Handbook for young people with diabetes

What is diabetes? 

Self-monitoring 

of blood glucose 

Insulin therapy 

General principles 

for changing doses 

Injection areas 

and methods 

Nutrition 

Physical exercise 

Hypoglycaemia 

and ketoacidosis 

Handbook 

for young people 

with diabetes 

edited by Riccardo Bonfanti, Andrea Rigamonti and Giulio Frontino 

with the coordination of Franco Meschi 

Long-term 

complications 

Insulin pump 

Facing or clashing 


Special situations 

The future of people with 

diabetes 

Glossary

Handbook 

for young people 


edited by Riccardo Bonfanti, Andrea Rigamonti and Giulio Frontino 

with the coordination of Franco Meschi

With the contribution of: 

Roseila Battaglino, Clara Bonura e Valeria Favalli

Index 

Preface 5 

Introduction 7 

What is diabetes? 9 

Self-monitoring of blood glucose 19 

Insulin therapy 26 

Injection areas and methods 37 

Nutrition 42 

Physical exercise 52 

Hypoglycaemia and ketoacidosis 55 

Long-term complications 66 

Insulin pump 72 

Facing or clashing with diabetes 95 

Particular situations 98 

The future of people with diabetes 106 

Index

Preface 

The “SOStegno 70” Association was established in December 

of 2001 by a group of parents of children and young people 

with diabetes who felt the need for a point of reference and an 

opportunity to exchange information and experiences. 

When you receive a diagnosis of diabetes for your child, you 

feel lost, helpless, and unjustified guilt often arises. However, 

you immediately realise that there is no time to give in to your 

anxieties and insecurities because this would affect the child 

you have to protect and safeguard. It is a difficult time from 

a psychological point of view, and being able to rely on other 

people who are going through a similar experience is of great 

help. In fact, parents with a high level of experience may, without 

in any way substituting the indispensable contribution of their 

diabetologist, provide valuable suggestions for the daily practical 

management of the disease. 

For people involved in different activities, beginning to live with 

diabetes means quickly acquiring a number of medical skills which 

are essential to ensure optimal glycaemic control and to help the 

child to become independent in the management of the disease. 

This handbook was therefore created as a reference tool for young 

people with diabetes. 

One of the main purposes of SOStegno 70 to give support to 

young people with diabetes and their families in any diabetes 

centre in the country, through continuous practical training and 

information to ensure an ever improving quality of life and care. 

These activities are provided in collaboration with the Doctors of 

the Paediatric Clinics in Milan in which the Association has its 

offices – at the Pediatric Endocrinology and Diabetology Clinic at 

the San Raffaele Scientific Institute of Milano (a regional centre of 

reference in the field), and at its offices in Brescia at the “Spedali 

Civili” Hospital.

Preface 

The Association carries out general activities, such as the purchase 

of innovative monitoring and therapeutic devices, the organisation 

of age-specific diabetes camps – with the aim to provide education 

regarding an independent and aware management of their therapy 

– the establishment of scholarships for promising young doctors, 

public and institutional awareness in regard to this condition, and 

local activities specifically focused on the territory’s needs. 

All these initiatives are not only possible thanks to the funds 

raised, but above all because of the involvement and commitment 

of the Association’s volunteers. 

It is they, the volunteers, who are the backbone of SOStegno 70, 

with their constant presence in the hospitals, alongside families 

suffering the impact of the disease, and through their relationships 

with Doctors. They organise side events, providing effective 

operational support. 

Information, responsibility and therapeutic quality – with the 

children and their families at the heart of the matter: this is 

SOStegno 70. 

Patrizia Pappini 

SOStegno 70 

Insieme ai ragazzi diabetici Onlus 

www.sostegno70.org 

70 because this is the ideal blood glucose value of a healthy person. 

70 like hope, as a value that parents also wish for their children, in 

the not too distant future.

Introduction 

“When I was a child I became diabetic. I would take the 

urine glucose test 2-3 times a day and, occasionally, I would 

measure my blood sugar level at diabetes check-ups. By 

doing this I was considered a good boy with well-controlled 

diabetes. But now, if I test my blood glucose 5-6 times a day 

and the inject insulin 4-5 times a day, I am not considered a 

good patient.” This is what one of our diabetic “former child 

patients” told us. He is now a young adult with a good career, 

with a good position in society. 

Looking back at the previous edition of this handbook, I 

realise that it is true; we ask more and more from our young 

patients, but fortunately, technology has allowed us to make 

ever increasing progress in relation to the difficulties they face 

on a daily basis. 

Without doubt we require a lot of blood glucose tests, often 

too many, but the technical quality of blood glucose monitors 

and their multiple benefits have enabled us to achieve a 

precision and accuracy that was unthinkable a few years ago. 

More and more frequently the use of glucose sensors allows 

us to identify and resolve situations that are often difficult. 

The use of new types of insulin, and especially the 

increasingly widespread use of insulin pumps, are 

revolutionising the approach towards diabetes, allowing us to 

nearly simulate the physiological secretion of insulin. 

Recent improvements in diabetes management have been 

instrumental in getting decreasing values of HbA1c. 

Furthermore, diabetes complications have become almost an 

exceptional event in the lives of our young adults, even after 

many years of suffering from the disease.

Introduzione 

Introduction 

A more scientific approach to nutrition and the invaluable 

contributions of psychologists have proven to be fundamental 

in a challenging period such as the of adolescence. 

In recent years, many young doctors have achieved their 

specialisations in our group. They are now operating 

throughout the country with extreme competence, allowing 

close cooperation, therefore providing significant benefits for 

their patients. 

This presentation allows me to once again thank the youths 

and their parents. Their daily activities have allowed us to 

accomplish achievements that our group feels very proud of. 

We know that the sacrifices we ask for means securing their 

future. 

Giuseppe Chiumello 

Paediatric Endocrinology and Diabetes Centre 

San Raffaele Scientific Institute 

Milano, Italy



( 9


The purpose of this handbook is to provide useful information 

to young people with diabetes and their families, in order to 

promote proper diabetes self-management 

Diabetes is in your hands! 

A history of diabetes 

10 ) 

Diabetes mellitus is an ancient disease. It was already known about thirty-five 

centuries ago, and traces have been found in the history of medicine. 

The words “diabetes mellitus” derive from Greek and mean “siphon” or 

“fountain” and “sweet as honey” respectively, referring to the presence of sugar in 

the large quantities of urine. The Egyptians mentioned diabetes in a papyrus dating 

back to 1550 BC. Traditional Indian medicine, which dates back to the fifth century 

AD, mentions two types of diabetes, one that occurs in underweight people of all 

ages and the other that is common in overweight people. For a long time in the history 

of medicine it was thought that diabetes was a disease of the kidneys – in 1679, an 

English physician called Thomas Willis described the urine of patients with diabetes as 

“beautifully sweet”. About a hundred years later, a physician from Oxford first observed 

that there were high levels of sugar in the blood of people with diabetes. This led 

him to suppose that the sugar was lost in the urine before being used. 

The key to understanding the real cause of diabetes was only discovered in 1889. 

In that year, Paul Langerhans discovered that there were groups of cells that were not 

associated with other pancreatic digestive processes within the pancreatic tissue. He 

also noticed that if these cells were damaged, a situation similar to diabetes developed. 

These cells have since been called “Islets of Langerhans” and it led to the opinion 

that they were able to produce a chemical (hormone) capable of preventing diabetes. 

These studies were confirmed by Josef Von Mering and Oskar Minkoswki, who 

discovered that it was possible to cause diabetes in an experimental animal by removing 

its pancreas. 

Since then all the efforts of researchers where focused on identifying the pancreatic 

extract that was able to cure diabetes. In 1921 the Canadians Frederick Grant 

Banting and Charles Herbert Best isolated insulin and used it in the famous experiment 

involving the dog named arjorie. In 1922, the young Leonard Thomson was the 

first child with diabetes in history to be treated with insulin. A few years later 

insulin was placed commercialized and millions of people now owe their lives to it.


What does having diabetes mean? 

In order to produce any kind of activity, whether mental or physical, the body 

needs energy. This energy is supplied from the cells through the combustion of a first 

choice “fuel” named glucose. Glucose is a simple sugar of vital importance, serving as 

a source of energy for all cells, especially those of the brain and muscles. 

At every meal we ingest a number of foods, such as bread, pasta, potatoes and 

fruit that contain sugar. During digestion, all of this sugar is converted into glucose, 

which is absorbed in the intestine and enters the bloodstream. Glucose needs insulin 

to be used by the cells. Like a key, insulin opens the doors of the cells, allowing the 

entrance of glucose. Furthermore, through insulin’s action, excess sugar is deposited 

in the liver as glycogen, and in adipose cells in the form of triglycerides. Glycogen and 

triglycerides represent the fuel reserves to draw from while fasting. They are reconverted 

to glucose through the action of glucagon, a hormone which works in an opposite 

manner to insulin. 

Insulin produced by the pancreas thus regulates the levels of glucose (sugar) in 

the blood. In fact, the pancreas of a person who does not have diabetes produces insulin 

day and night to keep adequate blood glucose. In children and adolescents 

with diabetes, insulin is not produced in a sufficient quantity to meet the body’s 

needs and therefore the levels of blood glucose rise. 

Classification 

Different types of diabetes mellitus may be develop in children. 

Diabetes mellitus Type I 

It may affect people of any age, but mostly appears in the ages between 0 and 

30 years, with two peaks of incidence around one to five years of age and 10 and 12 

years of age. 

In Italy, the annual incidence (number of new cases in a year) differs from region 

to region. In England the incidence is 10-12 cases per 100,000 inhabitants/year, while 

in Sardinia it is approximately five times as much. 

The incidence of childhood diabetes seems to be steadily increasing particularly 

in children younger than 5 years of age. 

( 11


Type 1 diabetes mellitus is a disease characterised by the 

inability of cells to use glucose – which then accumulates in 

the blood – due to the lack of insulin production by the ß-cells 

of the pancreas, secondary to their destruction by the immune 

system. 

12 ) 

Causes of diabetes 

Type 1 diabetes mellitus is caused by the destruction of insulin-producing ß-cells, 

which are present in the Islets of Langerhans of the pancreas. This leads to a progressive 

decrease in the production of insulin, resulting in increased blood glucose levels. 

It is an autoimmune disease. The immune system of people with type 1 diabetes, 

which is designed to defend the body from foreign agents, such as bacteria and viruses, 

is altered, thereby producing antibodies that destroy beta cells. This process is very 

slow and may take several years to be completed. 

In this period it is possible to look for autoantibodies to identify individuals at risk of 

developing diabetes with a simple blood test. Researchers are currently focusing their 

interest on these subjects at risk in the hope of identifying a drug or a vaccine that 

could stop the autoimmune mechanism and block or delay the development of diabetes. 

To date, however, only experimental protocols are possible, the effectiveness of 

which has yet to be demonstrated. 

At the San Raffaele Hospital, you can join one of the largest and most well-known 

studies in the world, which is called TrialNet, and which is coordinated by the American 

National Institutes of Health. The San Raffaele Hospital is the only Italian centre 

admitted to this programme and it is regularly assessed for conducting such studies. 

It is estimated that the symptoms of the disease arise when around 80% of the 

ß-cells have been destroyed. Therefore at clinical onset there may still be a certain proportion 

of cells that produce insulin. For this reason, during the first year of disease 

the insulin requirements may be low, and in some cases may remain reduced and suspended 

– the so-called “honeymoon” period. However, it is unlikely that this situation 

lasts for more than a year from onset as all the ß-cells are progressively and irreversibly 

destroyed. 

Why does the immune system attack the ß-cells? To date there are no known causes 

that trigger this destructive mechanism, or its behaviour. What makes the 

study of diabetes even more troublesome is that the pancreas is a difficult organ to 

evaluate because of its anatomical. It is known, however, that there is no single cause: 

the disease depends on the interaction between a genetic predisposition and one 

or more external (“environmental”) causes.


Genetic predisposition 

Some genes (probably more than 10-15) are responsible for increasing the risk 

of developing type 1 diabetes. However, possessing these genes does not mean that 

diabetes will surely manifest (as is the case for hereditary diseases). The vast majority 

of “predisposed” people with a will never develop diabetes because they do not encounter 

the environmental “triggering” agent. 

For example: in our department about one baby in ten possesses predisposing genes, 

but only one in a thousand of these will develop type 1 diabetes. 

It is known that part of this predisposition is determined by histocompatibility 

(HLA) antigens, which are molecules that regulate the immune system. Statistical 

analysis has established that diabetes is associated mainly with HLA DR3, DR4, DQ2 and 

DQ8 present in most of the children with diabetes but also in 20-60% of those without 

diabetes. Genetic predisposition is supported by the fact that 40% of identical twins 

develop diabetes and the fact that about 5% of first-degree relatives (parents, siblings 

and children) of a person with type 1 diabetes develop this type of diabetes. It is very likely 

that there is a certain “dysregulation” of the immune system at the basis of type 1 

diabetes. This would not allow to limit the destructive process involving ß-cells, which 

ultimately determines insulin dependence. It is thought that an initial ß-cell aggression 

occurs with reasonable frequency, but normally the process is controlled by regulatory 

T-cells thereby preventing type 1 diabetes. Children with diabetes have an increased risk 

of developing other organ-specific autoimmune diseases such as hypothyroidism and 

celiac disease. It is important to emphasise that the immune system of a child with diabetes 

is normal and does determine an increased risk of infection. 

Environmental factors 

It is assumed that one or more environmental triggers may acrivate the immune 

response that triggers Type 1 diabetes in in a predisposed individuals. Unfortunately, to 

date there are only hypotheses (infections? diet? other?) and no specific factor has yet 

been identified. Finding e trigger is essential as it would allow to create a foundation for 

future prevention. The so-called “environmental” (meaning “non- genetic” in a broad 

sense) trigger is definitely very important and responsible for the increasing incidence of 

diabetes that is found nowadays. 

Another environmental factor to take into consideration is that the prevalence of 

overweight and obese children is rising in several countries including Italy. This probably 

does not have a direct effect in the induction of the disease but may highlight earlier 

the presence of an ongoing autoimmune ß-cell destruction. It may therefore be considered 

an anticipatory factor. 

Another recently discussed environmental factor involves the gastrointestinal environment, 

as many of the immune system’s regulatory cells are generated in the intestine. 

The mechanism that correlates the intestinal flora and type 1 diabetes is not yet clear, 

but this is an area of on-going research. 

( 13


Maturity Onset Diabetes of the Young (MODY) 

This is a rare form of diabetes that usually manifests in people up to 25 years of age. 

It is a genetically determined type of diabetes (i.e. transmitted in a hereditary manner 

from parent to child with a very high frequency), and it is therefore characterised by 

the absence of autoantibodies and not associated with obesity. It is caused by a genetic 

defect in ß-cell function. In many cases, the diagnosis is carried out by the occasional 

identification of hyperglycaemia during routing blood tests. The diagnosis may be confirmed 

by genetic testing for determined genetic mutations. A number of MODY types 

are know: the most common form in Italy is MODY2, which usually does not require 

treatment and rarely causes complications. In some cases, however, it may require treatment 

with oral hypoglycaemic drugs or insulin. 

14 ) 

Neonatal diabetes 

Neonatal diabetes is a rare disease which affects about one out of 120,000 babies, 

and is characterised hyperglycaemia requiring insulin treatment in the first 6 

months of life. It is a disease that may be caused by a wide variety of genetic mutations 

that act through different mechanisms. It is not an autoimmune disease such as 

type 1 Diabetes. 

There are two forms of Neonatal Diabetes: the first and most common is Transient 

Neonatal Diabetes Mellitus (TNDM) which develops within the first six weeks of 

life and goes into remission within 18 months. In some cases it may recur later in life 

(typically during puberty). In more than 80% of cases, TNDM is caused by genetic alterations 

involving chromosome 6. Approximately 30% of the remaining cases of TNDM 

is instead linked to mutations in the KCNJ11 gene, which also causes Permanent Neonatal 

Diabetes (PNDM). The other forms of PNDM identified so far are related to other 

mutations: ACCD8, INS, IPF -1, GCK , FOXP3 and EIF2AK3. 

The diagnosis of the different forms of neonatal diabetes by identifying specific 

genetic mutations allows to define specific therapies, in some cases with orally taken 

hypoglycaemic agents rather than with insulin. 

Secondary diabetes 

There are other very rare forms of diabetes that are considered “secondary” (in the 

sense of being “caused by”) to different specific causes: pancreatic, liver, metabolic or 

hereditary diseases, or drugs that determine ß-cells damage. 

Diabetes Mellitus Type 2 

The first reports of cases of Type 2 diabetes in children, which appeared in the 

1970s, regarded obese adolescents of American Indian origin among Pima Indians in 

Arizona. Since the 1990s an increasing incidence of Type 2 diabetes has been reported 

in the United States, even in adolescents of African-American and Hispanic-American 

origins.


More recently, the phenomenon appeared to also affect the Caucasian population. 

In Europe and particularly in Italy, cases of type 2 diabetes are not currently numerous 

but their frequency is increasing. It is likely that the real extent of the problem 

is underestimated because the disease may manifests few symptoms for a long period 

of time. This form of diabetes mostly affects people above 40-50 years of age and is 

associated with overweight. These patients currently represent the majority of the diabetic 

population (90 %). 

It is not an autoimmune, but it has a significant hereditary component: in fact, 

about 90% of identical twins show this form of diabetes. A person with type 2 diabetes 

produces insufficient quantities of insulin to control blood glucose levels. This is 

due to the presence of insulin resistance, which makes insulin ineffective. It is therefore 

easy to understand why these individuals, unlike those with type 1 diabetes, may 

be treated with lifestyle changes (diet and regular exercise), or with the use of drugs 

that are able to stimulate insulin action and/or secretion (oral hypoglycaemic agents). 

In America, Asia and Australia, there have recently been an increasing number of 

cases of this type of diabetes in children and adolescents. This phenomenon is correlated 

to the high frequency of childhood obesity (which involves as much as 40% American 

children/adolescents), and ethnic minorities (particularly those of immigrant origins 

such as Mexicans, Asians, Indians) because of genetic predisposition. 

Risk factors 

Obesity. This is the most important risk factor for type 2 diabetes: more than 85% of 

children and adolescents are overweight at disease onset. Obesity may be considered 

a worldwide epidemic, especially in children. An important role in the pathogenesis 

of the disease is especially attributed to abdominal fat. Obesity in children and adolescents 

also causes a reduced sensitivity of peripheral tissues to the action of insulin. 

The pancreas tries to overcome this situation by increasing the secretion of insulin 

which in some cases may reache high concentrations in the blood (hyperinsulinemia). 

This balance may eventually break, resulting in an increase in blood glucose values. In 

a minority of cases this condition evolves, already in childhood, into overt diabetes. 

Genetics. Many genetic factors underlie the susceptibility of the disease by influencing 

insulin-resistance. Genetic predisposition is influenced by environmental factors 

and lifestyle. 

Family history. 45-80% of children with Type 2 diabetes have at least one parent 

with diabetes and 74-100% have a first and second degree relative with Type 2 Diabetes. 

Lifestyle. The role of nutrition in the pathogenesis of obesity and type 2 diabetes has 

been known for years, as is the role of a sedentary lifestyle. Physical activity is one of 

the factors that may improve glucose tolerance and insulin sensitivity. 

Gender and puberty. In the adult population the frequency of diabetes mellitus type 

2 is slightly higher in females: this phenomenon is much more marked in the paedia- 

( 15


tric population. The risk of developing type 2 diabetes is 1.7 times higher in female 

adolescents compared to male peers. Diabetes almost always manifests during or after 

puberty. 

Clinical manifestations 

Type 2 diabetes may also manifest with polyuria, polydipsia, and weight loss. However, 

unlike in type 1 diabetes, these symptoms are usually modest or absent. In some 

cases there may be an acute onset with ketoacidosis, although most patients are in 

good general conditions. Laboratory tests may show variable levels of blood glucose 

and glycosuria without ketonuria. 

From now on we will only be discussing type 1 Diabetes, which is the most 

common form in children and adolescents. 

Diagnostic criteria 

Diabetes is diagnosed by measuring the blood glucose levels and the presences of 

classic symptoms such as polyuria (frequent urination), polydipsia (constant unquenchable 

thirst) and weight loss (due to consumption of fat and muscle mass). 

16 ) 

Classic symptoms of diabetes or hyperglycemic crisis, with plasma glucose concentration 

200 mg/dL, 

or 

Fasting plasma glucose ≥126 mg/dL. Fasting is defined as no caloric intake for at 

least 8 h 

or 

Two hour postload glucose (≥200 mg/dL) during an OGTT


How it manifests 

In type 1 diabetes, blood glucose levels progressively increase due to an insufficient 

insulin production. This situation determines the onset of a number of evident clinical 

manifestations. 

The body is equipped with a range of alarm systems: one of them is activated when 

blood glucose levels exceeds the value of 180 mg/dL, and results in the elimination of 

excess glucose in urine. 

Since glucose needs a lot of water to be diluted, polyuria i.e. the emission of large 

quantities of urine frequently appears as the first symptom. When blood glucose 

levels are very high, waking up at night to urinate may become necessary: this 

symptom is called nocturia. 

Plenty of fluids are lost with urine, and therefore they must be replaced. This situation 

determines what is called polydipsia – intense thirst. As significant amounts 

of fluids are lost in urine, there is a progressive dehydration which may present with 

dryness of the skin and mucosal membranes. Moreover, the very “sugary” urine becomes 

a great breeding ground for bacteria or fungi which may cause urinary tract infections 

and vaginal discharge. 

Weight loss. Although there are high levels of glucose in the blood, it cannot be 

used to the lack of insulin. The body’s cells therefore exploit second choice energy 

sources such as stored fat and muscle proteins. In addition to losing weight, the body 

responds with an intense hunger called polyphagia to try to replenish the body 

with energy. Due to this metabolic derangement, also intense fatigue may progressively 

develop. 

Fats used as “second choice” fuel also produce waste such as ketones, which are 

eliminated in urine (ketonuria or acetonuria) and in exhaled air (acetone smelling breath 

with the characteristic odour of rotten fruit). If this process is not interrupted, 

the blodd’s acidity progressively drops eventually causing ketoacidosis, a serious 

acute situation that requires emergency hospitalization. 

( 17


Therapy 

When type 1 diabetes is diagnosed, the patient should be hospitalized in a paediatric 

ward in which there is a team (doctors, nurses, dietitians, psychologists - educators) 

specifically qualified to take care of children with diabetes. This group of specialists also 

monitors the child in outpatient check-ups. 

The treatment of diabetes does not end with the hospitalization of the patient 

but must be continued in in everyday life. The child and his/her family are therefore 

key players in the management of diabetes. 

Diabetes care is based on four cornerstones: 

self-control education 

insulin “replacement” therapy 

adequate nutrition 

regular physical activity 

The aim is to try to achieve the full psychological and physical well-being of the 

child and effective prevention of diabetes complications secondary to and adequate 

metabolic control. 

Prevention means avoiding the onset or slowing the progression of macrovascular 

and microvascular complications that could lead to a deterioration in the quality of 

life of a person suffering from diabetes. 

In other words, implementing prevention means avoiding damage to the eye’s 

retina, kidney, nervous system and circulation at especially for what concerns the heart 

and lower limbs. To implement an effective prevention strategy, all the therapeutic 

options in our possession should be used: insulin therapy, which has changed the natural 

history of insulin-dependent patients, remains the fundamental therapeutic tool. 

18 ) 

It is important for a child with diabetes and his/her family to 

learn how to manage themselves correctly in all the situations 

that life may present.


of blood glucose

Self-monitoring of blood glucose 

Doctors and other specialists are experts that provide the instructions, but it is the family 

that has to adapt the information to the needs of everyday life. Diabetes self-management 

may carried out by using specific tools, mainly blood glucose and ketone 

measurements, which allow to quickly identify glucose oscillations. Frequent testing, 

defined as “self-monitoring”, allows a child/young adult with diabetes, who is properly 

instructed by a health care team, to manage his/her own insulin therapy. 

It is important to note that only by carrying out these allows us to understand 

how blood glucose levels vary throughout the day. This means taking about 5 to 7 blood 

glucose values per day. 

It is absolutely impossible to rely on symptoms to determine your blood 

sugar level. 

A person who does not have diabetes has blood glucose levels that roughly vary 

between 65 and 126 mg/dL throughout the day. 

A youngster with diabetes should have the following reference values 

(reference values may be individually determined with a specialist): 

between 80 and 120 mg/dL when fasting 

between 90 and 180 mg/dL after meals 

between 120 and 180 mg/dL before bedtime 

Hyperglycaemia therefore means having a value greater than 120 mg/dL when 

fasting and 180 mg/dL after meals. These are reference values which children/adolescents 

with diabetes should aim for. It is impossible for a child with diabetes to 

never have hyper- or hypoglycaemia. Blood glucose oscillations should not raise 

concerns if they remain occasional. In preschool children (who are particularly sensitive 

to insulin) it may be necessary to increase the blood glucose reference ranges reduce 

the risk of hypoglycaemia. 

20 ) 

Where to perform blood glucose measurements 

Fingers are a particularly adequate site for blood glucose testing as they a richly vascularized. 

Small pricks can be performed, generating a small amount of blood which 

is sufficient for testing. 

Each finger may be pricked on the tip or on the side. It is important to use all 

the fingers in rotation to avoid the hardening of the skin and a reduction in sensitivity. 

Newer blood glucose meters use smaller blood samples (0.2-0.5 microlitres) and allow 

testing on alternative sites (palm of your hands and forearms). By using the forearm 

blood glucose variations may be observed with a delay of 15 minutes compared 

to the fingertip/hand. Therefore, alternative sites such as the forearm should be used 

only for fasting blood glucose determinations.


How the test 

The measurement of blood glucose at home is performed by taking a drop of blood 

from a small prick on the fingertips with a special calibrated lancing device, which makes 

it almost painless. 

If the temperature is low, warm your hands to increase the flow of blood. Generally, 

it is not necessary to disinfect where you prick the skin (washing hands with soap 

and water may be enough), but if you do make sure the finger is completely dry before 

proceeding. For hand washing we recommend using warm water: warm hands 

allow a better flow of blood. 

Place the drop of blood in contact with the test strip inserted in the instrument, and 

in a few seconds a blood glucose value will appear on the display. 

The devices are equipped with memory that can record the results obtained in previous 

weeks and allow you to check your average blood glucose level. 

It is also possible to connect the instrument to a personal computer, thereby obtaining 

statistics and graphs regarding your blood glucose values that are useful in the 

evaluation of glucose oscillations in specific tiems of the day. These data may be 

sent and/or discussed with your diabetes specialist. 

Each instrument has its own specific calibration: therefore it is neither recommended 

to frequently change the one you use, nor to compare the results obtained with 

two different instruments. 

Each meter has a margin of error of about 10-15%: therefore, by repeating the test 

multiple times within a few minutes you may get slightly different results (the higher 

the blood glucose value, the higher the difference) but which are still representative 

of the same blood glucose value at that moment. 

The meter must not be exposed to extremely high or low temperatures. 

Some older meters require verification of the code that appears on the strips that 

are used for dosage. A mismatch between the instrument’s code and the strips may 

lead to significant errors. Newer instruments do not require coding (“no-code” instruments). 

Certain substances may interfere with the performance of the test, such as certain 

medications (ie. Acetamol). 

( 21 

Possible errors when performing the test: 

it is necessary to dry your finger before pricking it, otherwise blood will be diluted, 

and the blood glucose value will be altered. 

be careful to temperature: 

> If it is less than 10°C, the measured values are lower than the actual values 

> If it is above 35°C, the measured values are higher than the actual values


When you perform the test 

The purpose of blood glucose monitoring is to determine whether or not insulin doses 

are adequate. In particular, it is important to know that: 

after meals (ie. breakfast, lunch and dinner) the blood glucose value depends on rapid-acting 

insulin administered before the meals; 

fasting blood glucose values (upon awakening, before meals, and at night) mainly 

depend on the long-acting insulin administered in the morning or at bedtime. 

How often to test your blood glucose 

The blood glucose test must be performed at different times of the day in order to 

obtain information in all time frames. In particular, we recommend and average of 5-7 

blood glucose measurements a day. 

You should measure your blood glucose levels often to adjust insulin doses according 

to your own needs, to assess the effect different activities and meals, and above 

all to have all the information you need to independently and safely change insulin 

doses. 

Patients who use insulin pumps usually check their blood sugar more frequently 

(8-10 times a day) to prevent possible hypoglycaemia and promptly and accurately 

adjust the dose of insulin (fine-tuning). 

Urine Dipstick Tests 

22 ) 

Urine dipstick tests complement the information provided by glucose measurements. 

Performing these tests is simple: dip the strips in urine, and the reactive squares will 

start progressively change color in a few seconds. You may obtain the result by comparing 

the colors on the strip with the reference table on the strip container. 

Glycosuria 

If your blood glucose is less than 160-180 mg/dL (renal threshold value) glucose will 

not be appear in urine. Therefore, a non-diabetic whose blood glucose rarely exceeds 

120 mg/dL, will never have sugar in his/her urine. 

However, if the blood glucose level exceeds this threshold, glucose will pass into the 

urine. The higher the blood glucose value the more glucose in urine there will be. 

This is why the amount of sugar in urine, also called glycosuria, may indirectly 

provide information on blood glucose levels. For example, if in the morning when you 

wake up the test shows a urine glucose level of 5 g/l, this means that during the night 

the blood sugar level was greater than 180 mg/dL, therefore providing an important 

information that would have otherwise been overlooked. Unlike blood glucose mea-


surements, glycosuria provides information that relates to a time interval; it does not 

detect the blood sugar level at the time, but its trend since the last time the bladder 

was emptied. 

Currently, the determination of glycosuria is of minor importance for those who 

regularly and frequently perform blood glucose tests. 

Sugar 

Blood 

Glycaemia 

180 

mg/dl 

Urine 

Urinary ketones 

It is also possible to determine acetone or ketones (ketonuria or acetonuria) in urine. 

Ketones are produced by the liver when fats and proteins are used to produce 

energy. If it is not possible to use glucose, the body will then rely on fat 

to produce energy. However, this also determines the production of waste material 

such ketones. Beyond a certain value, ketones accumulate in the blood and are then 

subsequently eliminated in urine and exhaled air. 

Therefore, when ketones appear in urine, it means that the cells were not able 

to use glucose but drew energy from fat. This may happen in two distinct situations: 

During prolonged hypoglycaemia, in other words when there is short supply of first 

choice fuel (glucose). 

In case of lack of insulin (and therefore hyperglycaemia), which prevents glucose 

from entering the cells. This may occur diabetes onset or with poorly controlled diabetes. 

These two situations can easily be distinguished by measuring blood glucose. The 

urine ketone test is of fundamental importance during in case of prolonged hyperglycaemia 

and during intermittent illnesses (ie. flu). A person with diabetes must 

never have ketones in his/her urine. 

( 23 

Interpretation of the tests 

A person with diabetes with good metabolic control will always have negative urine 

tests. The examples below refer, for purposes of convenience, to morning urine.


If neither glucose or ketones are found in morning urine 

this means that blood glucose was less than 180 mg/dL during the night; the possibility 

of hypoglycaemia cannot be excluded; a blood sugar level test in the night 

is necessary to check this. 

Glycosuria 

Acetonuria 

If only glucose is found in morning urine 

this result tells us that blood glucose exceeded the threshold of 180 mg/dL during 

the night. To determine the precise time and level it is necessary to check your blood 

sugar level several times during the night. 

If only ketones are found in morning urine 

hypoglycaemia probably occurred at night. Glucose is not present in urine as the 

180 mg/dL threshold has not been surpassed, however fat tissue had to be used therefore 

producing energy and ketones. 

24 ) 

If both glucose and ketones are found in morning urine 

the blood sugar level exceeded 180 mg/dL at night and fats were also used for energy. 

There are two possibilities: 

hypoglycaemia occurred followed by a significant rise in blood glucose, caused 

by the activation of counter regulatory mechanisms (hormones that release sugar 

stored in the liver). This phenomenon is called “rebound effect” and is the most 

likely hypothesis if it appears to be an isolated event and does not follow a period 

of poor control. To verify this hypothesis it is necessary to measure nigh-time blood 

glucose to prove the presence of nocturnal hypoglycaemia; 

there was a prolonged episode of hyperglycaemia caused by an insufficient dose 

of insulin. It is therefore necessary to measure your blood sugar immediately because 

this may be warning sign that the body is in a state of poor metabolic equilibrium 

and needs more insulin. Rapid-acting insulin must be administered and blood glucose 

must be checked every 2-3 hours. If blood glucose does not normalize within 

6 hours, it is better to contact your doctor immediately or go to the emergency department. 

This situation may also occur during acute illnesses. 

Capillary blood ketones 

Some devices, by using ketone-specific strips, can measure ketone concentrations 

from a drop of capillary blood, in the same way blood glucose is measured. In this 

way it is also possible to monitor blood ketone – which is very useful in case of poor 

metabolic control. With these meters, accurate measurements (values > 0.6 mmol/l 

are considered positive) allow to observe a rise in ketones long before the their presence 

in urine.


Blood ketone measurement are very important for the following patients: 

newborns or toddlers who use a diaper, making it difficult to test for ketones in urine; 

during infectious diseases; 

in all cases where diabetic ketoacidosis needs to be prevented; 

patients using insulin pumps, 

Monitoring for the presence of ketone must be carried out immediately in the presence 

of persistently elevated blood glucose and during any type of intercurrent illness 

(fever, diarrhoea, vomiting). The presence of ketone is an alarm signal that requires 

immediate action. 

The Glucose Diary 

Keeping a glucose diary with blood glucose values helps the self-management diabetes 

and helps caregivers evaluated glucose control more effectively. It is important record 

the following data in the diary: any change in weight, intercurrent illness (fever, 

infections, colds, etc.), menses, and physical activities. Statistical assessment of glucose 

values (e.g. monthly averages and variability indices) can be obtained using computers. 

Spreadsheets may can also be used record blood sugar levels. 

Pre-school children (under 6 years of age) require a lot of blood glucose level 

tests (up to 12 per day) because of the extensive variability in nutrition and physical 

activity and because they are not able to identify the symptoms of hypoglycaemia on 

their own. 

Day 

morning 

BG 

insulin 

BG after 

breakfast 

BG before 

lunch 

insulin 

BG after 

lunch 


snack 

insulin 


dinner 

insulin 

BG after 

dinner 

insulin 

bedtime 

BG 

nighttime 

BG 

( 25 

1 

2 

3 

4 

Morning 

Lunch 

Snack 

Dinner 

Night 

5 

6 

7

Insulin therapy


What is insulin? 

Insulin is a hormone produced by ß-cells harvested in the Islets of Langerhans in the 

pancreas: its main function is to maintain normal blood glucose levels. 

The pancreas is an organ located deep in the abdomen which performs two important 

functions: 

Exocrine: through the release of pancreatic enzymes, it allows the digestion of food 

(fat, sugar, protein) in the intestine 

Endocrine: through the release of hormones such as insulin, glucagon, and somatostatin 

into the bloodstream, which are essential for proper glucose metabolism. 

Except for the secretion of insulin, endocrine and exocrine functions are substantially 

normal in diabetics. 

The release of insulin from the pancreas is regulated by blood glucose levels: the 

pancreas of a person without diabetes secretes a small amount of insulin in a continuous 

manner, allowing the body to use blood glucose in order to produce energy 

for the body’s needs. This is called the basal insulin requirement. However, the insulin 

requirement and therefore its concentration in the blood does not remain constant 

during they day due to many influencing factors such as physical activity or an 

intercurrent illness. 

After having consumed a meal or beverage containing carbohydrates, 

blood glucose increases. In people without diabetes, the pancreas “automatically” 

detects a rise in blood sugar and secretes adequate amounts of insulin in a short time 

to prevent blood glucose from exceeding the normal levels. 

If the pancreas is unable to do this, blood glucose is not used by the body’s cells 

and therefore it increases (except in brain and muscle cells, in which sugar can enter 

regardless of insulin action). 

( 27



Type 1 Diabetes is treated via a “substitution” process: the insulin that the pancreas 

no longer produces is provided by an external administration. Many advances have 

been made since the discovery of insulin in 1922: it was initially, extracted from the 

pancreas of animals and then synthetically produced in laboratories. Human insulin 

obtained with molecular biology has been available for many years. 

Insulin is measured in units (abbreviation U) which can be dosed with a syringe, 

pen or insulin pump; in Italy the concentration is always 100 U/ml. 

The main purpose of the administration of insulin is, of course, to achieve the 

best possible glycaemic control throughout the day. Several studies have shown that 

insulin treatment with multiple injections (>4 per day) allows a better glycaemic homeostasis. 

By increasing the number of doses, the insulin secretion in the pancreas of 

a non-diabetic person is mimicked. 

There are currently various insulin formulations with different durations of action: 

regular or rapid-acting, rapid-acting insulin analogs, intermediate-acting insulin, 

long-acting insulin analogs, and premixed insulins. 

The possibility to use different types of insulin makes it easier to achieve optimal 

glycaemic control. Rapid-acting insulin are used before meals and long-acting insulins 

are used to cover the 24 h basal insulin requirement. 

28 ) 

However, obtaining an adequate glycaemic profile is not always simple. 

Numerous factors related to the mode of administration, absorption and action of 

counter-regulatory hormones, such as growth hormone which has a hyperglycaemic 

action, may make it difficult to achieve glucose control. 

In younger children it is also difficult to plan physical activity (often sudden, 

intense and unpredictable). During adolescence, a period characterised by the desire 

for freedom from constraints), the commitment to self-control is sometimes lacking.


Rapid-acting insulin 

This insulin is identical in structure to human insulin. It has a clear and transparent appearance 

and is also called “regular” insulin. It is used to cover postprandial needs. It is 

rarely prescribed in current practice, because rapid-acting insulin analogs are preferred. 

Mode of action: 

onset of action: 30 minutes after an injection 

peak action: after 2-3 hours 

total duration of action: 5-6 hours 

2h 

6h 

0 2 4 6 8 10 12 

p 

Example: insulin administered at 7 a.m. in the 

morning starts to act at 7:30 a.m., has its maximum effectat 9 to 10 a.m., and 

its effect ends at about 12 to 1 p.m. 

Monitoring blood glucose: 2 hours after a meal 

Administration method: 

if your blood sugar is in the normal range you have to start eating your 

meal 30 minutes after an injection 

in the event of hypoglycaemia (values less than 60 mg/dL) we recommend 

correcting the hypoglycaemia and taking the injection 15 minutes before 

meals 

when blood glucose is above 300 mg/dL, you can anticipate the 

administration by 40-45 minutes before the meal 

Fast-acting insulin analog 

This insulin, also called ultra-rapid insulin, is obtained by modifying the structure of 

human insulin in order to obtain a higher absorption rate than traditional rapid-acting 

insulin, with a mechanism of action that is closer to the postprandial insulin production 

of non-diabetics. 

It is an aqueous, sterile, clear and colourless solution. Formulations are available for 

syringe and pen administration. 

( 29 


onset of action: 10-20 minutes after the injection 


total duration: 3-5 hours 

1h 

3h 

0 2 4 6 8 10 12


EXAMPLE: ultrafast insulin injected at 1 p.m. starts to act at 1.10 p.m., has its 

maximum effectiveness at 2 p.m. and its effect ends at about 4 – 6 p.m. 

The duration depends on the total dose. In people who take more than 0.3 

units/kg of weight (for example, weighing 40 kg and take more than 12 units) 

the effect of ultrafast insulin can last up to six hours after the injection. 

Monitoring of blood glucose: 1-2 hours after a meal 

Administration method: 

if your blood sugar is in the normal range you should wait 10-15 minutes 

after an injection to start eating 

in the presence of hypoglycaemia we recommend to first correct the 

low blood sugar as shown in the diagram. After the blood glucose has 

returned in the normal range, administer the dose of insulin right before 

consuming the meal. 

in case of hyperglycaemia a correction dose is added to the meal dose 

30 ) 

By using a rapid-acting insulin analog, the time between injection and meal is reduced. 

You do not have to wait 30 minutes between an injection and a meal like traditional 

insulin as 15 minutes may suffice. 

In some situations it is not possible to predict the patient’s eating habits (because 

he/she has a variable appetite or because of illnesses that result in the loss of appetite, 

nausea or vomiting). In these cases it is possible to administer ultrafast insulin after 

meals, so that the injected dose is adequate in proportion to the amount of consumed 

carbohydrates. Ultrafast insulin must always be used for the administration of 

an extra- dose in the presence of occasional hyperglycaemia or snacks eaten between 

meals. The absorption rapidity reduces postprandial hyperglycaemia. 

As a result of the shorter duration of action, ultrafast insulin also reduces the risk 

of delayed hypoglycaemia. For these reasons it allows the elimination of “mandatory” 

snacks between meals. Ultrafast insulin must always be used alongside a daily dose 

of long-acting insulin. 

Intermediate-acting insulin 

Because of the presence of protamine (NPH), this insulin has a slower absorption from 

the injection area. It has a milky appearance. 


onset of action: 1-2 hours after an injection 


total duration:10-12 hours 

5h 

12h 

0 2 4 6 8 10 12


EXAMPLE: intermediate-acting insulin administered at 7a.m. starts working 

at 8 – 9 a.m. , has its maximum effectiveness at 1 p.m. to 3 p.m. and its effect 

ends around 7 p.m. 

Monitoring of blood glucose levels: while fasting, before meals 

Administration method 

Since the function of this type of insulin is to maintain the blood glucose level between 

meals through a slow and continuous release into the bloodstream, it is generally 

administered twice a day: in the morning in association with a rapid-acting insulin 

and in the evening before dinner or before bedtime. Being a suspension liquid it is necessary 

to shake it delicately by turning it upside down at least 10 times before use. 

Premixed insulin 

This is a type of insulin containing both ultrafast and intermediate-acting insulin 

(NPH). The proportion of rapid-acting and intermediate insulin varies depending on 

the type of premixed insulin; you can find the following proportions on the market: 

25/75, 30/70, 50/50, 70/30. The first number represents the percentage of rapid acting 

insulin and the second the percentage of intermediate-acting insulin. 

The use of pre-mixed insulins in children is strictly dependent on the stability of 

the blood glucose values as it is impossible to change only the rapid-acting proportion 

without affecting the intermediate dose. It is therefore a less “flexible” kind of insulin 

to use in children especially in case of unpredictable eating habits and physical activity. 


onset of action: 30 minutes after an injection 



2h 

10h 

( 31 

0 2 4 6 8 10 12 

EXAMPLE: premixed insulin administered at 7 

a.m. in the morning starts to work at 7:30 a.m., 

has its maximum effect at 9 to 10 a.m. and its effect ends at around 5 to 7 

p.m. 

Monitoring blood glucose levels: 2 hours after a meal and before the next meal 

Administration method: see those for the administration of rapid-acting insulin


Long-acting insulin analogs 

Long-acting insulin analogs ensure ‘baseline’ insulinization – the minimum insulin required 

between meals and rest. There are two types of similar long-acting insulins 

which are obtained by modifying the insulin molecule in order to obtain a slow absorption 

and therefore a long mechanism of action. 

Lantus (glargine). Lantus is an insulin whose effectiveness is maintained, in most 

cases, for 20-24 hours. 


onset of action: 2 hours after an 

injection 

peak action: it has no peaks, its action 

is homogenous 


h 

0 2 4 6 8 10 12 14 16 18 20 22 24 

EXAMPLE: if you inject it at 10 p.m. it will begin to work at midnight and last 

until 10 p.m. the next day. 

It is preferable to inject Lantus in the buttocks where the absorption is slower. 

Levemir (Detemir). Levemir is another long-acting insulin with a different mechanism 

of action compared to Lantus. This is also a transparent insulin and binds to circulating 

albumin once it has entered the bloodstream. It is then slowly released in order 

to obtain a prolonged effect. 

32 ) 


onset of action: 2 hours from injection 

peak action: while a dose of 0.2/0.3 

U/kg does not have a peak, a higher 

dose determines a peak after about 

6-9 hours. 


h 

0 2 4 6 8 10 12 14 16 18 20 22 24 

Levemir is normally injected twice a day.


How to store insulin 

To address this issue it is necessary to distinguish between insulin currently in use and 

unused insulin. 

Unused insulin should be stored in a refrigerator at a temperature between +2°C 

and +8°C. 

Insulin vials or pens which are being used are to be kept at room temperature 

(below 25°C) for a maximum period of one month. It must not be frozen, or exposed 

to excessive heat or direct sunlight. It may also be stored in the fridge – remember to 

bring it to room temperature at least 20 minutes prior to administration since refrigerated 

insulin may cause pain in the injection site. Insulin that is currently in use and 

stored in a refrigerator should be discarded 2 months after it’s first use. 

It is advisable to mark the date of first use in order to calculate the expiration date. 

Insulin therapy schedule 

By using different types of insulins it is possible to develop a daily administration schedule 

or ‘tailor-made’ insulin administration schedule for each child with diabetes, according 

to their individual needs. Different daily habits and individual insulin sensitivity 

make it impossible to determine standard insulin doses that are common to everyone. 

However, there has now been an acceptance of the theory that a greater number 

of boluses gives better control of blood sugar levels and therefore a lower risk of 

complications. However, we must not forget that only the patient’s cooperation and 

education in self-management, appropriate dietary education and regular physical activity, 

aid in achieving optimal control. 

The guiding principle of modern insulin therapy is to try to develop an insulin administration 

that mimics as much as possible that of physiological pancreas with working 

ß-cells. A normal pancreas continuously secretes a small amount of insulin (basal 

insulin) and then precisely increases/decreases insulin administration according to 

increasing (for example during a meal) or decreasing (for example during physical activity) 

blood glucose. 

This is the concept by which basal/bolus insulin regimens are considered the main 

mode of insulin replacement therapy. 

An overall daily dose of insulin of up to 1-1.3 units per kilogram of body weight 

is normal, especially during adolescence. 

When choosing a therapeutic regimen, one must take into account the habits 

and meal times of the child and his/her family: insulin use must be adapted to the 

needs of the person with diabetes and not vice versa. 

There are several possible regimens with at least 3 insulin injections per day. 

Schedules that are now considered effective involve the administration of rapid insu- 

( 33


lin analogs before meals and snacks and long acting insulin analogs in a single dose 

(usually at bedtime) or two doses at bedtime and in the morning. The use of premixed 

insulin is limited, particularly in children. 

Due to the scarsity of data present in literature regarding the use of long acting 

insulin analgos in children under 2 years of age, it’s prescription in this age group is 

very limited. Therefore, a schedule with intermediate acting insulin (NPH) and rapid 

acting insulin analogs is usually proposed. Intermediate acting insulin and rapid acting 

analogs may be mixed, allowing for a reduction in the number of injections. This schedule 

is an alternative to the use of an insulin pump, which is probably the best therapeutic 

option in this age group. 

Examples of insulin regimens 

The insulin regimen that is by far the most used in patients of all ages is the so-called 

basal-bolus regimen. It consists of an injection of rapid-acting insulin analog before 

each meal and and usually on injection of log acting insulin analog (usually glargine) 

at bedtime. 

Basal bolus regimen 

chedule 

Before breakfast: rapid acting insulin analog 

Before lunch: rapid acting insulin analog 

Before dinner: rapid acting insulin analog 

Before going to sleep: long acting insulin analog 

Another common regimen involves two injections of rapid acting insulin analog 

alone before breakfast and dinner, an injection of rapid acting insulin analog mixed 

with NPH before lunch, and NPH insulin at bedtime. 

chedule 

34 ) 

Schedule 

Before breakfast: rapid acting insulin analog 

Before lunch: rapid acting insulin analog + NPH 

Before dinner: rapid acting insulin analog 

Before going to bed: NPH 

The latter regimen is may be an alternative for young children of up to 6 years of 

age as the bedtime NPH profile may better satisfy the insulin requirements of a preschool 

child. 

Type 1 diabetes may be considered well-controlled when the blood sugar level 

values are optimal (HbA1C < 7.5% or 52 mmol/mol) regardless of the type of schedule, 

the number of injections or the daily insulin requirement.


General principles for changing doses 

How and when to change an insulin dose depends on the type of insulin regimen, however 

there are certain ‘golden rules’ that on has to keep in mind. 

After meals, blood sugar values mainly depend on rapid-acting insulin, while fasting 

blood sugar levels usually depend on the activity of delayed insulin. 

In the presence of a single high blood glucose value (hyperglycaemia) it is wise to 

check your blood glucose level in the following days in a that same time-frame, in order 

to see whether or not it is a sporadic event. 

If blood glucose is still high for 2 or 3 consecutive days in the same time frame, 

and no specific causes may be identified (ie. diet and/or exercise), it is necessary to 

increase the dose of insulin acting at that time by 10% (usually 0.5-1 U). In the following 

days you should check your blood glucose in the same time period to evaluate 

the adequacy of the insulin dose modification. If blood glucose is still elevated, one 

can repeat the 10% increase. 

If an unexplained hypoglycaemia occurs, the dose of insulin acting in that timeframe 

should be reduced by 10% (0.5-1 U) the following day. 

There are many factors that affect blood glucose levels (diet, exercise, illnesses, 

menstrual cycle, etc), and insulin is only one of them. Thus, before deciding on changing 

your insulin dose it is always important to ask yourself the following questions: 

At what time is your blood glucose too high or too low? 

Are there any identifiable reasons (exercise, diet, illness or other)? 

Which type of insulin is acting in that time period? 

How much do you need to increase the dose? 

Insulin-to-carbohydrate (IC) ratio 

The IC ratio expressesas the amount of carbohydrates (in grams) that is metabolized 

by one unit of rapid acting insulin. For example, a ratio of 1/15 means that 15 g of 

carbohydrates are metabolized by 1 unit of insulin. 

( 35 

EXAMPLE: A person with a IC ratio of 15 decides to eat 75 grams of 

carbohydrates. 75:15 = 5. He/she must therefore plan a preprandial bolus of 

5 units. 

The IC ratio is generally calculated by dieticians on the basis of a careful analysis 

of the dietary records kept by the person with diabetes. The latter should, at least for 

a few weeks, record the blood sugar level before each meal or snack or drink containing 

carbohydrates, as well as the blood glucose level afterwards and the carbohydrate 

content of the meal (or weight or type of food with the ingredients). 

The IC ratio may vary considerably during the day. For example, those who exer-


cise in the afternoon and have a sedentary morning find that their insulin ‘works better’ 

- and therefore ‘burns’ more carbohydrates - at dinner rather than at lunch. The 

same is true in the summer compared to winter. 

36 ) 

Correction factor 

Each person has ‘his/her’ correction or insulin sensitivity factor (ISF). To calculate it you 

have to add all the units of insulin administered in a day (consider only insulin administered 

ad main meals and bedtime) and divide the constant 1800 by the total number 

of units. For example, if the sum of the units of insulin taken during the day is 90, 

1800:90 is 20, which is the correction factor. In this case, in the event of hyperglycaemia, 

each unit of insulin lowers the blood glucose by 20 mg/dL. 

Insulin sensitivity varies over time, for example during puberty, or when exercising 

or during the menstrual cycle. The insulin sensitivity variances are important and 

are taken into account by Doctors in determining the standard doses of injections, but 

generally they do not deteremine a significant change in the ISF. In younger children 

(as well as people who are more sensitive to insulin than on average), the ISF may be 

different at different times of the day. 

The correction factor allows to determine the amount of insulin required to return 

to normal glucose levels in case of hyperglycaemia. In order to calculate the 

amount of insulin required you have to subtract your target glucose value (ie. 120- 

150 mg/dL) from the measured value (ie. 240 mg/dL) to obtain the desired decrease 

in blood glucose. Assuming an ISF of 20 , the difference between the measured blood 

glucose level (240 mg/dL) and the acceptable level (120 mg/dL) will be divided by 

20 to obtain the number of units to be injected as an ‘extra dose’. 

The ISF is also useful in cases where the blood sugar level is less than the target 

value before meals, for example, 70 instead of 90 mg/dL. In this case, one may subtract 

the ‘food’ bolus by the number of units required to bring the blood glucose level 

to the target value. Since 90-70 is equal to 20 and the correction factor is 20, it 

will be sufficient to reduce by one bolus of insulin to ‘cover’ the meal and reduce the 

risk of hypoglycemia.


and methods

Injection areas and methods 

The only minimally invasive means of administering insulin a regular and relatively 

unaltered absorption is by injecting it in the subcutaneous tissue with an insulin pen, 

syringe, of insulin pump. It is therefore fundamental to learn correct insulin preparation 

and injection techniques. An error in this practice may determine inadequate glucose 

control. 

Available injection devices 

Syringes for U-100 insulin: 

0.3 ml (30 U) with increments of 0.5 to 1 U, 8 mm and 30 G calibre needles. 

0.5 ml (50 U) with increments of 1 U, 8 mm to 12.7 mm length and 29 to 30 G calibre 

needles 

1 ml (100 U) with increments of 2 U, 8 mm to 12.7mm and 29 to 30 G calibre 

needles 

Tools 

U100 insulin pens (prefilled or reusable pens): 

with 3 ml cartridges 

with 4 mm, 5 mm, 6 mm, 8mm, 12.7 mm length neelds, and 28 to 33 G calibre 

needles 

with increments of 0.5, 1, and 2 U. 

38 ) 

Drawing insulin with a syringe 

Firstly, disinfect the vial cap. 

Draw the desired units of air (corresponding to the amount of insulin to be injected) 

into the syringe. 

Inject the units of air into the insulin vial. 

Without withdrawing the needle, invert the bottle and draw the units of insulin you 

need. At this stage it is important that there are no air bubbles in the syringe to 

avoid injecting air and therefore fewer units. The bubbles can be eliminated repeating 

the procedure or by ‘tapping’ the syringe with your finger and eliminating air 

by injecting out of the syringe. 

Cover the needle with the specific cap, being careful not to touch it with your fingers 

because it is sterile. 

Mixing two types of insulin in the syringe 

It is sometimes necessary to mix rapid acting with intermediate acting insulin. 

Firstly, sanitize the caps of both bottles. 

Draw a number of units of air into the syringe equal to the units of required delayed 

insulin.


Inject the unit of air into the delayed insulin vial. 

Pull the needle out and draw a number of units of air into the syringe equal to units 

of regular insulin requirements. 

Inject the unit of air into the rapid-acting insulin vial. 

With the needle still in the vial, turn the rapid-acting insulin vial upside down and 

draw the amount required, ensuring you eliminate any air bubbles in the syringe. 

Insert the needle into the vial of delayed insulin and draw the required units, being 

careful to not inject insulin back into the vial. 

If an excessive amount of intermediate acting insulin is drawn, the syringe must be 

thrown away and the procedure must be repeated with a new syringe. 

Cover the needle with the specific cap. 

If you draw the insulin from a pen cartridge (penfill) it is not necessary to inject air. 

The sequence described above is the correct one; the procedure must be performed 

without reversing the order in which you draw different types of insulin: first 

draw rapid-acting insulin, then intermediate-acting insulin. 

If the intermediate acting insulin is drawn first, and a small amount should be 

injected into the rapid-acting insulin vial, the latter would be altered and must therefore 

be disposed of. 

Injecting technique with a syringe 

derma 

subcutaneous fat 

( 39 

muscle 

Disinfect the area of the body you will be injecting. 

Remove the syringe’s cap. 

Softly pinch and lift the skin and subcutaneous tissue with your thumb and index. 

Hold the syringe like a pencil and firmly insert the needle into the skin at an angle 

of between 45° and 90°: 

injecting at 45° is recommended where there is a normal or low amount of subcutaneous 

tissue;


injecting at 90° is recommended where there is an abundant amount of subcutaneous 

tissue. 

Release the skin fold and draw slightly before injecting the insulin. This prevents you 

from accidentally administering insulin into a blood vessel. If blood should enter the 

syringe during aspiration, the syringe should be discarded and a new insulin syringe 

and administration area should be prepared 

Wait a few seconds after injecting insulin, then remove the needle and gently dab 

the place where the needle was inserted with a cotton swab. Do not be alarmed if 

a small amount of blood should appear after the needle is removed: the rupture of 

capillaries during needles insertion is quite common. A small bruise may also appear 

and is due to the presence of capillary blood in the subcutaneous tissue. 

40 ) 

Injection technique with a pen 

Insulin pens are easy to use. They have a pen-like shape, a needle-mount, a n insulin 

reservoir, and a dose selector which can dial a dose with 0.5-1 Unit increments. Once 

the dose is selected and the injection is performed, insulin is administerd by pressing 

the plunger. 

Injection procedure with a pen is similar to that of syringes. However, there are 

certain things to keep in mind: 

ensure there is enough insulin in the cartridge; 

when the cartridge (or pen) is replaced, prime the needle with a couple units (repeat 

until insulin exits the needle); 

if you are using an intermediate-acting insulin pen, turn the pen upside down 4-5 

times before using it (remember it is an insulin suspension); 

after pressing the plunger, wait 10 seconds before withdrawing the needle; 

always change the needle after each injection; 

always inject at an angle of 90° when using a short 4-6 mm needle. 

All types of insulin are available in formats for use in pen (pen cartridges or disposable 

pens). Therefore, in the case of co-administration of rapid- and intermediate- 

acting insulin you should have either two separate pens or, if the doses are adequate, 

a pre-mixed pen.



The subcutaneous tissue is placed between the skin and muscle and has the most appropriate 

characteristics than any other superficial tissue for the regular and consistent 

absorption of insulin. It also allows the administration of insulin in an almost 

painless procedure. 

Insulin can be injected in almost all areas where there is a sufficient layer of 

subcutaneous tissue. The following areas are particularly recommended: 

the abdomen, excluding the circular area (2 cm radius) around the navel; 

the supero-lateral quadrant of the buttocks; 

the anterolateral surface of the thighs; 

the anterolateral surface of the arms. 

Nel ragazzo con diabete 

i valori di riferimento sono i seguen 

tra 80 e 120 mg/dL a digiuno 

tra 100 e 160 mg/dL dopo i pas 

tra 90 e 150 mg/dL prima di corica 

The absorption of insulin varies from area to area (it is fastest in the abdomen 

and slower in the limbs and buttocks). It is therefore appropriate to use one area for 

a specific tiem of the day to reduce variability. 

The injection area should be rotated on a daily basis. This is necessary to 

avoid the formation of lipodystrophies, an alteration of the subcutaneous tissue induced 

by the repeated injection of insulin in the same area which may cause a local 

thickening (hypertrophy) or depressions (atrophy) of the involved subcutis. In addition 

to being aesthetically unpleasant, lipodystrophies cause an inadequate and irregular 

insulin absorption. The suspension of insulin delivery in these areas usually deteremines 

a full recovery of the affected area, although it might take more or less time 

(usually months) according to the entity of the subcutaneous alteration. 

Lipohypotrophies, which are essentially the loss of adipose tissue, are usually less 

common then hypertrophies. Lipohpotrophies are believed to be due to an immune 

reaction to the specific type of insulin used. Therefore, switching to another insulin 

analog nay be useful to prevent the formation of new lesions. 

( 41

Nutrition

Nutrition 

Nutrients 

The word ‘diet’ may commonly be associated to the concept sof “deprivation”, “restriction” 

and “sacrifice”. However, in the case of type 1 diabetes, it often simply refers 

to the normalization of a diet that is often unbalanced. A dietary consult with a registered 

dietitian may provide the necessary information to set up a balanced diet, which 

is essential for obtaining and maintaining the psychological and physical well-being of 

any individual (not only people with diabetes). A regular diet should not be mistaken 

as a means of setting rigid rules may be hard to comply with. A regular diet must therefore 

be customized according to certain individual characteristics 

(age, weight, height, sex), work habits, physical 

activity and food preferences, in order to make it adequate 

and to satisfy individual needs. These characteristics allow 

you to precisely determine the energy expenditure and thus 

your individual caloric needs. 

A calorie is a unit of heat used to indicate the amount 

of energy that foods will produce in the human body. The 

amount of calories produced from food varies according 

to their nutrient composition. A healthy diet involves the 

carbohydrates 55% 

consumptions of adequate proportions of all nutrients. Nutrients 

are classified as follows: 

lipids 25% 

proteins 20% 

Organic substances: proteins, lipids, carbohydrates and vitamins 

Inorganic substances: minerals and water 

Proteins 

Proteins are used by the body for tissue repair and body mass growth. They are mainly 

found in foods of animal origin such as meat, fish, eggs, cheese and some vegetables 

such as legumes (peas, lentils, chick peas, broad beans and soybeans, etc). While it 

is true that these substances are essential to the body it is also true that an excessive 

consumption may be unhealthy. 

In modern day diets, in which the priority is to quickly and easily prepare a meal, there 

is an increased consumption of meats (especially cold cuts) and dairy products: this represents 

a prototype of a high-protein diet. To avoid an unbalanced diet, it is important to 

control the amount of protein-rich foods in main meals and snacks. Snacks do not only have 

the function of reducing the feeling of hunger between meals, but may also be used to 

prevent low blood glucose values. In this case they must provide energy that can be readily 

available: these include foods that are rich in carbohydrates such as fruit, bread sticks, 

crackers and biscuits. Foods containing high amounts of protein and fat (for example sandwiches 

made with cold-cut meat and cheese) require very long digestion times and therefore 

are not adequate in treating or preventing low blood glucose levels during the day. 

( 43

Nutrition 

Lipids 

Lipids or fats are the nutrients with the highest amount of calories: at the weight 

they provide twice as many calories as protein and carbohydrates. The dietary intake 

of fat is strongly linked to the use of fat as seasoning in cooking and food packaging 

(for example oils, butter, margarine, mayonnaise and bacon). In addition to 

these ‘visible’ fats we must consider the amount of those contained in foods, especially 

dairy products and meat. It is important to consider the percentage of saturated 

or unsaturated fatty acids contained in lipids. Food with a high content of saturated 

fatty acids are those of animal origin (butter, lard, etc.), which are difficult 

to digest and facilitate the deposit of fatty substances in the arteries. Lard, which is 

now rarely used at home, is widely used in the manufacturing of industrial products, 

and considerably increases the fat content of a diet. For this reason it is important 

to reduce the consumption of packaged products such as cakes and pizzas, replacing 

them with other similar home-prepared food with better quality ingredients. 

The fats we most recommend are those containing unsaturated fatty acids of vegetable 

origin (olive oil, seed oil). 

Carbohydrates 

Carbohydrates (or carbs) function as a supply of energy and are the most representative 

nutrient in a diets even for diabetics (about 50-60% of the total caloric intake). There 

is no need to reduce the total intake of carbohydrates in general except for one type: 

simple carbs (ex. sugar). There are in fact two types of sugar: 

Complex: mainly in pasta, rice, bread, breadsticks and biscuits 

Simple: mainly in table sugar, honey, jam, fruit, milk 

44 ) 

The first group includes carbohydrates that have a complex chemical structure 

which require longer digestion times and do not cause quick increases in blood glucose 

levels. They must be consumed daily in the prescribed quantities: starting a meal 

with a proper portion of pasta allows you to take the amount of complex carbohydrates 

required to satisfy the sense of hunger and to control it for hours afterwards. Extra 

care must be taken regarding the intake of simple types of sugar which are responsible 

for rapid changes in blood glucose levels. With the exception of milk and fruit, 

which are recommended in a daily diet, other foods that contain high amounts of simple 

sugars should be avoided and their consumption must be calculated in advance. 

The different carbohydrate-rich foods have a wide range of absorption time. An 

indicator of these characteristics is called the glycaemic index (see following table). 

It should be emphasised that this index does not provide absolute indications since 

the values may be affected by cooking methods or combination with other nutrients.

Nutrition 

FOOD glycaemic index (%) 

glycaemic 

index 

glucose 100 

Boiled potatoes, honey 80/90 

Boiled rice, potatoes 70/80 

Brown rice, beets, bananas, raisins 60/70 

Oatmeal cookies, frozen peas, french fries 50/60 

Canned beans, peas, oranges, orange juice 40/50 

Chick peas, apples, yogurt 30/40 

Beans, lentils 20/30 

Soybeans, peanuts 10/20 

Vitamins 

Vitamins are a homogeneous group of substances that have the same function in 

terms of nutrition. The amount of vitamins that must be included in a diet varies 

from a few micrograms to a few milligrams. In fact, they do not have a role in processes 

involving energy but in bio-regulation of important chemical and hormonal 

processes in the body. They are classified as follows: 

Fat-soluble vitamins A, D, E and K 

Water-soluble vitamins: C and B-complex vitamins 

The former dissolve in lipids: they are in fact contained in milk, fish, egg yolk and 

butter. Water-soluble vitamins are found in fruit and vegetables, legumes and cereals. 

Vitamins are substances that are particularly delicate and to preserve them it is necessary 

to adequately manipulate foods that contain them. They are especially denatured 

by the action of light and heat, and significant mechanical processes. For this reason 

it is usually better to avoid juicing or cutting fruit and vegetables several hours before 

consumption, or cooking them at high temperatures for a long time. 

Minerals 

Minerals, like vitamins, are substances with a bio-regulatory function. The recommended 

daily amounts ranges from 100 milligrams to 1 gram for those defined as macro 

elements (calcium, phosphorus and sodium), and a few milligrams for those defined as 

trace elements (iron, zinc and iodine). A balanced and varied diet that includes fresh 

produce ensures an adequate intake of these substances, as well as vitamins. 

( 45 

Water 

Water is an essential element for life and may be drunk essentially without limitations 

in the various formulations currently on the market: natural or carbonated.

Nutrition 

Fibre 

Fibre is not considered a nutrient because it is an indigestible substance that cannot be 

used by the body. However, it does have important functions: 

it helps reduce the calorie intake resulting in an early sense of satiety; 

it increases the volume of intestinal contents, and therefore stimulates bowel movements 

and eases the elimination of digestion residues; 

it reduces or in any case slows down the absorption of nutrients such as sugars and 

cholesterol. 

It is contained in food of plant origin such as fruit, vegetables, legumes and whole 

grains. Its mechanical action is greatly reduced if the food in which it is contained 

is liquidized. Therefore, it is advisable to consume vegetables and include wholegrain 

products in the diet. 

Classification of foods 

In relation to the content of nutrients, foods are classified into six basic groups 

with specific functions. Food substitution is necessary in relation to food belonging to 

the same group or food belonging to groups with similar characteristics. The six food 

groups are: 

46 ) 

Foods 

dressing fats: they provide lipids 

meat, fish and eggs: they provide protein and vitamin B 

milk and dairy products: they provide protein, calcium and vitamin B 

cereals: they provide carbohydrates and B vitamins 

legumes: they provide protein, iron and vitamins 

vegetables and fruit: they provide sugar and pro-vitamin A, vitamin C, minerals 

and fibre 

Meat and fish 

Meat may be eaten daily. The so-called white meats (chicken, rabbit, turkey) have a lower 

fat content. Twice a week they can be replaced with beef or horse meat. Cold-cut 

meats should only be eaten twice a week, from among the following: cooked ham, 

parma ham, speck (bacon), dried beef, trimmed of visible fat. 

Eating fish gives the advantage of providing high-quality protein and less fat and 

calories than meat. The following should be avoided: salmon, eel, sardines and mackerel, 

since they contain more fat.

Nutrition 

Eggs 

Eggs are rich in protein and are a good substitute for meat or fish, despite having a high 

cholesterol content. They can be eaten twice a week. 

Milk and dairy products 

In addition to providing protein and vitamins, they are essential for calcium intake. 

Milk may be consumed daily, remembering that it is a food, not a beverage. Among 

the commercially available products you should prefer semi-skimmed milk which, while 

preserving the content of calcium, is less rich in fat and calories. 

Cheese has more fat, protein and salt than milk. Therefore, it must be consumed 

in the right amounts two or three times a week. 

It is often regarded as light food to be consumed at the end of a meal but in 

reality its nutrient intake is high and it should be considered a real main course food. 

The types of cheese we most recommend are fresh and semi-fat cheeses such as: crescenza, 

mozzarella, quartirolo, certosina, cottage cheese, low-fat cottage cheese and 

smoked cheese. The ones to be avoided are those that are particularly fat or fermented 

such as gorgonzola, mascarpone, fontina, parmesan, Swiss cheese, taleggio, etc. 

FOOD PROTEIN (g) Lipids (g) Calories (kcal) 

Mozzarella light 20 10 172 

Crescenza light 

cheese 

19,4 10,3 176 

Mozzarella 19,9 16,1 224 

Caciotta 19,3 27,2 322 

Parmesan 27,5 28,1 363 

Emmenthal 29 30 386 

Cereals 

Cereals are particularly rich in complex sugars, and have a slow absorption. In particular, 

pasta helps blood glucose control and refrains hunger in the hours following a meal. 

In addition to pasta dishes, this group includes bakery products (bread sticks, crackers, 

biscuits, etc.), which are especially good for snacks. 

( 47 

Legumes 

Although legumes are plant-derived foods, they contain high-quality protein. This 

group includes beans, lentils, peas, chickpeas, broad beans and soybeans. They can be 

eaten twice a week replacing fish, meat, eggs, cold-cut meats or cheese. When they 

are packaged with cereals such as pasta or rice, they provide a complete meal that has 

protein with a biological value equal to that of meat. They are also important sources 

of vitamins and fibre and do not contain saturated fats or cholesterol.

Nutrition 

Dressings and cooking fats 

The fats used in the cooking of foods are made up almost entirely of lipids and are 

therefore particularly caloric. They are used to enhance the flavour of foods, but their 

uncontrolled use often causes nutritional problems that lead to overweight and alterations 

in blood lipids (triglycerides and cholesterol). They should be used sparingly according 

to the instructions provided by the diet. An easy way of dosing them is with 

common kitchen utensils: 

1 tablespoon = 10 grams of oil 

1 teaspoon = 5 grams of oil 

Plant-derived fats should be prefered such as extra virgin olive oil, for it’s optimal 

ratio of saturated and unsaturated fatty acids especially when consumed raw. In 

fact, fats subject to intense heating are altered, generating substances that are toxic 

for the body. If you wish to use seasonings during cooking, you can contain the damage 

by cooking foods at low heat for a short time, and by avoiding frying or reusing 

the same fat. 

48 ) 

Vegetables and fruit 

Fruit and vegetables belong to the same group because they both provide water, fibre 

and vitamins, but are not equivalent in terms of nutrition because of the different sugar 

content. Vegetables includes foods that are low in sugar and calories, and can be 

consumed without having to worry about precisely controlling their quantity. Fruits include 

plant-derived foods which are full of simple sugar and should be consumed at 

specific times and in the recommended quantities. In fact they are great for snacks and 

for dealing with mild hypoglycaemia. They can be consumed daily and chosen from 

among those with less sugar: pears, apples, oranges, tangerines, mango, pomegranates, 

grapefruit, strawberries, blackberries, blueberries, melons, watermelons. The following 

should be consumed with more attention: grapes, persimmons, figs, bananas, 

dry exotic fruit, syrupped fruits and fruit compote.

Nutrition 

Sweeteners 

The main and most obvious principle in the treatment of diabetes is the limitation 

of simple sugars in general and the exclusion of common sugar (sucrose), because of 

its hyperglycaemic effect. Fortunately, at present the food industry offers a wide range 

of alternatives to sugar which can satisfy the desire for sweet things without causing 

rapid changes in blood sugar levels. Being synthetic products in the majority of cases, 

they should be consumed with mdoeration despite their low caloric value. They can be 

classified into two major groups: 

High-intensity sweeteners 

Bulking agents 

The best known sweeteners belonging to the first group are aspartame and saccharin. 

Aspartame has a caloric value equal to that of sugar (about 4 calories per 

gram), but a sweetening power 200 times greater. Therefore it is used in small quantities 

that do not affect blood glucose levels. It can be used to sweeten hot or cold drinks 

as it does not leave a significant aftertaste. Being very unstable at high temperatures, 

it cannot be used in the preparation of products that require cooking. Saccharin is 

500 times sweeter than sugar. It can also be used at high temperatures without being 

altered. However, it possesses a metallic aftertaste, that may be unpleasant at times. 

Both of these products are so-called high-intensity sweeteners but lack volum/mass, 

which is especially important in the preparation of desserts, cakes and pastries. Bulking 

agents are sweetners that possess a mass effect. Fructose represents one of these bulk 

sweeteners, with a sweetening power which is twice that of sucrose. It has no particular 

counterindications, leaves no aftertaste, but its intake must be evaluated carefully 

because unlike the sweeteners described above, which have virtually no calories, it provides 

calories and affects your blood sugar level. The optimal solution is to use aspartame 

or saccharin daily to sweeten beverages and reserve the use of fructose (in controlled 

amounts) for the preparation of cooked sweets to be eaten occasionally. In this 

way it is possible to have the pleasure of enjoying a good cake without exceeding the 

relevant amount of calories and causing sudden increases in blood sugar levels. 

( 49

Nutrition 

The distribution of meals 

In addition to knowing about foods and choosing those that are most suitable, it is 

important to distribute their consumption throughout the day. A balanced diet is normally 

distributed over three main meals and two snacks consumed regularly at midmorning 

and in the afternoon. The regularity of the times at which meals are consumed 

is of particular importance in maintaining a good metabolic balance. Therefore, 

it is advisable to organize daily food consumption and avoid skipping or postponing 

one of these meals or snacks. This is the only way to optimize glucose values, control 

hunger, and avoid overeating at subsequent meals. Following these simple recommendations 

is not particularly difficult with proper nutritional education. However, these 

rules must be accompanied by a more specific diet plan studied in relationship to individualized 

needs. 

Carbohydrate counting 

Calculating carbohydrates (also called carbohydrate counting or CHO counting) is a 

technique that allows a more accurate assessment of the required insulin dose for a 

meal containing a determined quantity of carbohydrates. This allows greater freedom 

in terms of food choices while at the same time maintaining adequate post-meal glucose 

values. 

The basics of this technique are taught by the diabetes care team (especially 

by the dietician). However, a lot of “homework” is required to consolidate its practice 

in the first weeks/months. Periodical assessment is then performed confirm a correct 

CHO counting is maintained in time. 

50 ) 

The training is divided into four parts. The first and most simple part involves 

learning which foods contain carbohydrates. In reality it is not that simple: 

starchy foods and pastries are certainly among them, but so are certain legumes, 

fruits and vegetables, and some drinks. We need to know which recipes and preparations 

“hide” significant amounts of carbohydrates. 

The second part, which is perhaps the most difficult one, is to learn how to visually 

“weigh” food and beverages. It is easier for those who have some knowledge of cooking 

basics, but it is difficult for most people. At first it is necessary to use a scale to 

estimate quantities (how much does this sandwich weigh? And this portion of pasta? 

How much beer does this glass contain?). “Natural” measuring units are of great help: 

a spoon, cup, bowl, fist, and so on. Obviously you do not have to be absolutely precise: 

in most cases 64 g of pasta can be estimated as being 60 or 70, but if you have an 

error of 20g then the calculations start becoming inaccurate. 

How can they be calculated? Here is where the third part begins. You have to

Nutrition 

learn and memorize the percentage of carbohydrates contained in foods and dishes 

(carb counting booklets and mobile apps are also available), and the amount of 

carbohydrates in most common dishes that you eat. For example, uncooked spaghetti 

contains 80 g of carbohydrate per 100g of weight. Beer has 4 g of carbohydrate per 

100 g or cl. 

The fourth part consists of a simple multiplication. If a plate of spaghetti weighs 

60 g and spaghetti contains 8 g of carbohydrate per 10 g of weight, how many 

carbs are there on a plate? Six times eight ... forty-eight. And there’s the result. In 

doing so it is possible to estimate the total amount of carbohydrates in a whole meal. 

Many commercial products indicate the amount of carbohydrates per 100 g of weight 

or per portion (but be careful to read what is meant by ‘portion’). Once you know the 

amount of carbohydrates, all you need to know is the carbohydrate/insulin ratio (see 

pages 34-35) to estimate a dose with sufficient accuracy. Let us assume that in a meal 

the plate of spaghetti is the only dish containing carbohydrates. Those with an insulin 

ratio of 12 will need a dose of 4 units to “cover” the meal. 

Is it really necessary to calculate these values every time you sit down to eat 

a meal? Only at the beginning. After a while, especially if you keep a complete blood 

glucose-food diary, you will find standardized solutions thanks to previous experiences. 

The diary is a strategic aspect. You need to methodically list what you eat 

(with weights) for a few weeks, quantify carbohydrates, calculate the insulin units and 

the change in blood glucose levels before and 2 hours after a meal. If it is less than 40, 

with a maximum of 60 mg/dL, your calculations were correct. If it is greater, something 

did not work. What was it? Sometimes you find out on your own. Sometimes you find 

out with the help of a dietician or healthcare professional. 

“Successful” solutions should be memorized: in the majority of cases we eat 

more or less a limited amount of different foods. 

Your grandma’s spaghetti have need 8 units. The ice cream we all eat at a 

bar or in a piazza on summer evenings requires 6 units. The pint of beer we drink with 

friends requires 2 units. A “register of standard solutions” may be developed. However, 

it has to be updated because the portions and insulin sensitivity may change over 

time (think of the difference between the portions and units of a child and a teenager). 

( 51

Physical exercise


Regular physical activity is the third vital cornerstone of diabetes therapy. Regular 

exercise helps in to maintain cardiovascular and respiratory health, increase muscle 

strength, reduces the concentration of triglycerides and cholesterol, and ultimately 

reduces the daily insulin requirement by improving insulin sensitivity. It also helps by 

fostering socialization especially by practicing team sports. For these reasons, youth 

with Type 1 diabetes should be encouraged to practice sports – even competitive – regularly, 

and to enact measures to prevent glucose excursions during these activities. 

Obviously, only careful diabetes self-management allows the “diabetic athlete” 

to safely practice physical activities. 

When undertaking physical activity, the body generates energy by “burning” 

glucose; it is therefore essential to have an appropriate dose of insulin to allow glucose 

to enter the cells. Without insulin the glucose remains in the blood and cannot be 

used by muscles to produce energy. 

It is essential to adjust the insulin dose and sugar intake to reduce the risk of 

hypoglycaemia while exercising. 

After physical activity, the body needs to replenish its stocks of glucose, by extracting 

sugar from the blood. Therefore, the risk of hypoglycaemia increases also after 

having performed physical activities. 

Insulin sensitivity may increase after physical activity. This means that the same 

dose of insulin may have a greater effect than usual. This situation increases the risk 

of hypoglycaemia after exercising. 

A regular physical activity is strongly suggested to young 

people with diabetes. 

( 53


What to do before, during 

and after exercise 

Before starting a planned physical activity, the following things are necessary: 

1. In order to prevent hypoglycemia, decrease the insulin dose that will be 

active during the time you will perform physical activity. 

2. Fast carbohydrates for low blood glucose corrections, a glucose monitor, 

and insulin are to be kept nearby in order to verify and correct any 

glucose excursions. 

3. Check your blood glucose immediately before starting phsycial activity. 

Blood glucose between 100 and 180 mg/dL 

Take 15-20 grams of carbohydrates. Since physical most activities (especially aerobic) 

consume glucose, you need to “refuel” with sugar in order to have a sufficient 

amount of glucose available. 

Blood glucose > 250 mg/dL without ketones 

You may practice sports after an insulin dose adinistration. In this case you 

have to inject an extra dose of rapid acting insulin. High blood glucose is mainly 

due to low insulin levels. Therefore, glucose cannot enter the cells and your blood 

glucose will fail to drop despite physical activity. 

Blood glucose > 250 mg/dL with ketons 

54 ) 

You should not perform physical activity. Immediately inject a correction dose 

of rapid acting insulin because in this situation you are risking diabetic ketoacidosis. 

Wait until the injected insulin takes effect. After 90-120 minutes, check your 

blood glucose. If you blood glucose is within normal range you can carry out your 

planned activity 

Blood and urinary ketones may still be positive even with a proper blood sugar 

level as they are eliminated from the body slowly. However, it is important to verify 

that they progressively reduce. 

Hypolycaemia 

Physical activity must absolutely be avoided. In this case correct it with 15 

g of simple carbohydrates, until the blood glucose level exceeds 100 mg/dL (see 

‘How to correct a hyperglycaemia’ on page 87).


While exercising: 

1. Take 15-30 grams of simple carbohydrates per hour of exercise performed. 

The amount of ingested carbohydrates should be adjusted according to the blood 

glucose trend, type of physical activity, duration and degree of training. 

2. Check your blood sugar every 1-2 hours of physical activity. 

By measuring blood glucose while exercising you learn how your blood glucose 

oscillates and may determine whether the dose of carbohydrate and/or insulin 

administration is adequate or not. 

3. Drink regularly. 

After physical activity: 

1. Check your blood gluocose to verify the effectiveness of the steps you 

took. 

2. To avoid hypoglycaemia after a few hours of exercise: 

decrease the dose of insulin that acts during the hours of physical activity (it’s 

more useful for untrained people); 

have a carbohydrate-rich snack or meal to “refill” the body with sugar and reduce 

the risk of hypoglycaemia after exercising. 

The risk of hypoglycaemia after exercise may persist for 24-36 hours depending 

on the degree of training. 

Caution. Counter-regulatory hormones (adrenaline, glucagon, GH, cortisol etc...) 

are released into the bloodstream during very intense and short bouts of physical 

exertion such as sprinting or jumping (anaerobic activity). These hormones are able to 

release glucose from the liver resulting in an increase in blood glucose and therefore 

hyperglycaemia. 

During competitions, you should check your body’s adaptation to training and in 

particular your blood glucose trends. You should therefore monitor your blood glucose 

frequently--continuous interstitial glucose monitoring may in these cases be very 

useful. These guidelines are only a starting point and are useful to discover the individual 

reactions to physical stress. 

( 55 

Which sports to avoid 

All sports may be practiced when an adequate self-mangement is carried out. However, 

some must be practiced with caution: martial arts, boxing, motor racing, motorcycling, 

swimming solo, scuba diving, parachuting, hang gliding, bobsledding, and 

all those sports that expose you to harsh environmental conditions and the risk of major 

trauma.

Hypoglycaemia 

and ketoacidosis

Hypoglycaemia and ketoacidosis 

Hypoglycaemia 

This is one of the most frequent problems that a person with diabetes faces. Hypoglycaemia 

means thatblood glucose is below the normal range – less than 70 mg/dL. 

To understand hypoglycaemia you need to know how the human body works 

and why it requires sugar. 

Sugar, or rather glucose, is an important source of energy for the human body, 

particularly for the central nervous system, which is completely dependent on sugar in 

order to function. Sugar is present in many foods in the form of carbohydrates. After 

being ingested, they are digested and converted into glucose, which is absorbed, thereby 

causing an increase in blood glucose. 

Tissues take the sugar they need from circulating blood glucose for energy. This 

occurs under the control of insulin that allows tissues, such as muscle and adipose tissue 

in particular, to use sugar as fuel. Insulin, however, has another important function: 

to stimulate the liver to accumulate sugar in the form of glycogen, a reserve material 

which the organism may use whenever it is needed. 

If it is not replenished for a certain period of time, the glucose circulating in blood 

is used as energy. This determines a decrease in blood glucose levels. This also generates 

a decrease in insulin levels and the production of another hormone, glucagon, 

also of pancreatic origin, that acts in the opposite manner to insulin, releasing sugar 

from the deposits in the liver in order to increase the blood sugar levels. Thus, glucagon 

and insulin are two hormones of pancreatic origin that control the concentration 

of sugar in the blood in a very intricate manner. 

Insulin 

( 57 

Glycaemia 

Glucagon 

Adrenaline


An imbalance between the amount of insulin and glucose in the blood can lead 

to blood glucose being too low (less than 50-60 mg/dL). In these cases it activates 

an “emergency system” that leads to the production of so-called counter-regulatory 

hormones: adrenaline, cortisol, growth hormone. These substances stimulate the release 

of sugar from the deposits and the construction of new sugar by the liver, channeling 

it towards the most important organs such as the brain and the heart. When 

this emergency system is activated, hypoglycaemia is physically perceived (see Symptoms 

below) and you should immediately ingest sugar. If you do not, blood glucose 

may continue to fall, causing symptoms of brain functioning impairment (e.g. seizures 

or coma). 

Mild hypoglycaemia 

Moderate hypoglycaemia 

Severe hypoglycaemia 

70 mg/dl 

60 

50 

40 

30 

20 

58 ) 

Symptoms 

The clinical characteristics of hypoglycemia depends on the duration and severity of 

the event and may vary from mild symptoms to rare cases of coma and seizures. From 

a clinical point of view, hypoglycaemic episodes might be distinguished as follows. 

Mild hypoglycaemia: this is the most common case and occurs when your blood 

glucose drops below 70 mg/dL. For glucose values the body triggers a hormonal 

response in order to increase blood glucose levels. This hormonal response is responsible 

for the initial symptoms: 

Paleness and sweating 

Trembling 

Palpitations and an accelerated heartbeat 

Tingling sensation of the skin 

Irritability, nervousness, 

anxiety


Mild hypoglycaemia is generally perceived and can be corrected by ingesting 

quickly ingesting fast carbohydrates, thereby resolving the problem. 

Moderate hypoglycaemia: when blood glucose levels continue to fall, the symptoms 

described above may be associated to others caused by a decrease in the concentration 

of glucose in the brain: 

Drowsiness, decreased concentration 

Changes in behaviour, irritability 

Decreased vision 

Confusion 

Fatigue 

Hunger 

Headache 

It is often family members or friends who notice a change in character and/or ask 

the youth whether they are feeling well or not. However, even in these cases it is possible 

to self-correct correct hypoglycaemia with consumption of fast carbohydrates. 

Recovery usually takes about 10-15 minutes. 

Severe hypoglycaemia: this is a hypoglycaemic episode in which the intervention 

of another individual is necessary because the person involved is physically 

unable to provide for him/herself. In these cases, the blood sugar level 

is usually less than 30 mg/dL and the patient may present the following symptoms: 

Slumber 

Inability to appropriately reply to questions 

If nothing is done soon, the situation may worsen leading to: 

Loss of consciousness 

Seizures 

Coma 

( 59 

During severe hypoglycemia, the intramuscular injection of glucagon (see below) 

eventually followed by the intravenous infusion of a dextrose containing solution may 

resolve the situation within a few minutes. However, cases of residual neurological disorders 

have been described – such as difficulty in articulating words or a mild hemiparesis 

– which usually disappear spontaneously after a few hours. 

Every individual perceives hypoglycaemia in a different way. Do not worry if different 

symptoms appear at different times. Everyone learns to recognize his/her personal 

symptoms and to act accordingly. However, it is important that friends, as well as 

family members, are informed of this situation and know how to recognize the symptoms 

of hypoglycaemia in order help when needed.


Asymptomatic hypoglycaemia: some people do not perceive the presence of 

low blood glucose (40-50 mg/dL). Without warning symptoms, the correction of 

low blood glucose is delayed thereby increasing the risk of severe hypoglycemia. 

This situation may arise in two cases: 

people with a long history of diabetes whose counter-regulatory hormones are not 

triggered correctly; 

people who are frequently subject to hypoglycaemia. This situation leads to a reduction 

in the “symptoms threshold”, which means that the body gets used to a lower 

blood glucose level and therefore does not trigger the alarm system except for extremely 

low blood glucose levels. 

This phenomenon is perfectly reversible: with careful and prompt treatment of any 

hypoglycaemic episode the hypoglycaemic threshold may be brought back to normal, 

even though it may result in an increase in glycosylated haemoglobin. 

Nocturnal hypoglycaemia: hypoglycaemia may occur frequently at night and 

be unnoticed. Sometimes you may wake up at night with nightmares or sweating, or 

the following morning you may feel tired, have a headache, or find it difficult to concentrate. 

This type of situation may be very common and therefore should be actively 

pursued. This means that you must carefully monitor your blood glucose at night and 

perform a blood glucose test around 2-3 a.m., the time when 75% of hypoglycaemic 

episodes occur. 

Causes of hypoglycaemia 

Hypoglycaemia is always caused by excessive insulin administration. Hypoglycaemia is 

a common occurrence and the causes can often be identified: 

60 )


Causes 

Hypoglycae 

Skipping a meal or a snack, eating less than usual 

Incorrect use of insulin 

> Insulin overdose 

> Administration of the wrong type of insulin (rapid-acting rather than slow) 

> Injection in sites of lipodystrophy 

Unplanned intense exercise 

Needle inserted too deep, into the muscle 

Injection in a blood vessel 

Increased blood flow at the injection site due to overheating 

> Shower or hot bath after an injection 

> Excessive rubbing before or after the injection 

Injection practiced in an area subject to muscular effort 

Consumption of alcoholic beverages 

Frequency of hypoglycaemia 

Hypoglycaemia is common in the daily life of a child and a teenager with diabetes. Experience 

with continuous glucose sensors shows that the frequency is much greater 

than is expected. The DCCT study shows that greater metabolic control intensity inevitably 

results in an increase of hypoglycaemic episodes. In fact, the DCCT group of 

teenagers had a higher frequency of hypoglycaemia (64 episodes/100 patients/year). 

The development of new diabetes management tools, such as rapid- and long-acting 

insulin analogs, insulin pumps, and continuous glucose monitors, have made it possible 

to achieve a better glycosylated haemoglobin with a lower frequency of hypoglycaemia 

(less than 10 episodes/100 patients/year). 

Blood glucose tests (2-3am) are twice as important because it reduces the duration 

of a possible hypoglycaemic episode. This is essential as the severe consequences, 

such as seizures and/or death are directly proportional to the duration of hypoglycaemia. 

How to treat hypoglycaemia 

If hypoglycaemic symptoms are perceived: 

1. First, stop any activity you are involved in, especially if you are practicing 

a sport, working or driving. 

2. The most important thing is to always check your blood glucose: never 

trust your symptoms alone! 

3. If the value is less than 70 mg/dL, you are having low blood glucose. 

4. To quickly bring blood glucose levels back to normal, take 15 g of fast 

carbohydrate (ex. sugar). For young children or toddlers, 15 g may be too 

much. The amount must be calculated by multiplying the child’s weight in kg 

by 0.3 to obtain the number of grams. 

5. Check your blood glucose after 15 minutes: 

( 61


if your blood glucos is below 100 mg/dL, take an additional 15 g dose of sugars; 

if your blood glucose is above 100 mg/dL, hypoglycaemia has been properly 

corrected. 

15 g of ordinary sugar is contained in: 

½ can of sugared drink 

½ fruit juice 

1 fruit juice with no added sugar 

3 candies 

2-3 sachets of sugar 

1 apple 

15 g of sugar should increase blood glucose by about 45 mg/dL (1 g of sugar increases 

the blood sugar level by approximately 3 mg/dL). 

If hypoglycaemia occurs at night or long before the next meal, it is better to also 

consume complex carbohydrates (bread sticks, biscuits, etc.). 

If you have low blood blucose before a meal, you may also reduce the insulin doses 

for that meal according to the correction factor. 

EXAMPLE: before meals, the blood glucose reference value is between 80 

and 120 mg/dL. If your blood glucose is 75 mg/dL and your correction factor 

is 40 mg/dL, you can reduce your meal bolus by 1 unit to decrease your 

blood glucose drop after a meal by 40 mg/dL. 

62 ) 

Never eat sweets to correct hypoglycaemia (snacks, chocolate, cake, etc), 

because they take a longer time to increase blood glucose (therefore increasing low 

blood glucose exposure) may then raise your blood glucose excessively. If a sachet of 

sugar corrects hypoglycaemia in 15 minutes, a chocolate bar takes 60 minutes (fats 

also reduce glucose absorption). 

If you correct your blood glucose in the wrong way, you are likely to raise it 

excessively. In time this may determine an increase in your glycosylated hemoglobin.


How to treat severe hypoglycaemia 

1. If the youth is partially conscious put some sugar in his/her mouth, preferably 

under the tongue. The sugar that is absorbed in the oral cavity will allow 

him/her to regain consciousness, and other fast carbohydrates may be given 

subsequently. 

2. If the situation does not improve and/or worsens (for example with 

slumber or seizures), glucagon must be administered (1 vial for children older 

than 6 yrs, or ½ a vial for children under 6 years of age) by injecting it into 

the muscle. This injection will be effective within 10-15 minutes and may be repeated 

after 30 minutes if the situation does not improve. 

Glucagon kits are sold in pharmacies. You must always check the expiration date. 

They can be stored in the refrigerator, but can be kept at room temperature for a 

long time (less than 20°C for 36 months, 20-30° for 3 months). Anyone with diabetes 

needs to have at least one glucagon kit at home. Glucagon can cause side effects such 

as nausea and vomiting. In this case give cold sweet drinks in small sips every 5-10 

minutes. Glucagon may have e lesser effect if the hypoglycaemia is caused by alcohol 

abuse – in this situation it is necessary to go to the nearest emergency department for 

the intravenous infusion of glucose. 

3. In any case, if you are unable to improve the situation, it is better to 

reach the nearest emergency department, where intravenous dextrose may 

be administered to resolve the event. 

N.B. Patients who are unconscious should never be given oral carbohydrates 

(fluid or solid) as there is a risk of inhaling and consequently worsening the 

situation. 

People with diabetes should always carry simple carbohydrates for a prompt 

correction of hypoglycemic events. It is also suggested to carry a medical identification 

card (pendant or bracelet) that may be useful for rescuers in case of loss of consciousness. 

( 63 

Preventing hypoglycaemia 

The day after the occurrence of an unexplained hypoglycaemic episode, make a 

10% reduction in the dose of insulin that is active in the time period in which the 

low blood glucose occurred. 

In the case of sports activities you should have a small snack or reduce the dose of 

insulin (as explained in the previous chapter).


Prefilled with dilutant 

Inject dilutant 

in glucagon vial 

Keeping the syringe 

in place, shake 

slightly to allow 

for full dilution. 

Draw to take 

diluted 

mix back into 

syringe. 

Inject mix, in thigh 

or gluteal muscles 

preferably, or 

alternative muscle 

spots should 

the former be 

unavailable. 

64 ) 

In the presence of intermittent illness during which a child or adolescent is lacking 

appetite, administer ultrafast insulin after the child has consumed the meal (to be 

sure of how much they are eating and to prevent an excess of insulin administration) 

and/or reduce the dose. 

If you plan to drink alcoholic beverages, first of all do not abuse it (excessive alcohol 

consumption increases the risk of hypoglycemia and may prevent blood glucose 

from rising). Remember to monitor your blood glucose regularly and consume carbohydrates 

(simple or complex) when needed. 

Continuous glucose monitors (CGMs) are new tools for the prevention of glucose 

excursions (low and high blood glucose). They possess alarms for thresholds (e.g. 

70 mg/dL for lows and 200 mg/dL for highs) as well as for trends, and hypo-/hyperglycaemia 

predictors. The alarms are represented by acoustic and vibration alerts. However, 

recent studies show that patients do not perceive 75% of alarms. 

In addition, newer insulin pumps may also integrate the information supplied by 

CGMs and may automatically suspend insulin delivery in case of a CGMs hypo alerts. 

These instruments have may determine a significant reduction in hypoglycaemia 

and improve metabolic control.


Ketoacidosis 

This term defines a condition characterised by increased blood acidity caused by the 

accumulation of ketone bodies. 

This situation occurs when the cells burn fat because they are unable to use glucose 

as the main source of energy. This results in the production ketone bodies, substances 

that are toxic for the body and that may accumulate in the blood (ketonemia) causing 

an increase in acidity. This waste product is eliminated from the blood in the urine 

(acetonuria) and in exhaled air, giving breath an acetone odour. 

Causes 

Lack of insulin: this situation occurs at the onset of diabetes before insulin therapy 

is undertaken. 

Insufficient insulin administration: this happens to people who do not properly manage 

diabetes (for example skipping insulin doses) or specific situations such as intermittent 

illnesses (in which insulin doses must be adjusted). 

Signs and symptoms 

Hyperglycaemia 

Glycosuria: due to the inability of cells to use blood glucose, the latter accumulates 

in the blood, exceeding the renal threshold 

Acetonuria: excess waste is eliminated in the urine 

Signs 

Symptoms 

Acetone breath odour: the excess waste is eliminated in exhaled air 

Dehydration: due to excessive fluid loss (osmotic diuresis) with frequent urination 

Weight loss: due to the consumption of fat tissue 

Vomiting 

Increased depth and rate of respiration 

Unconsciousness 

The presence of acetone in the urine or blood in association with frequent 

hyperglycaemia is a warning: you must not delay in taking remedial action. Diabetics 

should never have acetone in the urine or acetonemia with a value greater than 

0.6 mmol/L. Using the specific strips to detect the presence of ketones is important to 

prevent the onset of ketoacidosis and for monitoring the situation over time, in particular 

in risk situations such as in intermittent infections. 

If you are experiencing the onset of hyperglycaemia and acetonuria or acetonemia, 

action should be taken immediately by the administration of additional doses 

of short-acting insulin (bolus equal to 10% of the daily dose) and consult a Doctor 

as soon as possible. Ketoacidosis is a serious situation and needs to be treated in 

hospital as soon as possible. 

( 65

Long-term 

complications

Long-term complications 

Maintaining adequate glucose control allows you to reduce the risk, delay the onset 

and/or slow the progression of so-called complications correlated to diabetes. People 

with diabetes are more likely to develop eye, renal and peripheral nerve damage as a 

result of poorly controlled diabetes. 

Fifty percent of patients with type 1 diabetes do not develop complications, 

even after over 20 years of disease, thanks to well-managed treatment. The complications 

are not related to diabetes per se but are directly proportional to the exposure 

to hyperglycaemia. 

Optimal glucose control significantly reduces the risk of complications in the 

short and long term: in fact, poor metabolic control determines a four-fold increase 

in the risk of complications. 

If detected early, complications can be treated effectively. Currently, therapeutic 

novelties provide us with new opportunities and the ability to achieve near-normal 

glucose control. These tools theoretically allow us to achieve a complete prevention 

of complications (which do not develop with glycosylated haemoglobin < 6.5%). This 

is why the goal of insulin therapy is to expose diabetics to high glucose levels (>180 

mg/dL) as little as possible. 

It is in your interest to read and learn about all the problems that may be correlated 

to diabetes. The content of this handbook will help find the right reasons to convince 

you to avoid the risk of complications. 

( 67


Microvascular complications 

Microvascular complications are caused by an alteration of the small blood vessels 

(microangiopathy) secondary to elevated exposure to high blood glucose levels. 

Microvascular complications: eyes (retinopathy), kidneys (nephropathy) and nerves 

(neuropathy). 

Retinopathy 

The eyes of a person with diabetes may suffer damage to the retina, a tissue located 

in the back of the eye that has the function of receiving the images and transmitting 

them to the brain via the optic nerve. The retina is nourished by capillaries nutrients 

and oxygen which are necessary for its function. Retinopathy occurs when these capillaries 

are damaged due to unstable or continuously high blood glucose levels. 

The process that leads to the deterioration of the retina has three phases: 

the walls of small blood vessels dilate and become more fragile, forming microaneurysms 

they subsequently become permeable and first let liquids cross the capillary wall, 

causing the formation of edema, and then red blood cells, causing small hemorrhages. 

These two processes slows circulation and promotes the development of blood clots 

that block capillary blood flow 

therefore, the retina stimulates the formation of new capillaries which are more fragile 

and more easily damaged, causing further bleeding 

Main visual consequences of retinopathy are: 

Image distortion 

black or red spots or cobwebs 

decreased vision 

retinal detachment 

68 ) 

Retinopathy 

If the onset of visual impairment is not followed by a period of improved metabolic 

control and an eye examination, retinopathy may progress leading to blindness. 

By performing a fundus oculi examination and fluorescein angiography, ophthalmologists 

may now even detect small and early capillary alterations. Even drug therapies 

have also recently emerged. 

The early changes of diabetic retinopathy are reversible by beginning an adequate 

diabetes management. However, when this is not possible or is not enough, laser 

treatment may be performed on damaged capillaries and reduce visual impairment. 

The only way to detect early retinal changes (when symptoms of impaired sight have 

not yet emerged) is to perform annual fundus examinations.


A careful fundus examination once a year may prevent very 

serious problems. 

Nephropathy 

In the past this was the most frequent complication (30-35%) among people with 

long-lasting diabetes. It is caused by damage to the small blood vessels that supply 

blood to the kidneys as a result of persistently elevated blood glucose levels. 

The kidneys have the function of filtering out toxic or excess substances from the 

blood and reabsorbing substances that are instead useful for the bod. Therefore, each 

kidney has a membrane with many holes which acts as a filter. A small protein called 

albumin passes through this membrane. 

In the presence of initial capillary and kidney damage, the holes widen, allowing a 

greater amount of albumin to pass: this is called microalbuminuria. This situation 

can be reversed, by reestablishing adequate glucose control and in some cases with 

the use of specific anti-hypertensive drugs (nephropathy is often associated with a 

rise in blood pressure). 

If this situation is not properly treated or investigated, the membrane allows the passage 

of larger proteins, leading to persistent proteinuria. 

If this damage continues, the kidney filtering capacity of reduces and may progress 

to kidney failure. 

Currently the incidence of nephropathy has decreased compared to the past, due to 

early diagnosis and annual screening for microalbuminuria, as well as the possibility to 

treat it properly. This is also in relationship to better current self-management of diabetes 

during childhood, improved doctor-patient relationships, and the availability of 

precise means for self-monitoring of blood glucose at home. It is suggested test for 

microalbuminuria at least once a year and always promptly treat any urinary tract 

infections in order to eliminate other causes of renal damage. 

As with retinopathy, a careful managemenet of blood glucose reduces the risk of 

nephropathy and, even when microalbuminuria is already present, it allows to delay 

the progression to permanent kidney damage. 

( 69 

Neuropathy 

The metabolic changes caused by poor glycaemic control are also responsible for damage 

to the peripheral and vegetative nervous system. 

Peripheral neuropathy 

Peripheral nerves, such as those in the upper and lower limbs, are those most affected 

by this type of disease.


Nerve damage evolves in two stages that can be distinguished on the basis of the 

patient’s symptoms and nerve functioning tests. 

1 st stage: functional tests are positive but there are no symptoms 

2 nd stage: functional tests are positive and there are symptoms: 

> tingling and a painful stinging sensation 

> muscle cramps 

> reduction of thermal sensitivity, which is painful and vibratory 

Neuropathy is responsible, alongside a reduced blood blood flow (vascular complications), 

for the diabetic foot, which facilitates the onset of accidental injuries/lesions 

due to reduced sensitivity and impaired healing. Therefore it is also easier to have 

infections in the affected limb to too poor circulation. 

However, the diabetic foot only develops in people with long lasting and poorly 

controlled diabetes. It may nonetheless be prevented also by following a few precautions 

such as wearing comfortable shoes and correct pedicure. 

Autonomic neuropathy 

This term refers to the damage to the nerves that serve internal organs, such as the 

heart and gastrointestinal tract. 

This kind of complication, which occurs after many years of poorly controlled 

diabetes, may be identified by the following symptoms: 

lowering of blood pressure during changes in position 

increased heart rate and abnormal heart function 

slowed gastric and esophageal emptying 

occasional diarrhoea alternating with constipation 

incomplete emptying of the bladder 

impotence 

70 ) 

Neuropathy


Macrovascular complications 

Complications affecting the large blood vessels may determine poor blood flow to the 

heart (myocardial infarction) and brain (stroke). These circulatory deficits occur with 

greater frequency in the diabetic population with poor metabolic control. 

The main cause of deterioration is macrovascular atherosclerosis. The arteries, 

vessels that carry oxygenated blood from the heart to the rest of the body, are progressively 

occluded by the gradual thickening of the arterial walls due to high blood 

glucose and lipids. Therefore, the tissues receive an insufficient supply of oxygen and 

nutrients and undergo ischemia. The obstruction of the coronary arteries reduces the 

hearts’ blood supply causing myocardial suffering which may progress to myocardial 

infarction – the same happens in cerebral vessels, causing a stroke. 

This can happen to people of any age, but the people most at risk are smokers, 

people with a sedentary lifestyle and those who are overweight. 

Useful tips to reduce the risk of any type of complication: 

careful self-monitoring of blood glucose levels and ketonuria/ketonemia 

check-up visits on a quarterly basis as an outpatient at a diabetes 

healthcare centre 

annual inspection of the fundus 

periodically check blood pressure 

checking the value of blood lipids (cholesterol and triglycerides) 

following a proper diet plan and maintaining an adequate body mass index 

performing regular physical activity 

stop smoking: cigarette smoke increases the risk of cardiac and vascular damage, 

in addition to causing lung cancer. 

Well-controlled diabetes may reduce the risk of complications 

to the point of eliminating them. 

( 71

Insulin pumps

Insulin pumps 

What is an insulin pump? 

A insulin pump is a device that continuously delivers rapid-acting insulin analogs, 

thereby replacing multiple daily injections. The pump allows you to better mimic the 

physiological pancreatic insulin secretion. 

The pump is a programmable device for administration of a continuous flow of 

basal insulin. The amount of basal insulin is initially established with the aid of a diabetes 

healthcare team and is tailored to the person’s daily needs. The basal rate of insulin 

can be programmed with different hourly rates depending the insulin requirements 

at different times of the day. 

A dose of insulin is manually administered through the pump before each meal 

or snack as one would do with inejctions. The pump is equipped with an insulin cartridge/reservoir. 

Insulin is pumped from the reservoir through the infusion set, consisting 

of a thin tube with a small flexible cannula on the end. The latter is inserted into 

the subcutaneous tissue of the abdomen by means of a needle, which is then removed, 

and fastened with a plaster. 

This small device can be clipped onto your belt or kept in a pocket; there are a 

number of cases, even waterproof ones. 

The operation of the pump is controlled by a display that shows each type of 

programmed function. The pump has acoustic alarms and error reporting functions. It 

may also be turned on and off or removed at any time of the day. 

Pump use does not determine any kind of limitation in daily activities. It provides 

more flexibility during the day as it eliminates the need for multiple injections and the 

carrying of injection material (pen, vials, needles, syringes). 

Using an insulin pump requires motivation towards a more frequent blood glucose 

monitoring and involves specific education (defined as second level education) 

prior to its use. 

( 73

Insulin pumps 

Inclusion criteria 

In our centre, the patient must be in the following condition in order to use a pump: 

be able to properly perform intensive insulin treatment, including the correct management 

of hypo and hyper glycaemia; be able to accurately count carbohydrates 

and have no psychological barriers preventing the attainment of adqequate metabolic 

control. 

If properly managed, the pump allows a reduction of mean blood glucose and 

therefore glycated hemoglobin (by an average of 0.2-0.5 %) and a better distribution 

of blood glucose levels with a lower number of blood glucose readings below 70 and 

above 180 mg/dL. Meta-analyses in literature suggest that the insulin pump allows a 

significant reduction of hypoglycaemia, particularly severe hypoglycemia. 

However, there are risks that are correlated to this kind of insulin administration. 

In particular, diabetic ketoacidosis may have a rapid onset due to the an interruption 

of insulin infusion (ie. due to needle or catheter obstruction). For this reason, the use 

of an insulin pump requires careful self-monitoring through frequent blood glucose 

and ketone tests. There are specific rules of conduct for hyper- and hypoglycaemia 

that should be followed meticulously to limit the rare but possible risks of connected 

to pump us. A continuous glucose monitoring device may help in the establishment 

of a more precise insulin pump. 

How it works 

74 ) 

The insulin pump is a device that allows you to receive subcutaneous insulin 24 hours 

a day. The pump has certain basic components: 

a small computer with software and memory 

a display 

an electric motor 

an insulin reservoir. 

The pump is connected to the subcutaneous tissue through a small tube (catheter) 

and a subcutaneous cannula. Insulin is infused under the skin: in other words in 

the same area in which insulin is administered by injection. The pump administers insulin 

subcutaneously in small doses (micro-doses) continuously for 24 hours a day. 

The device remains continuously connected to the subcutaneous tissue, with the 

exception of periods of disconnection, which can last up to 2 hours (see ‘Temporary 

Disconnection’ on page 79).

Insulin pumps 


People who use the pump must check their blood sugar levels frequently (at least 

6 times a day), because the insulin pump only administers rapid-acting insulin analogs, 

and in case of malfunctioning the body remains without insulin withn a few 

hours from the interruption of insulin infusion. The only way to be promptly aware of 

any kind of malfunction is by measuring your blood glucose at regular time intervals. 

In order to verify the actions and decisions you take, the data should be recorded 

in a ‘blood glucose diary’ that must include the following: 

daily blood glucose levels trend 

insulin boluses for meals and correction 

amount of carbohydrate consumed 

sports practiced 

possible presence of ketonemia 

possible change of infusion set 

any additional useful notes. 

The insulin pump diary therefore allows you to have quick summary of decisions 

and activities that have been carried out during the day. All this information (which 

translates to experience) is helpful to improve blood glucose in the future. 

The infusion set 

The infusion set is a set of components that connects the insulin reservoir of the pump 

to the subcutaneous tissue. 

The insulin reservoir 

The insulin reservoir is a special fillable cartridge that fits into an insulin pump. By means 

of a piston drived by the pump’s motor, insulin is “pumped” through the infusion 

set to the subcutaneous tissue. Obviously, the reservoir must be filled immediately before 

you use the pump and everytime an infusion set change is required. This procedure 

involves the following: 

firstly, you must take particular care with hygiene during all procedures to avoid 

contaminating the insulin that will be administered by the pump. 

you must avoid creating air bubbles when filling the reservoir; it is useful to remove 

the vial of insulin from the refrigerator a few minutes before filling the reservoir. 

check that the plunger of the reservoir is moving properly without abnormal resistance 

if air bubbles are formed in the reservoir, the pump will administer air instead of insulin, 

with the result of obtaining high blood glucose levels. Therefore, you need to 

( 75

Insulin pumps 

check that there are no air bubbles in the reservoir and, if present, you have to eliminate 

them. Air bubbles are not dangerous in themselves because they end up in 

the subcutaneous tissue and not in the bloodstream. They can be avoided of by turning 

the pump with the catheter pointing downwards (“upside down”) any air bubbles 

will settle on the plunger and will not be infused un less the pump is turned 

back around. 

the infusion set (including the reservoir) should be replaced every 2-3 days, even if 

the reservoir is not empty. The pump is able to activate an alarm when the reservoir 

contains just a few units of insulin. 

Do not stay “in reserve” 

If the insulin reservoir is empty, the pump cannot infuse insulin subcutaneously. To 

avoid being left with an empty insulin reservoir you must: 

always check there is a sufficient amount of insulin remaining in the reservoir before 

you leave home 

replace the insulin reservoir as soon as the empty reservoir alarm sets off 

Set the alarm parameters in the reservoir to a level which allows a sufficient dose of 

insulin (e.g. 20U). 

The reservoir is connected to the catheter by means of an adapter, which must 

be securely screwed on to prevent insulin from leaking. 

76 ) 

The catheter 

The catheter connects the reservoir of insulin to the subcutaneous cannula. The insulin 

catheter has two tubes inserted into one another: the outer one is round but the 

insulin flows through the inner catheter which, to be more resistant, has is star-shapeed. 

This makes the catheter resistant to compression, stretching and knots. Since 

the catheter is transparent, you can see whether an air bubble has formed in the inner 

tube. 

Air bubbles are a problem because air may be infused instead of insulin. A 2.5 cm 

long air bubble covers the space reserved for 0.5 units of insulin. With a 2.5 cm long 

air bubble, those who take insulin at a rate of 0.2 units per hour will remain without 

insulin for two and a half hours. 

Insulin and the catheter material are not completely compatible, which may result 

in the formation of insulin precipitates which block or significantly reduce the 

flow of insulin. For this reason it is necessary to change the catheter every 2-3 days, 

even if it works regularly, or whenever there is any doubt as to whether it is working 

properly. 

There are catheters of different lengths, and you can choose the length you find 

most suitable. The catheter is connected mechanically to the cannula under the skin. 

You can remove the catheter from the cannula whenever you wish to.

Insulin pumps 

The cannula 

The subcutaneous cannula allows the passage of insulin to the subcutaneous tissue. 

From this tissue, insulin is then absorbed in the bloodstream and is distributed throughout 

the body. The insertion areas for cannulas under the skin are the abdomen (preferred 

area) and buttocks. 

Insertion of the cannula 

The cannula is inserted subcutaneously using a needle that acts as a guide. This can 

be done manually or by using appropriate insertion devices. 

Once positioned, the needle is removed and the cannula remains in position in 

the subcutaneous tissue. The cannula is then attached to the skin by means of a plaster 

that prevents it coming loose. The cannula is made of flexible material and does 

not cause pain. There are vertical and oblique cannulas. There are tubes of varying 

lengths, so you can choose the one you find most suitable. 

To prevent skin infections, be careful to disinfect the chosen insertion area before 

placing the cannula. 

If you see or feel signs or symptoms of infection or inflammation (redness, swelling, 

pus, itching, etc.) in the insertion side, you must immediately: 

remove the cannula 

clean the area where it is inserted 

apply an antibiotic and local anti-inflammatory ointment. 

The risk of infection is higher if you keep the cannula in the same place for more 

than three days. This is another reason why it is necessary to change the insertion 

area at least every three days. 

The cannula insertion determines a micro trauma in the skin and for this reason 

micro-scars may remain visible. If this happens, it is important to change the cannula 

every 2-3 days and check the insertion procedure. 

Other technical information 

The pump is powered by batteries. Ensure they are charged and replace them over time. 

The pump is waterproof (different pumps have different degrees of waterproofness). 

If the pump is in perfect condition, water droplets or temporary immersions 

are not a problem. Since you can temporarily disconnect the pump, it is preferable to 

avoid dipping it into water to avoid potential damage or malfunctions. 

The pump has a “key lock” function that avoids the risk of accidentally activating 

certain functions. 

( 77

Insulin pumps 

Basal insulinization 

The pump administers insulin subcutaneously in two ways: basal and bolus. Basal 

insulin consists of insulin microboluses administered continuously. For example, 0.5 

units/hour (U/h) is equivalent to the administration within one hour of 0.5 units of insulin, 

‘broken down’ into micro-boluses administered every few minutes. The amount 

of basal insulin corresponds to the need for insulin during fasting and in resting conditions. 

The term used is ‘basal rate’, because the pump is a machine that pushes insulin 

in a certain amount of time: like a car traveling at 50 or 100 km/h, a pump pushes 

insulin at a rate of 0.4 U/h or 0.8 U/h. 

The pump allows you to change the rate of administration of basal insulin during 

the daily 24 hours, covering different insulin needs during fasting and resting periods. 

Using the pump, you can program different daily regimens of basal infusion called 

to meet different needs. For example, you can use a standard basal rate during 

certain days and another in the days when you practice sports, or one specially planned 

for the weekend. 

When the term ‘basal insulin’ is used you must keep in mind that this is not a particular 

type of insulin, but the way the pump is admistering it. 

78 ) 

How and when to change the basal insulin rate 

If the blood sugar level increases during a period of fasting or resting, you have to increase 

the amount of basal insulin, and thus increase the basal rate to make sure that 

blood glucose levels remain stable. If your blood glucose decreases during a period of 

fasting or resting, you should administer less insulin, to make sure that blood glucose 

remain stable. 

It is important to remember that when you change the basal insulin rate, the insulin 

concentration in the blood will slowly change. This is why it is necessary to increase 

or reduce the rate of basal insulin 1-2 hours before the previously identified rise 

or decrease in blood glucose. 

If blood glucose is not in the target range after a meal (up to 4 hours after a 

meal), you must change the meal bolus insulin. 

If blood glusoe is not stable during fasting and in the absence of physical activity, 

you have to change the basal insulin rate. 

To check whether the fasting and resting blood glucose level is stable, you must: 

check blood glucose at least twice 

compare the values and see if your blood glucose has risen, decreased or remained 

stable. 

It is not sufficient to evaluate only one glucose value alone. You must instead 

consider the comparison between two subsequent blood glucose tests. Blood glucose 

is considered stable if the variation in the blood glucose is less than ±30-40 mg/dL.

Insulin pumps 

Blood glucose level Basal rate Glucose trend 

12 a.m. 2 a.m. 

Example 1) 210 230 STABLE OK 

Example 2) 210 290 UNSTABLE too little 

Example 3) 210 120 UNSTABLE too much 

5 p.m. 7 p.m. 

Example 4) 130 121 STABLE OK 

Example 5) 130 193 UNSTABLE too little 

Example 6) 130 85 UNSTABLE too much 

In example No. 1, there is a blood glucose of 210 mg/dl at 12 a.m. and 230 mg/ 

dL at 2 a.m. (increased by 20 mg/dL): the glucose trend is stable and therefore the basal 

insulin in that time frame is correct. 

In example No. 2, there is a blood glucose of 210 mg/dL at 12 a.m. and 290 mg/ 

dL at 2 a.m. (increased by 80 mg/dL ): the glucose trend is unstable and therefore the 

basal insulin in that time frame is not sufficient. Therefore, the basal insulin rate must 

be increased starting from 12 a.m. . 

In example No. 6, there is a blood glucose of 130 mg/dL at 17.00 and 85 mg/ 

dL at 19.00 (reduced by 45 mg/dL): the glucose trend is unstable. Therefore, there is 

too much basal insulin in that tiem frame. You must reduce the basal insulin starting 

from 5 p.m. 

The basal rate is increased or decreased by 0.1 U/h if ongoing basal rate is greater 

than 0.5 U/I or by 0.05 U/h ongoing basal rate is less than 0.5 U/h. 

The temporary basal rate 

The pump allows you to temporarily increase or decrease the dose of basal insulin for 

a given time, without changing planned basal rate settings. This is called the temporary 

basal rate (or “temporary basal”): the rate of basal insulin infusion is increased 

or decreased according to a transitory necessity for a predetermined period of time. 

To use this function you have to decide: 

whether to increase or decrease the scheduled basal insulin rate 

by what percentage you should increase or decrease the scheduled basal insulin rate 

how long this temporary variation must last. 

( 79 

For example, if you continue to experience hypoglycaemia (for example during 

the night or during a prolonged physical activity), the planned basal rate can be reduced 

by 50% for 4 hours. With this function, you do not run the risk of changing the 

basal insulin rate for a transitory necessity, subsequently forgetting to return to the 

usual basal rate settings.

Insulin pumps 

Basal insulin suspension 

If you stop the administration of insulin at a given time, insulin will still be available 

for approximately the next 3-4 hours. Subsequently, when the subcutaneous insulin 

deposit is consumed, the body will be lacking insulin. Without insulin glucose remains 

in the blood and cannot be used by the cells to produce energy. 

The cells in your body will “burn” fat to create energy. This process will lead to 

the accumulation of ketone bodies in the blood and urine. To verify this situation, measure 

the blood glucose and ketone levels (see “ketones”). In case of prolonged lack 

of insulin, there is an increased risk of a diabetic ketoacidosis if insulin administration 

is not promptly recommenced. 

Temporary disconnection 

In some cases it is possible to disconnect the pump from the cannula. This may be necessary, 

for example if you are having a bath, shower, practicing sports with physical 

contact, changing the set or for other needs. The maximum disconnection time is 2 

hours. After this time, you should reconnect your pump or administer insulin with a 

syringe or pen, so as to prevent your body from remaining without insulin. 

80 ) 

In order to disconnect the pump for a short time (less than 1 hour), you 

must: 

check your blood glucose 

disconnect the catheter from the cannula 

protect the cannula and catheter extremities with their specific cap 

do not suspend the pump infusion to avoid insulin from precipitating and occluding 

the catheter (there is an increased risk of insulin crystals formation when the flow is 

interrupted) 

at the end of the disconnection period, connect the catheter to the cannula and 


if necessary, correct an eventual high blood glucose with a bolus of insulin, applying 

the insulin sensitivity factor (also called the correction factor, see page 35). 

EXAMPLE: Before you take a shower, measure your blood glucose level, 

disconnect the catheter from the subcutaneous cannula, protect the cannula 

with its specific cover, keep the pump in operation, and reconnect the 

catheter to the cannula when you have finished showering.

Insulin pumps 

When pump disconnection exceeds one hour (maximum 2h), you should administer 

a small insulin bolus to replace the basal insulin that should’ve have been infused 

if the pump were not disconnected. A bolus corresponding to 50% of the basal 

rate must be administered during the disconnection period. 

Do the following to determine the amount of insulin to be administered 

as a bolus in place of baseline: 

decide how long you will disconnect the pump for (max 2 hours) 

check the planned basal insulin rate during the disconnection period 

calculate a 50% basal insulin rate for the period of disconnection. 

EXAMPLE: you decide to disconnect the pump for 2 hours. The baseline 

planned in those 2 hours of disconnection is 0.6 U/h, during which the pump 

will infuse 1.2 U of insulin in 2 hours (i.e. 0.6 U in the first hour and 0.6 U in 

the second hour). You have to calculate 50% of the total of planned basal 

insulin for the 2 hours the pump is disconnected (i.e. half the baseline of 2 

hours). 

The bolus to be administered with the pump, before disconnection, is 

therefore equal to 0.6 U. 

In order to disconnect the pump for more than 1 hour (maximum 2 hours): 


administer a bolus of insulin equal to 50% of the planned quantity of basal insulin 

in the disconnection period 

disconnect the catheter from the cannula 

protect the cannula and catheter extremities with their specific cap 

keep the pump operational (do not suspend infusion) with the planned basal rate 

to avoid interrupting insulin flow (thereby reducing the risk for occlusion). 

at the end of the disconnection period, check your blood glucose and reconnect the 

catheter to the cannula 

if necessary, correct an eventual high blood glucose with a bolus of insulin, applying 

the insulin sensitivity factor (also called correction factor). 

( 81 

Caution. After a meal or correction bolus there will be a substantial amount of 

available insulin in your blood, even if you disconnect the pump. In this case, your body 

will hardly be lacking insulin for the following 3-4 hours after the bolus has been 

administered.

Insulin pumps 

Insulin boluses 

It is often said that the pump gives freedom to the person who uses it. However, this 

“gift” comes at a price. In fact, the pump allows a more precise bolus insulin administration 

(for meals and high blood glucose). It is therefore necessary to be able to properly 

assess the required insulin dose – this requires precise calculations. 

The correction bolus 

The pump makes it very easy to administer correction boluses: the amount of insulin 

needed to bring blood glucose back to target range. To calculate the amount of required 

insulin, first calculate the difference between your current high blood glucose and 

your desired target. Divide this difference by the sensitivity or correction factor. For 

example, if the factor is 20, divide the difference between the current high blood glucose 

(for ex. 240 mg/dL) and desired target glucose( 120 mg/dL) by 20 (240-120=120 

→ 120/20=6). The result – 6 – is the number of units to be administered as correction 

bolus (which may be added to a meal bolus if you plan to eat). Remember that your 

insulin sensitivity may increase during physical activity and this calculation may thus 

overestimate your correction bolus. 

82 ) 

Insulin sensitivity or correction factor 

Each person has an individual insulin sensitivity factor: to calculate it you must your 

average daily insulin requirement (the sum of basal and bolus units). Then divide the 

constant 1800 by the number of units representing your daily insulin requirement. For 

example, if your total daily insulin requirement is 90, 1800/90 is 20, which is the correction 

factor. Therefore, in case of hyperglycaemia, each unit of insulin lowers the 

blood glucose level by 20 mg/dL. 

The correction factor is also useful in cases where the blood glucose before meals 

is less than the target value: for example, 70 instead of 90 mg/dL. In this case, subtract 

from the “food” bolus as many units as needed to bring the blood glucose level 

to the target value. In this case, given that 90-70 is equal to 20 and that the correction 

factor is 20, just decrease the insulin bolus by 1 unit to reduce the risk of hypoglycemia 

after the meal. 

The ‘food bolus’ 

The insulin standard bolus administered using a pump is similar to that administered 

with an injection of rapid-acting insulin analog (e.g. Novorapid, Apidra, Humalog). 

The bolus is also referred to as a wave (standard, square or dual wave bolus), according 

to how the bolus is delivered by the pump. An insulin bolus should always be administered 

before eating. This is because ultrafast insulin takes about 15 minutes to 

start its effect.

Insulin pumps 

If you are not sure of the amount of carbohydrates that you will consume during 

a meal, you should administer a bolus before the meal anyway (calculate a bolus that 

covers the minimum amount of carbohydrates you are sure to consume). Then complete 

the meal bolus with the insulin required for the rest of the carbohydrates you have 

eaten and have not considered in the initial bolus. However. this tyope of conduct 

must be an exception, not the rule. 

How to calculate the “meal bolus” 

The amount of insulin required at meals depends on the amount of carbohydrates in 

the meal. At our Centre, all those who wish to start using a pump must follow an educational 

process that teaches them how to assess the amount of carbohydrates in a 

meal (or snack or drink) with sufficient accuracy. 

This technique, called carbohydrate counting or CHO counting, will be described 

in greater detail in another chapter, since it is not specific to insulin pump therapy. 

Once you have defined the amount of carbohydrates in a meal (in grams), in order 

to define the dose of insulin required you need to use a dividing factor known as 

the carbohydrate/insulin ratio. This ratio, initially determined by the team, is not constant: 

it may vary during the day and continues to change according to growth and 

pubertal development and must be continually verified by checking pre- and postprandial 

glucose values. 

The carbohydrate/insulin ratio is expressed as the amount of carbohydrates in 

grams that are metabolized by a single unit of rapid acting insulin. For example, a 

15/1 ratio means that 15 g of carbohydrates are metabolized by one unit of rapid acting 

insulin. 

EXAMPLE: a person with a carbohydrate/insulin ratio of 15 plans to eat 75 

grams of carbohydrates. 75 divided by 15 = 5. Therefore, the meal bolus will 

be of 5U. 

Using the pump, you can set a maximum dose of insulin to administer as a bolus. 

In this way, you may prevent from administering an excessive insulin bolus by mistake. 

( 83

Insulin pumps 

Special boluses 

Using a pump, the amount of insulin required can be infused in the form of a bolus 

with different distribution characteristics. 

Standard bolus: administers the required insulin as you would with a pen or syringe. 

Square wave bolus: distributes the amount of insulin required over the course of several 

hours, at a constant rate (you can imagine it as a very big basal rate). 

Dual wave bolus (or combined bolus): administers a portion of the bolus as a standard 

bolus and a portion like a square wave bolus. 

Dual-wave (Combined) bolus 

Use a dual wave bolus when sugars consumed during a meal are absorbed slowly. This 

may the case in meals that are rich in fiber, fat and protein (the nutrients reduce the 

absorption time of carbohydrates). Blood sugar levels are therefore likely to increase 

gradually over time, even when the standard bolus has finished its activity. For example, 

the intake of salad or spinach after a plate of pasta slows the absorption of carbohydrates. 

Pizza also determines a slower absorption of carbohydrates. 

Using a dual wave bolus, you can: 

Cope with an immediate need for insulin in order to limit an increase in blood glucose 

after meals (standard bolus) 

Distribute the insulin over following hours, in order to control the progressive increase 

of blood glucose related to the slower absorption of carbohydrates (square wave 

bolus). 

84 ) 

In order to program the dual wave bolus, the pump asks: 

The overall amount of insulin to administer 

The percentage (or units) of insulin to be administered as a standard bolus and the 

percentage (or units) of insulin to be administered as a square wave bolus 

The duration of the square wave bolus. 

EXAMPLE: you eat a pizza and drink a can of a sugared beverage: the overall 

amount of carbohydrates consumed is 150 g. If the carbohydrate/insulin 

ratio is 15, divide the total carbohydrates (150) by 15. 

Therefore, 150 divide by 15 = 10 U of insulin. You can decide to administer 

40% of the required bolus immediately in the form of a standard bolus and 

60% in the form of a square wave bolus over the course of 3-6 hours. The 

pump will administer 4 U in the form of a standard bolus and 6 U in the form 

of a square wave bolus over the following 3-6 hours, with a basal rate of 2 

U/hour.

Insulin pumps 

Square wave bolus 

A square-wave bolus is used when a meal lasts a longer than usual, such as a wedding 

reception. A square wave bolus is sort of like administering a very substantial temporary 

basal rate. Alternatively, in these situations you can administer a series of small 

boluses, based on the amount of carbohydrates consumed, although there might be 

an increased risk of overlapping boluses and therefore low blood glucose. 

In order to program the square wave bolus, the pump will ask: 

The overall amount of insulin to administer 

How long the administration of the dual wave bolus needs to last 

EXAMPLE: at a wedding reception, a person with a carbohydrate/insulin 

ratio of 12 plans to consume about 240 g of carbohydrates. 

1. The total amount of consumed carbohydrates is divided by the 

carbohydrate/insulin ratio: 240 divided by 12 = 20. 20 U of insulin will be 

required in order to “cover” the wedding meal. 

2. The meal and the subsequent period of digestion may approximately 

5 hours. The person decides to administer a square wave bolus over 

a period of 5 hours. An equivalent basal rate of 4 U/hour will be 

administered over a period of 5 hours. 

Caution. When using a pump it is easy to forget to administer the meal bolus. If you 

forget, even only a few times, your HbA1c may increase significantly. However, pump 

alerts can be set at specific times as a reminder. 

The bolus calculator 

The pump is able to suggest how many units of insulin are required for a bolus (for a 

correction and/or meal. This function is called the bolus calculator. 

( 85 

To use this feature, you must set the pump parameters to customize the calculation: 

The glycaemic target, i.e. the blood glucose level which you aim for in a certain time 

interval 

The insulin sensitivity factor 

The carbohydrate/insulin ratio in the different time intervals of the day 

The bolus activity duration (e.g. 3-4 hours). 

Once these parameters are set, every time you want to use this function you need to 

enter: 

The blood glucose measured at that time 

The amount of carbohydrates that you plan to consume

Insulin pumps 

Upon inserting these parameters, the pump calculates how much insulin to administer, 

depending on: 

The starting blood glucose level 

The glycaemic target 

The amount of carbohydrates consumed 

The amount of active insulin from a previous bolus (it subtracts the amount of active 

insulin that may have been administered earlier from the bolus that is being calculated). 

All of these variables can be calculated manually, but the pump helps to make 

calculations faster and more accurately as it also considers “insulin on board” (insulin 

that is still active from a previously administered bolus). 

For example, let us examine a person who has set the following parameters 

in his bolus calculator: 

Glucose target: 100 mg/dL 

Insulin sensitivity factor: 30 (1 U of insulin lowers the blood sugar level by 30 mg/dL) 

Carbohydrate/insulin ratio: 16 (1U of insulin “covers” 16 g of carbohydrates) 

Bolus Duration: 5 hours (the calculator will consider that the bolus will last 5 hours) 

86 ) 

At 16.00, the individual decides to eat a ham sandwich. 

1. The persons blood glucose is 190 mg/dL. The glucose target for this interval of 

time is 100 mg/dL. Therefore, the blood glucose is 90 mg/dL higher than target 

2. After applying the sensitivity factor, the result is that a 3 U need to be 

administered to correct the current blood glucose (90 mg/dL divided by 30 = 3 U) 

3. The person estimates that the sandwich contains 40 g of CHO. Considering a 

carbohydrate/insulin ratio of 16, this means that 2.5 U are required to “cover” it 

(40 g of carbohydrates divided by 16 = 2.5 U). 

4. At 4 p.m., however, part of the insulin used to cover lunch is still in circulation. 

The calculator ‘remembers’ that a 10 U bolus was administered at 1 p-m- and 

concludes that 4 U are still active at 4 p.m. In fact, after 3 hours, 40% of the 

bolus administered still needs to act. 

In conclusion, the bolus calculator adds the 2.5 U necessary for the sandwich to 

the 3 U necessary to correct the hyperglycaemia, but subtracts the 4 units still in 

circulation from the total (5.5 U) and therefore recommends a 1.5 U bolus. 

The bolus calculator calculates all the required variables. You only need to enter 

the measured blood glucose and the amount of carbohydrates.

Insulin pumps 

How to correct hyperglycaemia 

When blood glucose is above 250 mg/dL, it is necessary to: check whether the 

pump is operating correctly (reservoir, catheter and infusion site), verify previous commands 

in the pumps memory (boluses, basal, etc.) and measure blood ketones (positive 

if > 0.6 mmol/L) or ketonuria. 

Blood sugar > 250 mg/dL 

Check infusion set and previous boluses 

NO KETONES 

Pump-administered 

correction bolus 

Check both blood sugar and 

ketones one hour later 

KEtonEs 

If blood sugar is not reduced 

and there ar ketones 


and there are no ketones 

Administer a correction bolus with a pen, 

supplemented by 50% 

Change infusion set 

Keep pump connected with relevant basal rate 

Check both blood sugar and ketones one hour 

later 

Drink a lot 


and/or ketones are not 

reduced 

Contact your Diabetologist 

o go to nearest emergency 

unit 

Administer a correction 

bolus with a pen 

Change infusion set 

Check both blood sugar 

and ketones one hour later 

( 87

Insulin pumps 

If blood ketones are positive (>0.6 mmol/L): 

Use a syringe or pen to administer a bolus of rapid acting insulin, increasing the calculated 

bolus by 50% 

Replace the infusion set 

Keep the pump operational at the required basal rate 

Drink plenty of water and check blood glucose and ketones after 1-2 hours. 

If blood glucose has not decreased and the ketones are increasing, contact a diabetes 

specialist or go to the nearest emergency department 

If blood glucose is decreasing and the ketones are negative or decreasing, measure 

blood glucose every 1-2 hours until it returns to normal. 

How to correct hypoglycaemia 

The risk of hypoglycaemia is statistically lower in people who properly use an insulin 

pump. The correction of hypoglycaemia in pump users follows the same principles for 

those who use a syringe or a pen. Whenever you feel like or suspect that your blood 

glucose is low, the first thing to have to do is measure your blood glucose. A value 

below 70 mg/dL is considered low (hypoglycemia). 

Take 15 g of simple carbohydrates. 15 g may be too much for some children. To 

calculate the estimated correct amount, multiply your weight in kilograms by 0.3 to 

obtain the amount of grams of simple carbs. 

88 ) 

After 15 minutes, check your blood glucose again: 

If blood glucose is below 100 mg/dL, an additional dose of 15 g of simple carbs is 

necessary 

If your blood glucose is above 100 mg/dL, your low blood glucose has been properly 

corrected. 

15 g of simple carbs are contained in: 

½ can sugared drink 

½ fruit juice 

1 fruit juice with no added sugar 

3 candies (with sugar) 

2-3 sachets of sugar 

1 apple

Insulin pumps 

Never eat snacks or pastries (snacks, chocolate, cake, etc.) to correct hypoglycaemia, 

they determine a much slower rise in blood glucose and usually contain 

more carbs than necessary thereby increasing blood glucose excessively. 

If hypoglycaemia reoccurs, it is advisable to take simple carbs as described before 

and reduce the basal insulin rate by setting a temporary basal rate reduced by 50% 

until the next meal in order to reduce the likelihood of new hypoglycemic episodes. 

Caution 

15 g of simple carbs may not be sufficient to correct hypoglycaemia which occurs 

during physical activity. 

15 g of simple carbs may not be sufficient to correct hypoglycaemia after an 

excessive insulin bolus. 

If you correct your blood glucose in the wrong way, you risk 

increasing it excessively. 


It is essential to adjust the insulin dose and carbohydrate intake to reduce the risk of 

hypoglycaemia or hyperglycaemia during physical exercise. 

To identify how much insulin acts during a sporting activity, you must consider: 

The basal insulin rate 

How much insulin is still active from a previous bolus 

The amount of insulin that is still active from a previous bolus may be excessive 

(even if the pump has been disconnected) and increases the risk of hypoglycaemia. 

When exercise is over, the body needs to replenish its stocks of glucose, extracting 

it from the bloodstream. It also increases insulin sensitivity, meaning that the 

same dose of insulin has a greater metabolic effect. Therefore, the risk of hypoglycaemia 

also increases after physical exercise. 

( 89 

Before starting a planned physical activity you must: 

1. Evaluate whether to disconnect the pump and, if so, for how long. 

If you disconnect the pump: 

For less than 1 hour, check your blood glucose and disconnect the pump; 

For 1 to 2 hours: check your blood glucose and administer an insulin bolus equal 

to 50% of the basal rate required during the disconnection period (see ‘Temporary 

disconnection’).

Insulin pumps 

If you do not disconnect the pump: 

To avoid hypoglycaemia during physical exercise, decrease the basal rate for that 

moment of day (or use a reduced temporary basal rate for the necessary amount 

of time). This is useful during prolonged exercising, such as hiking or biking. 

2. Carry your blood glucose meter, insulin and the foods necessary to 

correct low blood glucose. 

3. Check your blood glucose before and regularly thereafter. 

Blood glucose between 120 and 180 mg/dL 

Consume 15-20 g of carbohydrates. Since you “burn” glucose during physical 

exercise, you need to “refuel” in order to have a sufficient amount of glucose. 

Blood glucose > 250 mg/dL without ketones 

After having administered a correction dose of insulin, you may carry out 

your planned physical activity. Administer a bolus of insulin (see ‘How to correct 

hypoglycaemia’, p. 87), but do so with extreme care, since your blood 

sugar will tend to decrease more than usual (physical activity increases insulin 

sensitivity). 

Blood glucose > 250 mg/dL with ketones 

Avoid physical activity. Administer a bolus of insulin as explained previously 

(see ‘How to correct hyperglycaemia’, page 86), When blood glucose and ketones 

are both elevated, there is an increased risk of ketoacidosis. 

90 ) 

Hypoglycaemia 

Avoid physical activity. In this case, perform a correction with 15g (or 30g in 

case you plan to start your physical activity afterwards) of simple carbohydrates, 

until the blood glucose exceeds 100 mg/dL (see ‘How to correct hypoglycaemia’, 

page 87). 

After physical exercise: 

If the pump has been disconnected: re-connect it (within 2 hours), check your 

blood glucose and correct your low or high blood glucose as necessary. 

For other precautions, see the section dedicated to physical exercise.

Insulin pumps 

In case of illness 

During intermittent illnesses (ie. the flu), insulin may not work as usual (febrile conditions 

increase the body’s resistance to insulin’s effect). This usually means that more 

insulin is needed to obtain the same metabolic effect. 

Hyperglycaemia 

If you administer a standard dose of insulin, blood glucose tends to rise more than 

usual. Therefore, high blood glucose may appear often during the a sick day. 

What needs to be done? 

Check your blood glucose often. IIf your blood glucose remains constantly high, increase 

your temporary basal rate and/or administer extra boluses of insulin. 

Measure blood ketones 

If you detect high blood glucose and ketones, immediately administer an extra dose 

of insulin as previously explained (see ‘How to correct hyperglycaemia’, page 86). 

If hyperglycaemia persists and/or you start experiencing abdominal pain and/or 

drink and urinate often, you should contact the diabetes healthcare team or go to 

the nearest emergency department – you may be undergoing diabetic ketoacidosis. 

Hypoglyceamia 

In case of vomiting or diarrhea (ie. Gastroenteritis), blood sugar levels tend to fall. This 

could lead to frequent lo blood glucose values. What needs to be done? 

Check your blood glucose often. 

In case of hypoglycaemia, take small sips of sugared liquids. 

Reduce all doses of insulin, especially boluses. Even when fasting for several hours, 

never completely suspend your basal insulin (see ‘The temporary basal rate’, page 

78), in order to prevent ketoacidosis. 

If you are unable to correct low blood glucose orally, go to the nearest emergency 

department. 

In case of intermittent diseases, a person with diabetes may take all the necessary 

medications (compatibly with ones allergies). However, there are drugs that increase 

blood glucose levels, such as cortisones. The use of these drugs requires an 

adjustment of insulin doses to maintain glucose control. 

( 91

Insulin pumps 

Transition to multi-injection therapy 

In case of need, you can always interrupt pump therapy and temporarily transition to 

multiple injection therapy using pens or syringes. 

To switch to a multiple injection regimen, you must: 

Calculate the total daily (24h) basal insulin dose 

Replace the units of basal insulin with a long-acting insulin analog. For example 

a baseline of 0.2 U/h is equivalent to a total daily dose of 4.8U, which may be 

rounded up to 5 U of long-acting insulin. 

Administer the same amount of units of rapid-acting insulin analog for meals (units 

of pump bolus = units of rapid-acting insulin analog injection) 

It is important to remember: 

That the injection of long-acting insulin must always be carried out at the same time 

To interrupt the insulin pump therapy 1-2 hours after the long-acting insulin has been 

administered. 

That the risk of overlapping insulin doses adminisetered by pump and injection if 

the transition is not planned correctly. 

In the first days after transition, you should check your blood glucose more often 

as insulin doses might have to be adusted. A few days may be necessary before 

the most correct multiple injection doses can be found. If necessary, contact your diabetes 

healethcare team. 

92 )

Insulin pumps 

Continuous glucose monitoring (CGM) 

It is possible to combine insulin pump therapy with continuous glucose monitoring 

(CGM). With CGM, one can better evaluate glucose trends in “real-time” and implement 

more precise insulin adjustments. 

Continuous glucose monitoring is performed by a subcutaneous sensor which 

remains in place for 3-7 days (up to 14 days in some cases). The sensor measures 

the concentration of (interstitial) glucose in the subcutaneous tissue, not in the blood. 

The interstitial glucose values are comparable to those in the blood in the majority 

of cases. 

The CGM system needs to be calibrated with blood glucose determination (approximately 

1 blood glucose value every 12 hours). Continuous glucose monitoring 

does not replace standard blood glucose monitoring, but provides additional information. 

Before making therapeutic decisions, it is always better to confirm that data from 

CGM with a blood glucose measurement. 

It is important to remember that CGM reading may be delayed (about 15-20 minutes) 

compared to capillary blood glucose. This delay increases when blood glucose 

is changing quickly. 

one arrow up 

check blood sugar 

two arrows up 


above 150 

mg/dL 

under 150 

mg/dL 

insulin bolus 

with IFS +10% 


30 minutes later 

insulin bolus 

with IFS +20% 

( 93 

two arrows down ‣‣ 


one arrow down ‣ 


under 150 

mg/dL 

above 150-200 

mg/dL 

under 100 

mg/dL 

above 100-150 

mg/dL 

15-30 g of 

fast-acting sugar 


30 minutes later 

15 g of 

fast-acting sugar 


30 minutes later

Insulin pumps 

The CGM a better understanding of glucose trends by showing a number of arrows 

with different inclination which represent different speeds of glucose variation. 

2 arrows indicate that your blood sugar level changes at a rate that is greater than 

2 mg/dL/min; 

1 arrow indicates that the glucose changes at a rate that is greater between 1-2 

mg/dL/min. For example, if your glucose trend is increasing, you may consider administering 

a small insulin to prevent hyperglycaemia. 

When you practice sports, eat or have just administered a bolus of insulin, blood 

glucose variations are more likely and more rapid. The sensor can show trend arrows 

that need correct interpretation. For example, if you have just taken a correction 

bolus for hyperglycaemia and the sensor shows two upwards pointing arrows, do not 

administer a second bolus of insulin, but wait until the first correction bolus has taken 

effect (1-2 hours). The arrows will probably soon disappear or even show a decreasing 

glucose trend. Remember that the sensor reads changes with a delay (lag-time) 

with respect to capillary blood glucose. Sensor accuracy is maintained if it is calibrated 

with stable blood glucose values. It is therefore important to avoid calibrating the 

sensor after meals or during physical activities. 

The algorithm that follows is an example and should be personalized and discussed 

with your diabetes healthcare team. 

Changes in insulin therapy 

94 ) 

Diabetes self-management is the cornerstone of multiple injection therapy and it is 

important that children and adolescents with diabetes actively manage their disease 

as soon as possible. The hardest part of this independence-acquiring process is gaining 

the ability to estimate insulin doses. In fact, the amount of insulin that each child/ 

adolescent needs is a variable that must be continually adjusted according to: 

Growth in height and weight 

Habits and lifestyle 

Physical activity 

Any intermittent illnesses 

Menstrual cycle 

To properly adjust doses, you must be able to correctly interpret blood glucose 

and ketones, and understand the mechanism of action of the insulin types that are 

being used.

Facing or clashing 

with diabetes

Facing or clashing with diabetes 

96 ) 

If you are a child/adolescent with diabetes, you will probably think of your daily 

diabetes management with a sense of boredom or anger. For example, you may feel 

that your insulin injections are an injustice and that they make you feel different from 

your peers or family members. You might ask yourself “Why do I have to take insulin 

and my brother doesn’t?” or “Why do I have to drink Coke Zero instead of normal 

Coke, like my friends do?”. 

If you’re a teenager with diabetes, it is crucial to maintain many friendships, 

commitments, interests and hobbies. However, some typical characteristics of this age 

can contribute to making your relationship with diabetes difficult. During adolescence, 

changes in your body and your mind may easily foster insecurity. This is why some 

children/adolescents of the same age see diabetes as a more serious and disturbing 

condition than it really is. Your natural growing need for emancipation and independence, 

can make you less accepting of the advice and monitoring supplied by family 

members and healthcare team. 

The typical uncertainties of adolescent age (“How am I seen, what do others 

think of me?”) may lead you to imagine that others may have negative connotations 

towards diabetes and its treatment which may then reflect on you. Some react by 

trying to deny the existence of the problem (diabetes), thus neglecting daily diabetes 

self-management. 

The duration of these negative reactions may vary. A frank conversation with a 

family member or friend, a discussion with peers with diabetes, or a dialogue with 

your healthcare team, may help understand that you may have neglected diabetes because 

of a desire to break the rules, or to get back at your parents. These confrontations 

may help you understand that neglecting diabetes management may be correlated 

to an unfounded fear that peers might look down on you upon discovering 

your therapeutic needs. Refusing to manage diabetes, may also reflect pre-existing discomforts 

or difficulties in other areas of your life (schoo, family, relationships). 

Once you have understood the real reasons behind these difficulties, you can 

constructively direct your efforts towards diabetes control, ensuring your well-being in 

the present and future, and increasing your self-esteem. With the limitations and obstacles 

that diabetes may bring forth, a teenager has the opportunity to find strength, 

resource, and acquire special skills that may help in dealing with other difficult situations 

in life. In fact, you may become better prepared to deal with the future that, as 

with all adolescents (with or without diabetes), may provide gratification and satisfaction, 

as well as burdens and difficulties. 

A person with diabetes should always remember to make healthier lifestyle 

choices than those of a person without diabetes!

Facing or clashing with diabetes 

In addition to all the actions necessary to achieving glucose targets, it is essential 

that you follow a healthy lifestyle: 

Eat as healthy as possible 

Maintain an adequate body mass index 

Exercise regularly physical activity is essential to keep in shape 

Do not smoke: smoking is the best way to ruin all your other efforts. 

( 97

Particular situations

Particular situations 

Intermittent illnesses 

Normal infectious diseases caused by viruses and bacteria can alter glucose control. 

Childhood rashes (measles, rubella, chicken pox, etc.), infections of the upper respiratory 

tract (tonsillitis, otitis), gastroenteritis and influenza are especially frequent during 

childhood. 

During an infectious disease, blood glucose tends to increase as insulin, in these 

situations, fails to act effectively. The greatest risk for a child/adolescent with diabetes 

during an infectious disease is the development of ketoacidosis. It takes about 24 

hours to develop and once started it tends to progressively worsen if adequate measures 

are not taken. 

What needs to be done to prevent ketoacidosis 

Frequent evaluations of blood glucose, blood/urine ketones are necessary in order to 

correctly adjust insulin doses. 

Maintain an adequate supple of carbohydrates. If you are unable to ingest solid foods, 

you need to drink sugared beverages (lemon tea, etc.). When suffering from 

persistent vomiting and hypoglycaemia, take small and frequent sips of sugared beverages. 

In case of hypoglycaemia and an inability to ingest food (such as in cases of gastroenteritis), 

small doses of glucagon may be administered subcutaneously using an 

insulin syringe at doses of 1 unit for each year of age, from a minimum of 2U to a 

maximum of 15 U. The dose can be repeated 1½-2 hours later. 

If blood sugar levels are consistently high, increase rapid-acting insulin doses, as it 

is easier to manage when food consumption is irregular. 

If blood sugar levels are consistently high (above 300 mg/dL) and ketones are persistently 

present, take an extra dose of rapid-acting insulin using your insulin sensitivity 

factor and increase the dose by 50% percent (for example if your standard 

correction dose for a specific hyperglycemia should be 6U, administer 9 units of insulin). 

Your blood glucose and ketones should progressively decrease. 

If you are unable resolve the situation, call your diabetes healthcare team or go to 

the nearest emergency department. 

( 99 

Never completely suspend insulin, even if you are consuming 

little or no food.


Useful tips 

If unresolved, ketoacidosis requires emergency admission to hospital for 

the infusion of fluids and intravenous insulin. 

In case of fever, you can take common fever medications. As far as 

antibiotics are concerned, it is best to consult your healthcare provider. 

A child with diabetes deals with common intermittent illnesses as all other 

children do, and does not have a weaker immune system. 

A child with diabetes can take all the necessary medications that a doctor may 

prescribe (compatibly with allergies). In some cases, insulin doses may need to be 

adjusted. 

Travel and holidays 

People with diabetes can travel anywhere for holiday or business reasons. Just be well 

organized and follow these tips: 

Before leaving 

Plan any vaccinations required for the country you will be visiting. 

What to pack: 

Syringes/pens and/or infusion 

Suitcase 

sets and related needles 

Test strips to determine blood glucose and ketones 

Lancets 

Glucagon 

Simple carbohydrates 

100 ) 

It is always best to bring more material than the amount you plan to use during 

your stay. If you are traveling by air, do not put insulin in your cargo luggage: the 

low temperature of the cargo could freeze the insulin, altering its biochemical properties. 

Always keep insulin, glucagon, syringes or pens or infusion sets and related 

needles, glucometers, lancing devices, lancets and simple sugars in your hand luggage. 

Make sure to ask your doctor for a certificate stating your medical condition and 

your need to carry insulin and all necessary equipment for diabetes management during 

your travel (in English if you go abroad). We recommend that you apply for a travel 

insurance that covers medical and hospital care expenses in case of emergency.


During a trip 

When on a ship, if you suffer from motion sickness, you can take common motion 

sickness medication. These medications do not alter glucose control. By plane, it is 

possible to ask the airline for a gluten free menu. By car, bus or train, it is advisable 

to carry an adequate amount of carbohydrates for the duration of the trip. 

Crossing time zones 

You might take flights abroad in countries with different time zones. In these cases, 

pay particular attention to your schedule and the insulin dose. For time differences of 

less than 3-4 hours, do not take additional doses of insulin, but upon arrival take the 

usual dose of insulin corresponding to local time. If the difference is greater than 3-4 

hours, take an extra dose of rapid-acting insulin equal to 10-15% of the total dose 

4-5 hours after the last administration; upon arrival, administer the usual dose of insulin 

corresponding to local time. It is always better to discuss the best option with your 

diabetes healthcare team before you leave. Always perform an adequate number of 

blood glucose tests during the trip and first days of your stay as your glucose variability 

may increase due to the change in time zone. 

Dental treatment 

People with diabetes can undergo routine dental procedure without the need for specific 

precautions. It is advisable to contact the anaesthesiologist in advance if general 

anaesthesia is required. Blood clotting and tissue healing is absolutely normal in a person 

with diabetes in good control. 

While tooth cavities is unaffected by glucose control, the onset of periodontitis 

(alveolar pyorrhea) may be influenced by consistently high blood glucose levels. 

Proper oral hygiene, brushing and flossing after every meal, is essential in avoiding 

frequent dental treatment. 

( 101


Pregnancy 

A woman with type 1 diabetes can have a successful pregnancy, as long as the pregnancy 

is planned. 

As always, it is essential that the female of childbearing age with diabetes receieves 

proper education, regarding the planning of pregnancy and the need for optimal 

metabolic control especially before and during pregnancy. This reduces the 

risk for fetal complications related to poorly controlled diabetes (malformations, hypoglycaemia, 

macrosomia). 

Pregancy in the context of diabetes should be closely monitored ina a diabetesspecialized 

center throughout all its duration. It may often be necessary to increase 

insulin doses, even two or three fold, in order to maintain stable blood glucose levels 

and therefore an adequate HbA1c. Fetal growth should be evaluated by ultrasound 

at regular intervals and delivery should be planned as close as possible to the end of 

pregnancy. There is no need to resort to a Caesarean section unless medical or obstetric 

issues arise. 

Children of diabetic mothers with adequate glucose control still weigh slightly 

than average in spite of all efforts. However, with the exception of specific situations, 

there are usually no particular problems. The greatest risk for these children is the onset 

of hypoglycaemia, jaundice or hypocalcaemia in the first hours following birth. 

Normal breast-feeding recommendations apply to diabetic mothers as well. Breastfeeding 

usually requires an increased carbohydrate intake (about +50 g of carbohydrates 

per day) and an increased fluid intake. These measures do not normally affect 

insulin doses. It has been shown that breast-fed children may have a reduced risk 

of developing type 1 diabetes. Severe diabetes complications (advanced retinopathy 

and nephropathy) of diabetes can be a contraindication for pregnancy. 

102 ) 

Planning pregnancy 

It is important for conception and pregnancy to progress in a context of optimal glucose 

control. Contraception ma also be suggested and be discussed with your diabetes 

healthcare team. 

Natural methods of regulation and fertility control: 

> ovulation method: this is based on the observation of cervical mucus to determine 

the fertile period; 

> basal body temperature method: this is useful to recognize the end of the ovulatory 

Contracepti 

phase. Good levels of effecicacy are obtained in patients who are well motivated 

and have undergone adequate education. 

Barrier contraception (condoms or diaphragms): these are recommended, 

especially for younger people. They are also important for the prevention of sexually 

transmitted diseases.

Contraceptio 


Intrauterine devices (spiral): these are not recommended, especially for young 

methods 

women, due to possible side effects. 

Oral contraceptives (low-dose estroprogestins) provide a good safety profile, 

but may interfere with glucose control, resulting in increased insulin requirements 

and increased body weight. Periodic blood tests will be necessary, especially to serum 

lipids and coagulation. The same contraindications apply as for non-diabetic 

patients. 

Smoking 

Smoking is the leading cause of lung cancer, chronic bronchitis and pulmonary emphysema. 

It is also one of the primary risk factors for diseases of the heard (coronary artery 

disease), major vessels of the lower extremities (gangrene) and of the brain (strokes). 

In fact, smoking is the cause of a third of the deaths in middle-aged people. 

Why is smoking harmful? The chemicals in tobacco are responsible for lung diseases: 

tar restricts the flow of air into the lungs and carbon monoxide decreases the 

oxygenation of peripheral tissues. Nicotine in cigarettes causes addiction to smoking. 

Only adequate glucose control and a careful lifestyle will prevent microvascular 

and macrovascular complications: it is therefore necessary to avoid adding another 

risk factor. 

Studies involving complications clearly demonstrate that smoking is able to abolish 

the preventive effect of an adequate glucose control (which is often obtained with 

great sacrifice). 

In terms of the risk of complications, it is as if smokers who have achieved and 

HbA1c of 7% (i.e. within the target value) actually achieved a value of 8.5% due to 

the risk of complications induced by smoke. 

Therefore: 

( 103 

1. Avoid smoking: once you start, it is very difficult to give up. 

2. If you are already a smoker: 

Pick a day to stop smoking: throw away all your cigarettes, matches and lighters 

on 

Fill your day with commitments, do sporting activities, but do not allow yourself 

to be bored 

Ask your doctor, family and friends to help you during this period


3. There are many immediate benefits: 

You will feel much better both physically and mentally 

You will be able to taste food properly again 

You will improve your sense of smell 

You will no longer bother non-smokers. 

Do not smoke: you will live better and longer. 

Diabetes camps 

104 ) 

Diabetes awareness and education are the starting point in the management of diabetes. 

Self-management education means providing children/adolescents with diabetes 

and their parents with the necessary tools to deal confidently with the daily diabetes-related 

issues. 

During hospitalization, outpatient visits, and specific diabetes-update meetings, 

doctors, nurses and dieticians provide theoretical education and training regarding 

the practical aspect. 

Diabetes camps are a particularly interesting event for children/adolescents with 

diabetes. In these camps, children/adolescents with diabetes go on a week trip with 

their diabetes healthcare team (doctors, nurses, dieticians, psychologists). During this 

trip they are provided with daily educational and recreational activities which provide 

theoretical and practical diabetes-related information which can be applied in 

everyday life. Camps are organized at holiday resorts that also offer the opportunity 

to practice sporting activities. Discussions with other peers with diabetes can 

provide useful insights and solutions to the daily obstacles that diabetes may 

provide.


Recommended check-ups 

A routine outpatient visit should be performed every 3-4 months, during which glycated 

hemoglobin or HbA1c is evaluated. HbA1c may be evaluated by taking venous 

blood or capillary blood samples (in the same way blood glucose is tested). 

Hemoglobin, which has the function of carrying oxygen, has a tendency to bind 

glucose slowly and irreversibly: therefore, if blood sugar levels are high for a long time, 

glucose binds with hemoglobin to form glycosylated or glycated hemoglobin. 

Glycated hemoglobin provides information regarding glucose control over the previous 

three months. 

Following an international convention and starting from January 2011, HbA1c 

will no longer be expressed as a %, but as mmol/mol. 

In the non-diabetic population, normal Hba1c values are 4-6% (24 to 42 mmol/ 

mol). 

Children/adolescents with diabetes should try to achieve near-normal HbA1c – 

values below 7.5% (56 mmol/mol) are considered adequate. An American study has 

shown that maintaining an HbA1c below 7% (42 mmol/mol) may prevent a relevant 

proportion of diabetic complications. Elevated HbA1c’s mean that previous 3 months 

have been characterised by a releveant number of high glucose values. 

Currently, the evaluation of diabetes-selfmanagement also assesses the distribution 

of blood glucose values through the use of computer programs. In addition 

to average blood glucose level, blood glucose variability and exposure to hypo- and 

hyperglycaemia are also important. The percentage of values above 180 mg/dL and 

less than 80 mg/dL are evaluated – the goal is to achieve as high a number of blood 

glucose levels within the target range. In addition, you can obtain other glucose variability 

indices to more accurately assess glucose control. 

Certain blood tests and examinations should be performed annually. These include 

screening for thyroid and celiac disease, microalbuminuria, fundus oculi examination. 

After 10 years of diabetes duration or before the transition to an adult diabetes 

outpatient clinic(at 18 years of age), it is good practice to undergo a complete screening 

for diabetes complications: microalbuminuria, electromyography (which analyses 

the functionality of the peripheral nervous system), re-evaluation of the situation in 

the retina (fundus oculi and, if necessary, retinal fluorescein angiography) and Doppler 

ultrasound of the carotid arteries. 

( 105

The future of 

people with diabetes

The future of people with diabetes 

Type 1 diabetes is an ancient illness, but we have only been able to treat it effectively 

since 1922, when insulin was discovered. Marvelous advances in diabetes treatment 

have been developed in these 90 years, particularly for what concerns technology. 

There is no doubt that with the development of self-management tools for home 

use, a significant improvement in the quality of life of people with diabetes has been 

achieved – this has been made possible with the development of newer and more 

precise instruments such as blood glucose meters and continuous glucose monitors, 

as well as increasing continuous education for patients and parents regarding all 

aspects of diabetes. 

Let’s take a look at the future of diabetes! 

Prevention 

It has become clear for some time that type 1 diabetes arises when one or more 

“environmental” factors, called “triggers”, activate an autoimmune response that 

destroys ß-cells in genetically predisposed individuals. “Environmental” dose not only 

refer to factors that are strictly related to the environment (such as chemical pollution, 

etc.) but to anything with which the body may come into contact in the environment. 

Genetics. The fact that type 1 diabetes correlated to other autoimmune diseases 

(thyroiditis, celiac disease, certain forms of allergy) suggests that in some individuals 

the immune system is less capable of distinguishing between external agents and the 

cells of one’s own body, and is therefore more inclined to develop autoimmune diseases. 

Preclinical phase. Despite an onset which may suggest a condition that has developed 

rapidly, we now know that what may seem the beginning of type 1 diabetes is 

actually the final stage of a long-lasting phenomenon which consists of two phases. 

In the first phase antibodies start to damage beta cells, while in the second phase 

beta cells are slowly destroyed. During this preclinical stage, we are able to identify 

those in whom this immune process is taking place by searching for autoantibodies. 

It is easier to identify a person at risk of type 1 diabetes mellitus in a family in which 

there has already been a case of diabetes mellitus, rather than someone in the general 

population. However, the presence of different antibodies (ICA, GAD, IA2, IAA, 

ZNT8) is not uncommon in the general population and in only a minority of cases do 

they determine ß-cell destruction. 

( 107


In the second phase, well before the appearance of the typical symptoms of diabetes 

onset, it is possible to detect abnormalities in rapid insulin secretion per performing 

an IVGTT (a test which evaluates the insulin response to a dose of glucose administered 

intravenously). Individuals with specific antibodies and altered IVGTT have 

more than a 90% chance of developing diabetes, particularly those with a high genetic 

predisposition. 

Unlike monogenic diseases in which there is a clear cause-effect relationship 

between gene and disease, in type 1 diabetes the relationship is indirect. Therefore 

it does not seem useful to intervene on the genetic aspect of the disease since more 

than one gene is probably involved in the disease process. 

The search for the “trigger”. The most interesting aspect involves searching for environmental 

factors (or others) that may trigger an autoimmune response involving 

the development of autoreactive cells and antibodies directed against ß-cells. By identifying 

the cause, it would then be possible to avoid or delay the the onset or progression 

of the disease. 

Research protocols on this topic are being carried out throughout the world. There 

is a long list of substances currently undergoing trials with the aim of discovering 

whether or not they could act as “diabetes triggers”. Hopefully in the future there will 

be an “antidote” capable of preventing such an important disease. 

Tertiary prevention. Currently, greater results are possible in what is known as “tertiary 

prevention” – interventions aimed at maintaining residual secretion in newly diagnosed 

patients. A very interesting topic, especially for what concerns research centre, 

involves the study of regulatory cells and the future possibility of being able to 

modify these cells in order to avoid the need to resort to immunosuppression. 

108 )


Transplants 

Transplants are considered a possible “treatment” for diabetes. A transplant is the transfer 

an organ, tissue or cells from a donor to the patient. There are several types of transplants 

which may be used in the treatment of diabetes. 

Pancreas transplantation 

Pancreas transplantation is a surgical procedure in which the whole organ is transplanted. 

It was the first technique to be tested in order to improve glucose control 

and stop the progression or prevent the onset of degenerative complications related 

to diabetes. 

Pancreas transplantation eliminates the need for daily insulin administrations in 

the majority of patients. However, this type of surgery is demanding, it is often difficult 

to find a compatible donor and above all, it requires the administration of immunosuppressive 

therapy to prevent rejection of the transplanted organ by the immune 

system. Immunosuppression is a debilitating and involves a high risk of inducing a secondary 

tumour and life-threatening infections. 

These are the reasons why its use is very limited and it is only suitable for patients 

with nephropathy who require a kidney transplant due to end-stage renal failure. 

In this case, the two transplants are performed simultaneously. Pancreas transplantations 

have good graft survival percentages, good insulin independence results 

among recipients, as well as good secondary prevention of macrovascular and microvascular 

complications. 

Islet transplantation 

Pancreatic islet transplantation is more interesting due to its future prospects. This 

type of transplantation involves the administration of an extract of pancreatic islets – 

the group of pancreatic cells which include insulin-producing ß-cells. Unlike pancreatic 

transplantation, it is not a major surgical procedure: it is performed by injecting 

the pancreatic extract into the portal vein which leads to the liver, the target organ in 

which the islets will be implanted and should survive. 

The technique itself does not pose particular difficulties, it can be repeated and 

does not involve the risks of major surgery. This procedure also involves issues related 

to compatibility and immunosuppression, which, as has been said, has relevant side 

effects and must be administered for life. Another obstacle concerns the limited survival 

of pancreatic islets as they are identified and destroyed by the patient’s immune 

system within a year or two from transplantation, making it necessary to return to insulin 

therapy. Different protocols are underway to determine the best assortment of 

immunosuppressive medication and different transplant locations – for example the 

bone marrow – in order to achieve longer survival. 

( 109


Stem Cell Transplantation 

This is a very active subject of research in diabetes. In fact, difficulties in obtaining 

pancreatic tissue for the transplantation of islets will be crucial in the medium term. 

Unfortunately, studies on the generation specialized pancreatic cells from totipotent 

stem cells have shown limited results although an enormous progress is continuously 

being made. 

Prevention and treatment 

of complications 

Researchers are trying to identify biological markers that may precociously predict the 

development of diabetes complications and therefore prevent or delay their onset. Research 

on certain medications and proteins such as acetylsalicylic acid and C-peptide 

(insulin’s connecting peptide) are under way. 

110 ) 

Artificial pancreas 

This technological tool involves an automatic and glucose sensor-drived continuous 

subcutaneous infusion of insulin. It comrpises a programmable insulin pump which 

administers insulin subcutaneously or in the peritoneum and a subcutaneous glucose 

sensor which continuously determines interstitial glucose levels. A computer algorithm 

manages the administration of the insulin by evaluating the data from the glucose 

sensor. Some artificial pancreas designs also include a glucagon pump. 

It might still take some time before a true artificial pancreas – a fully automatic 

pump – is achieved. This is due to two major limitations: the duration of insulin and 

the accuracy of the glucose sensor. There is also some concern due to the risk of technical 

malfunctions which may lead to excessive or insufficient insulin administration. 

However, these tools may lead to the normalization of blood glucose and consequently 

a drastic reduction in diabetes complications without causing a significant increase 

in hypoglycaemia. If this technology will be effective in doing so, it may represent an 

optimal solution until effective biological and immunological therapies are developed. 

There is a cure for diabetes and research will find it.

SOStegno70 - Insieme ai ragazzi diabetici 

Sede operativa: Clinica Pediatrica 

Ospedale San Raffaele, Via Olgettina, 60 – 20132 Milano 

Tel. e Fax + 39 02.2643.3403 

Sezione di Brescia: Azienda Ospedaliera Spedali Civili 

Clinica Pediatrica, Piazzale Spedali Civili, 1 – 25123 Brescia 

Tel. 338.6844921 

Centro Regionale di Riferimento per la Diabetologia Pediatrica 

Centro di Endocrinologia dell’Infanzia e dell’Adolescenza 

Clinica Pediatrica – Ospedale San Raffaele 

Istituto di Ricovero e Cura a Carattere Scientifico 

Via Olgettina, 60 - 20132 Milano 

Per appuntamenti: Tel. 02-2643.2643 

Reparto di Pediatria: Tel. 02-2643.2622

Handbook for young people with diabetes

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