions more often. The tip of your thumb per meal would be a good amount of fat.

Foods that contain fat are: High in Unsaturated Fats (choose more often) • Vegetable oil (such as olive and canola oil) • Non-hydrogenated margarine • Nuts and seeds • Salad dressing (made with oil) • Olives • Avocado

Balance the food on your plate. Include carbohydrate foods (whole grains, beans or lentils,dairy, fruit, and vegetables), with some protein and a little added fat. 9

High in Saturated Fats (eat less often) • Butter, cream • Sour cream, cream cheese • High fat meats, bacon, chicken skin • Shortening, lard • Mayonnaise • Salad dressing (made with cream, eggs)

The Healthy Plate A healthy plate can be divided up into different portions. Make: • ½ of your plate vegetables • ¼ of your plate protein foods (example meat, fish, poultry, beans) • ¼ of your plate starchy foods, (example, cereal, bread, rice, pasta, potato, corn) • Add a glass of milk/yogurt and a fruit and you have a balanced meal! You can save your fruit, milk or yogurt for a snack if you want to • Watch your portion sizes. If you don’t know how much rice, pasta or cereal you have on your plate, measure it with a measuring cup. You only have to do it once to get an idea of how much you are eating. OR... • Using your hands to help with portioning, have no more than the size of your fist when choosing pasta, rice, potato, cereal or other grains, and fruits. Add fat to your food using the tip of your thumb as a serving guideline. Include lots of vegetables at meals – the amount you can hold in both cupped hands. Protein foods (meat/chicken/fish) should be the size of your palm and thickness of your baby finger.

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For Smaller Appetites

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For Larger Appetites

Breakfast: Toast (2 slices whole grain bread) Peanut butter (1-2 tbsp, 15 mL-30mL) ½ cup grapes or 1 medium fruit Coffee or tea

Breakfast: Toast (2 slices whole grain bread) Peanut butter (1-2 tbsp, 15 mL-30mL) Cereal (½ cup, 125mL) ½ cup grapes or 1 medium fruit Milk (1 cup, 250mL) Coffee or tea

AM Snack (if more than 5 hours between meals) 1 medium fruit or ¾ cup no sugar added yogurt or 3 small plain cookies

AM Snack (if more than 5 hours between meals) 1 medium fruit or ¾ cup no sugar added yogurt or 3 small plain cookies

Lunch: Sandwich – 1 -2 slices whole grain bread -lean meat, chicken, or fish (2-3 oz, 60-90gm) -tomato, lettuce, onion -margarine or mayonnaise (1tsp, 5mL) Green salad with dressing (1 tsp, 5mL) Fruit yogurt (3/4 cup or 175mL) or 1 apple Diet pop or water

Lunch: Sandwich – 1 -2 slices whole grain bread -lean meat, chicken or fish (3-4 oz, 90-120 gm) -tomato, lettuce, onion -margarine or mayonnaise (1 tsp, 5mL) Soup (1 cup, 250mL) & Soda crackers (7) Celery sticks or raw vegetables Fruit yogurt (3/4 cup or 175mL) or 1 apple Diet pop or water

PM Snack (if more than 5 hours between meals) 1 medium fruit or ¾ cup no sugar added yogurt or 3 plain cookies

PM Snack (if more than 5 hours between meals) 1 medium fruit or ¾ cup no sugar added yogurt 3 plain cookies

Dinner: Potato (1 medium) or pasta (1 cup cooked) or rice (2/3 cup cooked) Vegetables (as desired) Margarine or oil (1-2 tsp, 5-10 mL) Lean meat, chicken, fish (2-3oz, 60-90gm) Low Fat Milk (1 cup, 250 mL) Coffee, tea or diet pop

Dinner: Potato (1 large) or pasta (1 ½ cups cooked) or rice (1 cup cooked) Vegetables (as desired) Margarine or oil (1-2tsp, 5-10mL) Lean meat, chicken, fish (3-4 oz, 90-120 gm) Melon (1 cup) Low fat milk (1 cup) Coffee, tea or diet pop

Evening Snack: (if blood sugar less than 8.0mmol/L) Soda crackers (7) or 1 slice bread or 3 plain cookies Low fat cheese (1 oz, 30gm)

Evening Snack: (if blood sugar less than 8.0mmol/L) Melba toast (4) or 1 slice bread Low fat cheese (1 oz, 30gm) Low fat milk (1 cup, 250mL) 12


PHYSICAL ACTIVITY Most people who have diabetes can exercise to improve blood sugars and keep fit. Some forms of exercise/activity such as walking are inexpensive. Exercise can be done anywhere,any time, alone or with other people. It is important to do what you can. If you have physical limitations try and exercise to your limits. Sometimes it is important to just MOVE! You should try to work towards adding up to 30 minutes of exercise at least 5 days a week. Start with 10 minutes at a time – every bit counts.

Always carry fast acting sugar (i.e. glucose tablets) and a follow up snack (i.e. granola bar) to treat low blood sugar. You may need to check your blood sugar during long (over 1 hour) or intense exercise. Do check your blood sugar after exercise as well. Like other aspects of your treatment, an exercise program should be planned in consultation with your doctor. Your insulin dose may require adjustment due to exercise, so speak with your doctor or diabetes educator.

10 minutes + 10 minutes + 10 minutes = At least 30 minutes 13

Remember to check your blood sugar before exercise. If blood sugar is less than 5.0mmol/L have a snack before starting exercise (i.e. fruit, granola bar).


Check off the type(s) of insulin you are taking. Take note of when you should take your insulin, how soon it starts to work, when it works the hardest and how long it lasts.

CHECK OFF WHICH INSULIN(S) YOU TAKE

TYPES OF INSULIN

** These are generic guidelines. Refer to product monograph, as each type of insulin may have different times.

APPEARANCE

WHEN IT SHOULD BE TAKEN

WHEN IT STARTS WORKING (ONSET)

WHEN IT WORKS THE HARDEST (PEAK)

HOW LONG IT WILL LAST (DURATION)

Rapid Acting

Apidra® (glulisine) Novorapid® (aspart) Humalog® (lispro)

Clear

15 mins. or less before a meal

10-15 mins.

60-90 mins.

3-5 hrs.

Short Acting

Humulin® R or Regular Novolin® ge Toronto

Clear

Approximately 30 mins. before a meal

30 mins.

2- 3 hrs.

6.5 hrs.

Intermediate

Humulin® N Novolin® NPH Humulin® 30/70 (30% short + 70% intermediate) Novolin® 30/70* (30% short + 70% intermediate)

Cloudy

As prescribed

1- 3 hrs.

5- 8 hrs.

Up to 18 hrs.

Cloudy

Approximately 30 mins. before a meal

Premixed (Short Acting + Intermediate) Premixed (Rapid + Intermediate) Long Acting

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INSULIN NAME

* There are other premixes available, not listed.

Humalog® Mix 25 (25% rapid + 75% intermediate) NovoMix® 30 (30% rapid + 70% intermediate) Lantus® (glargine) Levemir® (detemir)

Cloudy

15 mins. or less before a meal

Clear

(Usually once a day at the same time)

Premixed insulin will have the same onset, peak and duration as the types of insulin in the premix.

90 mins.

No peak. It provides a steady dose of insulin

Up to 24 h

(Lantus® 24 h,

Levemir® 16-24 h)

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STORING INSULIN • Insulin should be taken at room temperature •S  tore insulin at room temperature if being used within 30 days •S  tore extra insulin in refrigerator if not being used within 30 days • When using refrigerated insulin warm by rolling bottle/cartridge gently between your palms

Where to Inject • Insulin is absorbed fastest from the abdomen followed by the arms, then the thighs and slowest from the buttocks • Choose one area for injection before moving into another area, for example, use all the spots in your abdomen then move to your thigh • Allow one inch between sites in the same area

• Insulin, unopened and stored in the refrigerator, is good until the expiry date on the cartridge or bottle •O  nce the bottle/cartridge is used, it is good for approximately 1 month only

• Do not freeze insulin • Do not heat insulin • Do not place insulin in the sunlight

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• It is important to move injection sites around, injecting in the same spot all the time can cause that area to build up fat underneath the skin (lipohypertrophy)

• Do not warm insulin in the microwave

• This lumpy area will prevent insulin from being absorbed properly, causing your blood sugars to swing very high or low

• Do not store your insulin pen in the refrigerator

• Avoid injecting into an area that you are going to be exercising – i.e, don’t inject into your thigh if you are going for a walk or run 18


Preparing an insulin injection using an INSULIN PEN WHAT TO DO

WHY?

1. Wash your hands.

To keep equipment & skin clean.

2. Check that you have the correct pen with the insulin needed for that time of day.

To make sure you have the right kind of insulin.

3. Gently tip the pen upside down and back to mix the insulin 4-5 times. 4. Screw the needle onto the pen tightly. 5. Remove the 2 covers from the needle. 6. With the needle pointing downwards, dial 2 units and push on plunger (repeat if necessary until 2 drops of insulin fall off the needle tip).

his flushes the air from the needle and ensures you T are getting the correct dose.

7. Make sure the dial has returned to “0.�

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8. Select your dose and inject. Push plunger completely in then count slowly to 6 before removing.

This ensures the entire dose of insulin gets absorbed.

9. Remove the used needle and dispose in sharps container.

You can get a sharps container at your pharmacy.

10. Do not store pen with needle attached.

Insulin can leak out and this will change the strength of the cloudy insulin if the needle is left on.

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LOW BLOOD SUGAR (Hypoglycemia) When blood sugar drops below normal, (less than 4.0 mmol/L), the supply of sugar to the brain is reduced. As a result you may feel and behave differently. Low blood sugar needs to be recognized and treated promptly. Severe hypoglycemia is a medical emergency and can cause loss of consciousness. Causes of Low Blood Sugar

What to do when you have a low blood sugar 1. Test your blood sugar level if possible to confirm you are having a low blood sugar 2. Raise your blood sugar by eating ONE of the following fast acting sugar choices: • BD Glucose Tablets (take 3 tablets)

• Too much insulin • Delayed meal • Did not eat enough carbohydrate • More than your normal amount of exercise • Skipped a meal • Injecting insulin into muscle used during exercise • Alcohol

3. Sit down and rest

Signs and Symptoms

4. After 15 minutes test your blood sugar

• Shaking or Trembling • Fast pounding heart

• Weakness • Poor coordination

• Sweaty • Dizziness • Confusion • Headache • Unsteady walk, • Numbness of lips staggering or around mouth • Slurred speech • Hungry • Mood swings (irritability/excitement)

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LOW BLOOD SUGAR (Hypoglycemia)

• Dex 4 (take 4 tablets) • Glucosol (take 6 tablets) • 6 oz (3/4 cup or 175mL) regular pop • 6 oz (3/4 cup or 175mL) unsweetened fruit juice • 1 Tbsp honey

5. If your blood sugar is under 4.0 mmol/L, have another sugar choice from the list above 6. Once your blood sugar is above 4.0 mmol/L you will need to eat something 7. If it is not your usual meal time, have a snack that includes a source of carbohydrate, such as one of the following…

½ a sandwich OR 1 slice toast with peanut butter OR 7 soda crackers and cheese OR 1 granola/cereal bar 22


8. If it is your usual time to eat a meal, go ahead and eat, you do not need to add more food, eat your usual amount 9. R  ecord your blood sugar in your log book 10. Tell your doctor or diabetes educator if you have frequent low blood sugars, you may need an insulin dose adjustment

SEVERE LOW BLOOD SUGAR: What your family needs to know Severe low blood sugar may cause passing out or loss of consciousness. If this happens, do not give the person anything to eat or drink by mouth. Have a family member call 911, and paramedics will administer GLUCAGON. Glucagon is used to treat a severe low blood sugar. Glucagon is a hormone that raises the blood sugar by releasing stored sugar from the liver into the blood stream. You can ask your doctor for a prescription for a glucagon kit. Family members will need to be trained on how to administer glucagon.

DIABETES DRIVING GUIDELINES If you use insulin, having a low blood sugar while driving can be dangeous and you can be charged with IMPAIRED DRIVING! Things You Should Know: • Always test your blood sugar just before starting to drive and at least every 4 hours on long trips. Test more often if you usually do not feel symptoms of low blood sugar. • If your blood sugar is under 4.0 mmol/L (low blood sugar) – DO NOT DRIVE. Treat with a fast acting sugar (i.e., glucose tablets). Wait 15 minutes and retest blood sugar. Eat a carbohydrate snack. Wait 45-60 minutes before driving after effective treatment of a low blood sugar. • If your blood sugar is between 4.0 – 5.0 mmol/L) – do not begin to drive without eating some carbohydrate (i.e., granola bar, sandwich).

Your Responsibilities: • Know how to prevent, recognize and treat low blood sugar.

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For complete information on driving guidelines: www.diabetes.ca

Websites Here are some useful websites that can provide information about diabetes. You can also visit the websites of the manufacturers of the type of insulin you take. The Canadian Diabetes Association www.diabetes.ca Healthy Ontario www.healthyontario.com Health Canada www.hc-sc.gc.ca 25

WHEN I SHOULD CHECK MY BLOOD SUGAR LEVELS DATE

Driving is a RESPONSIBILITY… Not a right. Be prepared and \DRIVE SAFELY!

WHEN I TAKE MY INSULIN

•S  ee your doctor or diabetes educator if you have more than 2 episodes/week of low blood sugar. Your insulin or medication may need to be adjusted.

MY INSULIN DOSE

•M  ore in-depth assessment is needed – Ask your doctor.

MY INSULIN TYPE

Commercial Drivers Using Insulin:

Use this chart to fill in information about your insulin routine

• Wear medic alert identification

MY INSULIN

• Always have a fast acting sugar source (e.g. glucose tablets) and a follow up carbohydrate snack (i.e. granola or cereal bar) with you and in the car.


Teaching Guide for Starting Insulin