The previous section emphasized the importance of exercise and dietary habits for the timing and amount of needed insulin. Modern life for many people entails substantial day-to-day variations in eating and exercise. When beginning an insuJin program, regularize these factors as much as possible, at least for the short term until the insulin program and approximate doses have been established.
Have a detailed discussion with the patient about his normal day and how it is affected by habits, hobbies, sports, work, weekends, travel, etc. Identify the variables. Emphasize uniformity at work—avoid varying shifts, work trips, wide swings in physical work, and other changes during the transition onto insulin. Have the patient postpone vacations, stressful family events, and other nonessential happenings.
Patients should see a registered dietitian for evaluation of their eating habits, and to be educated in the importance of consistency in their meals. The concept of carbohydrate counting can also be introduced (discussed in Chapter 4).
Patients should receive basic diabetes education, preferably from a CDE, covering SBGM, proper injection technique, how to mix insulins if relevant, and how to recognize, avoid, and treat hypoglycemia. Identify factors that might influence insulin absorption—and thus kinetics of the insulin effect—such as massage, heat, and exercise. Also important is where one injects; insulin onset is quickest and its duration of action shortest from the abdomen, followed by the arms, then the buttocks and thighs. Practically, I generally recommend using the abdomen during the day and the thighs or buttocks for the bedtime injection. It is generally prudent to eliminate strenuous exercise for a while; when this is not possible, emphasize regularity of exercise in terms of intensity, timing, and doing it daily. Educating the patient about the effects of exercise on insulin dosing and absorption, risks of hypoglycemia and its avoidance, the best time to exercise, etc., will help avoid later confusion over the effect of variable exercise on the patient's glycemic response to the new insulin program.
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