Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-98

intensify therapy and/or achieve recommended BG targets. Frequent blood glucose monitoring using SMBG and/or sensors and close attention to meal planning and activity can decrease the risk of hypoglycemia (16,159). Making changes to self-management behaviours (such as eating less food, doing more physical activity) without appropriate insulin adjustments accounts for 85% of hypoglycemic episodes (160,161). Appropriate treatment of hypoglycemia is crucial in preventing recurring episodes and preventing undesired weight gain (see Chapter 8: Acute Complications).

Weight management Using intensive diabetes therapy does not automatically lead to weight gain. Some of the

possible explanations for weight gain are as follows (32,,2162,163): • Improved glycemic control and less energy lost through glycosuria. • Rehydration due to improved glycemia. • Anabolic effects of insulin on muscle fibre and adipose tissue

• Unphysiological pharmokinetic profiles that follow subcutaneous insulin administration. • Increased frequency of hypoglycemia and, therefore, increased energy intake to treat. • Over-treating hypoglycemia or treating with inappropriate foods that have additional energy (chocolate bars, cookies, etc.). • Over-eating in order to prevent hypoglycemia. • Higher intakes of protein and fat intake due to focusing solely on carbohydrate intake. • Lack of attention to portion sizes. There is a known potential for weight gain with IT. The DCCT revealed weight gain of approximately 4.5 kg (10 lbs) among participants in the experimental group (32). Variables associated most highly with weight gain were baseline A1C and changes in A1C. A hypothesis offered for this was that patients who were initially in poor control (thus glucosuric) were most likely to gain weight with improved control. A second hypothesis is related to the potential to overeat to prevent or treat hypoglycemia. Other hypotheses were also offered (32). There may be less weight gain with the use of rapid-acting insulin, compared to short-acting insulin, based on its action profile. Due to the later peak and longer duration of short-acting insulin, its use may necessitate the inclusion of snacks to prevent a low BG reaction. Rapid-acting insulin provides a more physiologic insulin replacement, with an earlier peak and shorter duration. Therefore, the use of rapid-acting insulin often eliminates the need for snacks to prevent hypoglycemia.