living with diabetes - tucson medical center · 2019. 1. 15. · page 6 living with diabetes while...

Living with Diabetes

Approved by Glycemic Oversight Committee 12/12/17

W H I L E P R E G N A N T

Table of ContentsWhat Is Gestational Diabetes .................... 2

What Can Happen To My Baby ................. 2

Blood Sugar Ranges For Gestational Diabetes ................................. 3

Diabetes Out Of Balance, Low And High Blood Sugar ....................... 3

Insulin Requirement During Pregnancy ..... 4

Insulin Resistance In Gestational Diabetes ................................. 4

Dietary Guidelines For Gestational Diabetes ................................. 5

Carbohydrate Counting ........................... 6

Examples Of Carbohydrates For Carb Counting .................................... 7

Foods Low In Carbohydrates ..................... 8

Non Carbohydrate Foods.......................... 8

Nutrition Labels ........................................ 9

Gestational Diabetes Meal Plan Recommendations ............................. 10-11

Eating Out Wisely ................................... 12

Exercise And Pregnancy .......................... 13

Stress Management ................................ 13

Medications Used In Pregnancy .............. 13

Symptoms Of Low Blood Sugar .............. 13

Insulin Therapy In Pregnancy .................. 14

How Your Insulin Works .......................... 14

Drawing And Injecting One Insulin ......... 15

Mixing, Drawing And Injecting Insulin .... 16

Preparing And Injecting With A Reusable Pen ............................... 17

Site Selection And Rotation ..................... 18

Proper Use And Disposal ......................... 18

Sick Day Management ............................ 19

Sick Day Food List ................................... 19

Morning Sickness .................................... 19

Ideas To Make You Feel Better ................. 19

Coping With Heartburn .......................... 20

What Is Preterm Labor ............................ 20

Extra Test(s) ............................................ 21

What To Expect After Delivery ................. 21

Reducing Your Risk After Gestational Diabetes .............................. 22

Healthy Start For My Baby ...................... 23

Breast Feeding Guidelines ....................... 23

References .............................................. 24

Living with Diabetes while PregnantPAGE 2

What Is Gestational Diabetes?It is a type of diabetes only in pregnancyn Usually goes away after the birth of the baby.n Usually detected at 24-28 weeks or the third trimester

(all women are screened.)n Normal hormone changes of pregnancy make some

pregnant women have higher blood sugar levels.

What are the risk factors?n Family history of diabetesn Overweight before pregnancyn Older than 25 yearsn Previous baby weighing over 9 poundsn Previous still birth or miscarriagen Gestational diabetes in another pregnancyn Member of an ethnic group with a high incidence of

diabetes such as Native American, Hispanic, African American and Asian

Causes: The hormones from the placenta work against the action of insulin. It is called “insulin resistance.”

As baby grows, more hormones are produced, causing more insulin resistance.

What Can Happen To My Baby?Most babies are born healthy, but if mothers’ blood sugar remains high, the following problems could occur:n Difficult deliveryn Possible C-sectionn A high birth weightn Baby gains too much fatn Baby may need to stay in hospital due to breathing

problems, low blood sugar or jaundicen Severe high blood sugars, birth defects or still birth

Keeping the blood sugars close to normal helps protect the baby from problems. We can help you.

How can I protect my baby?n Eat 5-6 small healthy meals and snacks every dayn Exercise dailyn Test your blood sugar 4 times each dayn Take your diabetes medication if needed

Tucson Medical Center PAGE 3

Hypoglycemia Low Blood Sugar

Hyperglycemia High Blood Sugar

SY

MP

TO

MS

EARLY

Blood Sugar 50-60 g Hungerg Headacheg Dizzyg Sweatyg Shakyg Grouchyg Increased

heart rate

Several Blood Sugars >180 g Very thirstyg Dry sking Increased urinationg Very tired

LATEg Slurred speechg Confusiong Seizuresg Passed outUse Glucagon or call 911

Blood Sugar >240 g Nauseag Vomiting

TR

EA

TM

EN

T

BG <60 Rule of 15/15g 15 grams fast acting

sugar such as 4 oz juice, 5-6 lifesavers, 4 glucose tablets, 8 oz skim milk

g Wait 15 minutesg Repeat blood sugar

testg If >60 eat meal

or protein with carbohydrate snack

g Call doctor or provider

g Test blood sugarg Drink water g Take medication –

do not omit

CA

US

ES g Too much

medicationg Missed meal or

snackg Unusual or

unplanned exercise

g Not enough medication

g Too much foodg Illness or infectiong Not enough exercise

Diabetes Out Of Balance – Pregnancy

Blood Sugar Ranges For Gestational Diabetes

Fasting 1 Hour After Meal

2 Hours After Meal

60-95 < 140 <120

Your provider will ask you to check your blood sugars 4 times each day.

1. Right after you wake up in the morning (after an 8-10 hour fast.)

2. One hour after you start eating or drinking your first food in the morning.

3. One hour after your first bite of lunch.4. One hour after your first bite of dinner or supper.5. You could set a timer or alarm to go off after the

start of your meal, about 1 or 2 hours, to remind you to check your blood sugar.

NOTE: People who are not pregnant are allowed to have higher blood sugars than you are…because they are NOT pregnant.


Insulin Requirement During Pregnancy

During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. These changes cause your body’s cells to use insulin less effectively, a condition called insulin resistance. Insulin resistance increases your body’s need for insulin a hormone produced by your pancreas. If your pancreas cannot make enough insulin, you will have gestational diabetes.

All pregnant women have some insulin resistance during late pregnancy. However, some women have insulin resistance even before they get pregnant, usually because they are overweight. These women start pregnancy with an increased need for insulin and are more likely to have gestational diabetes.

Insulin Resistance In Gestational Diabetes


Dietary Guidelines For Gestational DiabetesEat 3 regular meals and 3 snacks every day. The ideal timing is to eat your meals and snacks that contain carbohydrates 2-3 hours apart. This allows your blood sugar levels to normalize between each meal.

Drink at least six to eight 8-ounce glasses of water or sugar free, caffeine-free beverages every day.

Eat a variety of non-starchy vegetables such as broccoli, cauliflower, cucumbers, carrots, etc. each day with your meals and snacks.

Choose a variety of whole grain products, such 100% whole wheat bread, brown rice or whole wheat pasta.

Eat a variety of lean meats with each meal and snack such as lean beef, lean pork, skinless chicken and turkey. You may also eat meat substitutes such as low fat cheese, low fat cottage cheese, eggs and peanut butter.

Limit fish and shellfish to no more than 12 ounces per week. Products with low mercury concentration are safe to eat including: shrimp, canned light tuna, salmon, pollock and catfish.

Avoid fish with high concentrations of mercury such as shark, swordfish, king mackerel and tile fish.

Avoid drinking fruit juices or regular soda (unless your blood sugar is already too low.) Squeeze a fresh lemon into your water for variety. Use a water infuser pitcher with lemon, mint, cucumber or slices of strawberries.

Avoid eating table sugar or concentrated sweets, such desserts, jelly, jams, honey, candy or syrup.


Carbohydrate (carb) counting is simply counting the grams of carb from the foods you eat each day. It is becoming a way of life for many people, and it works especially well for those with diabetes. By measuring the number of grams of carb in your meal plan, you can better control your blood glucose levels and weight. The main carbohydrate containing foods are starches, fruits, milk/yogurt and sugar/sweets.

Almost all foods contain carbohydrates. The amount of carbohydrates in each product must appear in the product label. Therefore, one must learn how to read food product labels. For those foods that do not have labels, such as fresh fruit, learning the appropriate portions sizes of the food is necessary. The amount of carbs you eat at a meal is more important than the specific foods. The key is to eat only the amount of carbohydrates you need each day at the right times. Of course, you want to eat healthy carbohydrates foods such as whole grains, beans, non-starchy vegetables, fresh fruits and low fat milk.

Important Points to RememberManaging portion sizes is the most difficult part of carb counting, especially when eating out. It is important to follow the recommended portion sizes as indicated on your meal plan. The rest can be taken home to enjoy later. Even the healthiest foods can increase your blood sugar level above the goal if you overeat.

You may need to adjust the amount of carbohydrate you eat when you exercise. You should discuss this with your dietitian.

If your blood sugar levels go too high or too low, you need to review what you ate, the portion size, the type of food, and the time of day in relation to your meal plan.

Not everyone reacts to foods in the same way, so portions and choices need to be monitored to see what foods work best for you.

This label was produced by the Modest Nutrition team and should be used for educational purpose only.

1 teaspoonUse this for oil and butter

1 tablespoonPeanut butter

1 ounceof cheese

3 ounceTo measure your meats

1/2 cupEquivalent to size of computer mouse. Use for rice or pasta

1 cupFor cooked vegetables

8 ounces milk = 12 grams

small apple = 15 grams

1 carbohydrate choice = 15 grams

Carbohydrate Counting


Examples Of Carbohydrates For Carb Counting Starches, breads, grains and starchy vegetables

Each serving has about 15 grams of carbohydratesg 1 slice of bread (whole wheat, rye)g ½ English muffin, hot dog or

hamburger bung ½ pitag ½ cup of cooked cereal

(oatmeal, cream of wheat)g 1 5-inch pancakeg ½ cup beans, lentils or split peas

g 1 small 6-inch tortillag 1/3 cup of cooked rice or pasta g ½ cup of corn, hominy, peasg ½ cup of mashed potato g 6 saltine crackersg 3 cups of popcorng 3 graham crackers squaresg ¾ oz pretzels

Milk and yogurt – Each serving has about 15 grams of carbohydratesg 1 cup of skim, 1%, 2% or whole milkg ½ cup of evaporated milkg 1/3 cup non fat dry milk powderg 1 cup plain or sugar free yogurtg 1 cup soy/almond/rice milk (unflavored <15 grams)

Fruits – Each serving has about 15 grams of carbohydratesg 1 small apple, orange, kiwi,

pear or peachg ½ cup apple sauce (unsweetened)g ½ bananag ¾ cup of blackberries, blueberriesg 1 cup melon cubesg 12 cherriesg ½ cup canned fruits

(unsweetened or light syrup)

g ½ mangog 3 medium prunesg 2 figsg 2 tbsp raisinsg 1 cup whole strawberriesg 2 small tangerines g 15 grapes

Sugar and sweets – Each serving has about 15 grams of carbohydratesg 1 tbsp sugarg 1 tbsp honeyg 1 tbsp all fruit jelly or jamg 2 tbsp light maple syrup g 2 inches brownie (unfrosted)

g 2 small fat free cookiesg ½ cup of ice creamg ½ cup of sugar free puddingg 5 vanilla wafers


Foods Low In Carbohydrates

Non Carbohydrate Foods

Fats: Choose low fat and heart healthy types. Free Foods

Non-starchy vegetables: 1 cup of raw or ½ cup cooked vegetables = 5 grams of carbs

Proteins/Meat or meat substitutes: Include protein with every meal.

g Artichokeg Asparagusg Beans

(green, wax, Italian)g Bean sproutsg Beetsg Broccolig Brussels sproutsg Cabbageg Carrots

g Lean beefg Chickeng Turkey

g Cauliflowerg Celeryg Cucumbersg Eggplantg Green onionsg Greens

(kale, collard, mustard)g Radishesg Leeksg Mushrooms

g Lamb g Porkg Shrimp

g Mustardg Catsupg Broth**g Lemong Limeg Soy sauce**g Relishg Pickles**g Salsag Vinegar

Choose:g Olive oil or canola oilg Nuts and seedsg Avocadog Olives g Oil based salad dressingsg Margarineg Low fat sour creamg Low fat cream cheese

g Diet Jellog Sugar free gumg Sugar free iced teag Sugar free Kool-Aid g Waterg Diet sodag Crystal Lightg Sugar substitute (avoid

Sweet’NLow and Equal)**High sodium

Limit/avoid:g Butterg Regular cream

cheeseg Gravyg Mayonnaiseg Bacong Coconut

g Okrag Onionsg Pea podsg Peppersg Salad greensg Sauerkrautg Spinachg Tomato g Tomato juice g Turnips

g Salmong Fish (halibut, cod,

rainbow trout, herring)

AVOID:g Raw or uncooked meats, fish, poultry or eggs.g Raw or unpasteurized milk or dairy products such as soft serve

yogurt, brie, gorgonzola.g Deli meats unless they are heated until steaming hot.g High mercury levels fish such as shark, swordfish, king, mackerel and tile fish.

g Vegetable juiceg Water chestnutsg Water Cressg Zucchini


Nutrition Labels1. Read the serving size and number of servings

per container– Example:

Serving size = 2/3 cup Serving per container = 8

2. Read the grams of “Total Carbohydrates”– Example:

Total carbohydrate = 37 grams

DO NOT COUNT sugars separately. They are included in the grams of total carbohydrates.

If you eat 1/3 cup, the total amount of carbohydrates is 18 grams.

That is because if you eat 1/3 cup, you are actually eating half-servings of the product. Therefore, you will be eating: 37 grams divided by 2 = 18 grams or a little more than 1 carb choice

3. Dietary fiber: If the amount of dietary fiber is >5 grams you can subtract half of that amount from the total carbohydrates.– Example:

If dietary fiber is 8 grams, you can subtract 4 grams from the total carbohydrates.


Gestational Diabetes Meal Plan RecommendationsFor the Rest of Pregnancy

n No sugar/honey/pancake syrup/regular jellyn No juice or milkshakesn No Kool-Aid or regular Jello

n No regular soda or Gatoraden Drink water instead

Breakfast

n Limit carbohydrates (carb) to 30 grams (2 servings) n Include 2-3 ounces lean protein (meat/cheese/eggs/peanut butter/cottage cheese)

Sample Day 1 – Breakfast Sample Day 2 – Breakfastn 1 whole wheat english muffin n 1 scrambled egg n 1 ounce cheese n 1 tbsp butter or margarine

n Cheese quesadilla:– 1 6-inch corn tortilla – 1 ounce of low fat cheese

n 1 cup of low fat milk

AM Snack

n Limit carbohydrates to 15 grams (1 serving) n Include 1-2 ounces protein

Day 1 – AM Snack Day 2 – AM Snackn 1 cup yogurt less than 20 gm n ¼ cup of nuts

n 6 crackers n 1ounce low fat cheese

Lunch

n Limit carbohydrates to 45-60 grams (3-4 servings) n Include 3 ounces of lean protein n Include 3 cups raw or 1½ cups cooked non-starchy vegetables

Sample Day 1 – Lunch Sample Day 2 – Lunch

n Tuna sandwich:– 2 slices of whole wheat bread, 2 ounce tuna salad,

lettuce and tomato– 1 tsp mayonnaise

n 1 small pear n 1 cup of carrot sticks

n Chicken burrito:– 1 medium flour tortilla,1-2 ounce cooked chicken,

1-2 tbsp guacamole, lettuce and tomaton 1 small orange

Afternoon Snack

n Limit carbohydrates to 15 grams (1 serving) n Include 1-2 ounces protein

Day 1 – PM Snack Day 2 – PM Snack

n 12-15 small grapes n 1 ounce low fat cheese

n 1 cup melon cubesn ½ cup low fat cottage cheese


Gestational Diabetes Meal Plan Recommendations

Gestational Diabetes Meal Plan Recommendations For Breastfeeding

Dinner

n Limit carbohydrates to 45-60 grams (3-4 servings) n Include 3-4 ounces lean protein n Include 3 cups raw or 1½ cups cooked non-starchy vegetables

Day 1 – Dinner Day 2 – Dinnern 1 medium baked potato n 1 cup low fat milkn 2-3 ounce grilled chicken breast n 1 cup of steamed broccoli n 1 tbsp low fat sour creamn 1 tsp butter or margarine

n 2 6-inch corn tortillas n 1 cup low fat milkn 2 ounce ground beef n 1 ounce grated low fat cheesen Chopped lettuce, tomato, onion and salsa n 1 tbsp low fat sour cream

Bedtime Snack

n Limit carbohydrates to 30 grams (2 servings) n Include 1-2 ounces lean protein

Day 1 – Bedtime Day 2 – Bedtimen 3 graham crackers n 1 tbsp natural peanut butter

n 3 cups light popcornn ¼ cup of nuts

For Breastfeeding

n Increase breakfast carbohydrates to 45 grams n Increase lunch and dinner carbohydrates to 60 grams n Increase all snacks to 30 grams of carbohydrates with 1-2 ounces protein

When Done Breastfeeding

n Omit snacks n Limit carbohydrates to 45-60 grams per meal (3-4 servings) n Lean protein 3-4 ounces per mealn Include a lot of non-starchy vegetables n No juices/regular soda/Gatorade


Eating Out WiselyEating out can be a challenge when trying to maintain a good blood sugar control. The cooking methods and the portions sizes tend to be different than the ones you use at home. Below you will find some suggestions to help you make healthy food selection enjoy your meal and still maintain a good blood sugar control when eating out.

Fast Food Restaurants1. Select plain small hamburgers. You may add mustard

and/or light mayonnaise but avoid any sweet sauces or spreads (such as ketchup, thousand island or barbecue.)

2. Choose English muffin or whole wheat bread when available. Avoid biscuits and croissants for breakfast.

3. Choose grilled chicken or other lean meat options. Avoid breaded and deep fried foods and if you must eat these foods, remove the bread or batter coating.

4. Avoid sandwiches with cold deli meats as they may contain Listeria (harmful bacteria.)

Mexican Food Restaurants1. Select carne asada (charbroiled beef) or chicken and

vegetable fajitas. You may add 1or 2 corn tortillas for starch. Try to include a salad and salsa (especially Pico de Gallo) to avoid eating other side dishes such as rice.

2. Select cooked black or pinto beans instead of refried. 3. Order a salad or broth-based soup as an appetizer

right away. Try to avoid chips while waiting for the meal. A few chips will use up your carbohydrate allowance quickly.

4. Avocado, sour cream and olives are fine to include. These foods do not increase blood sugar levels but they add some fat calories - watch the portion sizes!

5. Be aware of the types of cheese used on some Mexican dishes. Avoid soft cheeses such as queso fresco (which may be made of unpasteurized milk.)

Asian Food Restaurants1. Select brown rice and steamed or sautéed protein

and vegetable dishes.2. Select miso soup, edamame and soba noodle dishes.

If you select rice or noodles be careful with the portion sizes.

3. Sushi rolls with cooked seafood or vegetables like avocado or cucumber are safe.

4. Lettuce wraps and fresh spring rolls wrapped in rice paper are other good options.

5. Ask for low sodium soy sauce and dishes with minimal sauces to avoid extra salt.

6. Avoid the “hidden sugar” sauces such as teriyaki, sweet and sour, oyster, plum and barbecue.

7. Avoid fried foods such as egg rolls, fried prawns or fried won tons.

Italian Food Restaurants1. Select fresh tomato sauce dishes. Avoid fettuccine

and other pasta with Alfredo sauce. 2. If you eat pizza, select a thin crust and add a variety

of vegetables. Avoid the extra cheese and meats. 3. Select oil and vinegar salad dressing and avoid

creamy dressings. 4. Avoid eating bread with your meals. However, if you

must eat it, then eat one piece and select a main entrée without any starch.

Other Hints When Eating Out1. Know your meal plan. If you don’t remember it then

use the Plate Method to select the proper portion and distribution of the food.

2. Ask for dressing and sauces on the side.3. Make a habit of ordering a salad or grilled

vegetables as your first course. 4. If you must have something sweet after your meal,

request fresh fruit as a dessert. 5. Don’t hesitate to ask questions about how a food is

prepared.


n Sweatingn Weaknessn Nausean Dizziness n Confusionn Blurred vision

Exercise & PregnancyBe good to yourself and your baby.

Regular exercise is one of the best things you can do during your pregnancy.

It is not harmful and may help control your blood sugar and weight gain.

Exercise should be something you can do easily. Start slowly and talk with your provider before starting.

Walking, swimming, stationary bicycling, dancing, low impact aerobics, yoga, Pilates and arm exercises are all good.

It is best to exercise 5 days a week, no longer than 30 minutes at one time. You must stop if you are dizzy or in pain.

Exercise 20-30 minutes after each meal will help lower blood sugar.

Drink plenty of water before, during and after exercise.

Stress ManagementIllness and emotional stress can make your blood sugars go up even when you are following your diet.

Relaxing your body can reverse this effect.Exercise: Remains one of the best ways to relieve stress.

Ask your health care provider about what exercises you can do safely.

If you feel overwhelmed or have family stress, use breathing, meditation, or any other relaxation techniques that you have learned.

Breathe Deep: Sit comfortably and put your hand on your belly. When you breathe, let your belly rise instead of your shoulders.

Relax your muscles: Tighten up and then relax your muscles one at a time. Start with your feet and work up.

Imagine a quiet restful place: Picture it in your mind. Rest a hand on your belly and picture your baby in a safe comfortable place to rest and grow.

Medications Used In PregnancyGlyburide: a pill that helps the pancreas produces more insulin and control after meal blood sugars. It should be taken 30 minutes before the meal.

Side effects: Low blood sugar, rash, headache

When taking glyburide you should do the following: n Monitor your blood sugarsn Eat your meals and snacks on timen Carry 15 gram carbohydrate snack when taking a

walk or exercising

Be aware of your signs and symptoms of low blood sugar. If you think your blood sugar is low take the following actions:n Check your blood sugar if possible.n If the blood sugar is 50-60, drink 8 ounce milk,

4 ounce fruit juice, or chew 4 glucose tablets.n Recheck the blood sugar in 15 minutes.n If blood sugar is not above 60, then repeat step 2

and 3.n Follow up with a carbohydrate and protein snack

such as crackers and peanut butter or a meal if close to meal time.

Metformin: A pill that decreases the amount of sugar your liver “overproduces” when you have diabetes.

Side effects: nausea, diarrhea, metallic taste in mouth

Symptoms Of Low Blood Sugar

n Nervousnessn Shakinessn Hungern Anxietyn Headachen Fast heartbeat


Bolus: Short-acting insulin Examples: Humulin R, Novolin R Onset: ½ to 1 hour n Peak of Action: 2-3 hours Duration: 3-6 hours

Starts to work quickly but has a short duration of action. Injection is usually before meals.

Bolus-Rapid Acting insulin: Examples: Humalog, Novolog and Apidra Onset: within 15 minutes n Peak of Action: 1-2 hours Duration: 3-4 hours

Starts to work very quickly, but lasts only a few hours. Injection is usually taken before a meal.

Insulin Therapy In PregnancyFor Gestational Diabetes: When diet, exercise, and oral medications fail to bring the blood sugar down, insulin should be used during pregnancy. Most women do not have to continue taking insulin after the pregnancy.

For Type 1 diabetes: Insulin therapy is mandatory.

For Type 2 diabetes: Depending on the stage of the disease, insulin therapy may be a temporary treatment.

Insulin is a hormone that lowers the blood sugar when it is too high. It helps achieve blood sugar target levels which will make a person with diabetes feel better and have more energy. Using insulin can help prevent problems with mother and baby.

Insulin can come in a vial or a pen. The needle is very small and not considered painful. A R.N. or Diabetes Educator will train you on how to draw the insulin up and give it once or several times a day. She will show you how to rotate the sites and dispose of the syringe or pen needle.

How Your Insulin WorksBasal: Steady and long-acting insulin that works between meals and throughout the night.

Bolus: Rapid burst of insulin that works to match food or lower high blood glucose.

Basal-bolus therapy: Also called “flexible therapy” because it allows for greater flexibility throughout the day. Meals do not have to be eaten at the same time every day and insulin can be taken prior to meals, whenever those meals are scheduled.

Basal-Intermediate-acting insulin: Examples: Humulin N, Novolin N Onset: 2-4 hours n Peak of Action: 4-10 hours Duration: 10-16 hours

Works more slowly than regular insulin, but last longer. Injection is usually taken 2 times per day (morning and night.)


Drawing And Injecting Insulin1. Wash your hands with soap and

water.2. Test your blood glucose and record

results in the log book.3. If you are using a cloudy insulin, roll

the bottle (do not shake) between your hands to mix.

4. Wipe the top of the bottle with alcohol and set it down.

5. Use a new disposable, one-time use syringe with each administration.

6. Draw the plunger out (pulling air into the syringe) to the mark that measures the dose of the insulin you will be taking.

7. Insert the needle into the top of the bottle.

6. Push the plunger into the bottle and inject the air from the syringe into bottle.

9. Leave needle in the bottle and turn the bottle upside down.

10. Draw up your dose (units) of insulin by slowly pulling back on plunger.

11. Remove any air bubbles. Air bubbles in the syringe will not harm you if they are injected, but they can reduce the amount of insulin in the syringe. To remove air bubbles, tap the syringe so the air bubbles rise to the top and push up on the plunger to remove the air bubbles. Recheck the dose and add more insulin to the syringe if necessary.

12. Remove the needle from the insulin bottle. Carefully replace the cap on the needle. 13. You are now ready to give the insulin. 14. Choose an injection site for your insulin shot.15. Do not inject near joints, the groin area, belly button, the middle of the abdomen, or on scars.16. Clean the injection site (about 2 inches of your skin) gently with alcohol. 17. Give the injection at a 90 degree angle (straight in.) 18. Push the plunger down to inject the insulin.19. Hold the needle in place for 5 seconds (count to five) before removing. 20. Pull the needle straight out. 21. Safely dispose of the needle into your sharps container.


Mixing, Drawing And Injecting Insulin1. Wash your hands.2. Pick up the CLOUDY bottle and turn it upside down.3. Roll the bottle gently between your hands to mix the insulin.4. Set the bottle back on the table.5. Wipe the top of both (clear and cloudy) bottles with alcohol.6. Remove the caps from the top and bottom of the syringe.7. Pull the plunger down to the correct unit mark for your CLOUDY insulin dose as ordered.8. Insert the needle into the CLOUDY bottle.9. Push the plunger down to inject air into the CLOUDY bottle.10. Withdraw the empty syringe from the bottle. Set the bottle aside.11. Pull the plunger down to the correct unit mark for the CLEAR insulin dose as ordered.12. Insert the needle into the CLEAR bottle.13. Push the plunger down to inject air into the CLEAR bottle.14. Leave the needle in the bottle.15. Turn the bottle upside down with the needle in it.16. Hold the bottle at eye level.17. Pull the plunger down to the correct unit mark for the CLEAR insulin dose.18. Look for air bubbles in the syringe.19. If you see air bubbles in the syringe, push the insulin back into the bottle, and repeat steps 17 and 18.20. Pull the bottle away from the needle, and set aside the CLEAR bottle.21. Pick up the CLOUDY bottle of insulin.22. Turn the CLOUDY bottle upside down and push the needle into the bottle. Be very careful not to move the plunger.23. Pull the plunger down and withdraw the correct number of units for the CLOUDY insulin.24 The plunger should now be on the unit mark showing the total units of both the CLEAR and CLOUDY types of

insulin. For example, 6 units of CLEAR insulin are already in the syringe. Add 14 units of CLOUDY insulin for a total of 20 units in the syringe.

25. Pull the bottle away from the needle. Set both bottles on the table.26. Look for air bubbles in the syringe.27. If you see air bubbles, discard the dose and begin again.28. Set the syringe down. Do not let the needle touch anything.29. Pinch or spread the skin at the chosen injection site.30. Wipe the area with alcohol. Let the alcohol dry.31. Pick up the syringe. Hold it like a dart.32. Insert the needle straight into the skin at a 90-degree angle. Make sure the needle is all the way through the skin.33. Push the plunger down to inject the insulin. 34. Hold the needle in place for 5 seconds (count to five) before removing. 35. Pull the needle straight out. 36. Safely dispose of the needle into your sharps container.


Preparing And Injecting With A Reusable Pen1. Wash your hands with soap and water.2. Test your blood glucose and record results in the log book.3. If you are using cloudy insulin, turn the pen upside down and right side up several times or roll the pen between

your hands, to mix it. Do not shake vigorously. 4. Take the cap off the pen. 5. Clean the rubber stopper of the cartridge with alcohol swab. 6. Remove the paper tab from disposable, one-time-use needle. Always use a fresh, sterile needle. 7. Screw needle onto the pen.8. Remove outer plastic needle cap and inner needle cover. 9. Prime the needle by dialing 2 units or per manufacturer’s instructions. Hold pen upright and push plunger on end

of the pen to push insulin through the needle. You should see a few drops of insulin at the tip of the needle. If you do not, repeat this step until you do.

10. Dial in dose of insulin you need.11. Clean area of skin where you will give the injection. 12. Push the needle straight in, using a palm grip, keeping the thumb up.13. Push plunger on end of the pen with thumb to inject the insulin. 14. Count to 5 or 10 slowly before taking the needle out of the skin. Do not rub skin. 15. Replace the outer plastic needle cover, unscrew and remove the capped needle. 16. Discard used needle in your sharps container.17. Place the outer pen cap on the pen for storage. The pen should not be stored with a needle attached.

(Insulin may leak out, or air may leak in, if stored with the needle on.)18. Do NOT refrigerate insulin pens once in use.


Site Selection And RotationInjection Sites1. Move the site of each injection. Inject at least 1½

inches away from the last injection site. By rotating your injection sites, you will make your injections easier, safer, and more comfortable. If the same injection site is used over and over again, you may develop hardened areas under the skin that keep the insulin from being absorbed properly.

2. The abdomen except for area around the belly button.

3. The top and outer thighs, avoid injecting too close to the bony area above the knee.

4. The back of upper arms where there is fatty tissue.5. The abdomen absorbs insulin the fastest, followed

by the arms, thighs and buttocks. 6. As the pregnancy progresses and the fatty layer

between the skin and the baby becomes thinner, stop injecting in the abdomen and use the other sites.

Proper Use And DisposalTo maintain healthy injection sites, only use syringes or pen needles one time.1. Needle reuse contributes to the build-up of scar

tissue, which may interfere with insulin absorption. Insulin may not work as expected if injected into that area.

2. Please remember that syringes and pen needles are sterile products that are designed for single use only. They are no longer safe after one use.

Dispose of the Syringe and Needle1. Use a hard plastic empty (old laundry detergent

container) or commercial “sharps” container. When the container is full, replace the lid and tape securely and write “Do Not Recycle.”

2. Drop the entire syringe and needle into your container for used “sharps” equipment. When the container is full, put the lid or cover on it and throw it away with the trash.

Do NOT put this container in the recycling bin. Some communities have specific disposal laws. Check with your local health department for specific disposal instructions in your community.


Sick Day ManagementManagement Actions:1. Test blood sugars every 2-4 hours2. Drink more sugar free fluids to prevent dehydration3. Eat or drink carbohydrate food replacements or

nutritional supplemental drinks4. Call the provider if: BG >240, vomiting,

diarrhea several times, fever >100 degrees, Urinary Tract Infection

Nutrition Considerations:1. Eat small amounts of carbohydrates (15 gm) every

1-2 hours. See sick day food list below2. If vomiting, diarrhea or fever add caffeine free liquids3. Contact health care provider if unable to keep food

or liquids down

Sick Day Food ListSometimes you may be too sick to follow your regular meal plan. Eat 1-2 servings of the carbohydrate containing foods listed below every 1-2 hours as tolerated.

Use extra portions from the free foods list: broth, caffeine free beverages, diet soda and other sugar free drinks.

Each serving has about 15 grams of carbohydratesn 1 slice of toastn 6 saltine crackersn ½ cup regular gelatinn ½ cup of soupn ½ cup of regular ice creamn ¾ cup light yogurtn ½ cup of applesauce (no added sugar)n ½ cup of juicen ½ cup of regular clear sodan ** 1 can of Glucerna®, Boost® or Ensure®

** Carbohydrate content may vary. Please read nutrition label

Morning SicknessHow to Prevent NauseaDo not use coffee and alcohol since they can upset your stomach and harm the baby.

Keep away from stale odors, strong cooking odors, smoke, cleaning fluids, paints, perfumes, or other scents.

Do not eat foods that cause gas like garlic, onion, bell pepper, cabbage and beans.

Stay away from high fat foods that make you feel worse, such as: fried foods, fatty meats, gravies and sauces, oil, butter, cream or lard.

Ideas To Help You Feel BetterGet up slowly in the morning.

Get plenty of fresh air by opening windows, using fans, or taking a walk outdoors.

Drink water or no-calorie liquids at least ½ hour before or after meals.

If water makes you sick, try sipping on a sugar free tart drink such as sugar free lemonade.

Eat chilled food items from your meal plan instead of hot foods, such as fruit, cottage cheese, crackers, sugar free yogurt or nuts.

Eat all meals and snacks on your meal plan.

Contact your health care provider if you cannot follow the recommended meal plan.


Coping With HeartburnHow to feel relief1. Follow your meal plan2. Eat three meals and snacks at the right time3. Drink milk4. Drink fluids allowed between meals5. Eat slowly6. Do not eat before going to bed

Stay away from foods that can cause heartburn1. Greasy, fried or deep fried foods2. Spicy foods like chili or salsa3. Sausage4. Garlic5. Tomato sauces6. Pizza7. Coffee (decaffeinated and caffeinated)

Using antacids for heartburn1. Check with health care provider about which

antacid to take, how much is safe and which are low in salt.

2. Over-the-counter products may be helpful.

Examples that may help include: 1. Tums2. Mylanta3. Riopan4. Gelusil

Do not take Alka-Seltzer, baking soda, soda mints or Rolaids as they contain salt and aspirin

Exercise1. Take a walk. It may help2. Sit quietly and breath deeply

Resting1. Sit upright after meals2. Wait 2 hours after eating to lie down3. Sleep with head elevated

What Is Preterm Labor In Pregnancy?The usual length of pregnancy is 40 weeks. Preterm labor is contractions of the uterus that happen before the 37th week of your pregnancy. These changes are normal after 37 weeks and result in the birth of your baby. The earlier that your baby is born, the higher the risk that your baby will have problems.

If preterm labor is noticed early and treated, it may be possible to stop your contractions and prevent your baby’s preterm birth.

Warning signs of preterm labor:1. Menstrual-like cramps2. Pressure or heaviness felt in your abdomen, pelvis or

thighs3. Abdominal cramping: above or below the belly

button4. Change in vaginal discharge: thick ,sticky, yellow

mucous or water, and pink or bloody discharge; these are not normal

5. Uterine contractions, tightening or balling up of the uterus. A feeling like the baby is pushing out

6. Leaking fluid that you cannot control7. Feeling like something is not right, flu like symptoms

or feeling lousy

What to do to help prevent preterm labor?1. Drink plenty of fluids2. Take rest periods to put your feet up. 3. Share household duties with family members

What to do if you get the above warning signs:1. Lie on your left side2. Drink 2-3 glasses of water3. Call your health care provider


Will I Need Extra Tests During Pregnancy To Check My Baby’s Health?If you have gestational diabetes, your doctor may recommend that you have some extra tests to check your baby’s health such as:n Ultrasound exam, which use sound waves to

make images that show your baby’s growth and whether your baby is larger than normal.

n Non-stress test, which uses a monitor placed on your abdomen to check whether your baby’s heart rate increases as it should when your baby is active.

n A kick count, which counts the baby’s movements (kick, swish or roll). You should feel at least 10 movements in 1-2 hours.

What To Expect After Delivery?Most times, gestational diabetes goes away after the birth of the baby.

On your 6-8 weeks postpartum appointment, your provider will check your risk for diabetes with a lab test (75g 2 hour glucose tolerance test.)

Because you had diabetes during pregnancy, you are at risk of Type 2 diabetes in the future. Follow up with your primary care provider to be tested for it yearly.


Reducing Your Risk After Gestational DiabetesEat a healthy dietEat foods low in fat and watch portion sizes. Eat foods high in fiber such whole grains, beans and a variety of fruits and vegetables. Avoid sweets, high sugar beverages and fast food restaurants.

Keep a healthy weightIf you are overweight, lose weight. Aim to get to your goal weight within one year. Losing weight can help you reduce the risk of getting gestational diabetes with your next pregnancy. Women who remain overweight after pregnancy are more likely to develop Type 2 diabetes in the next 5 years.

Stay physically activeTry to exercise at least 3-5 times per week for 30-60 minutes. Remember any activity counts. Take the kids to the park, use the stairs instead of the elevator, park away from the entrance of stores or buildings, etc.

Breastfeed your babyStudies show breastfeeding your baby can reduce the risk of diabetes for you and your baby. Try to breastfeed for about 6-12 months. Breastfeeding can also help you to lose weight. If you are breastfeeding, you may continue to follow your gestational diabetes meal plan and add another carbohydrate choice for breakfast. Continue the 3 snacks, but once you stop breastfeeding, you may reduce them. Drink plenty of water and other sugar free beverages.

Plan for future pregnanciesGive your body a “break” from the effects of diabetes during pregnancy for at least 2 years. If you get pregnant again, remember to tell your OBGyn doctor you had gestational diabetes with your last pregnancy and possibly get tested for gestational diabetes earlier in the pregnancy.


How Can I Give My Baby A Healthy Start?You can give your baby a healthy start by breastfeeding.

Breast milk provides the best nutrition for your baby and protection against certain illnesses.

To help prepare for breastfeeding:Talk with your health care team about your plans to breast feed.

Ask your provider to recommend a certified lactation consultant to help you with breastfeeding.

Take a breastfeeding class. Pregnant women who learn about how to breastfeed are more likely to be successful than those who do not.

Talk with friends who have breastfed or consider joining a breastfeeding support group.

Breast Feeding GuidelinesBreastfeed as soon as possible after birth. The sucking instinct is very strong within the first hour of life.

You will need to add about 300-500 calories daily to your meal plan of 3 meals and 3 snacks a day.

Include 3 or more servings of milk products daily as well as plenty of fluids such as water and other sugar free, caffeine free beverages.

Continue taking the prenatal vitamin during breastfeeding to ensure that you are getting all the vitamins and minerals you and your baby need.

If you took insulin before your pregnancy, you will probably need to take less while you are breastfeeding to prevent low blood sugar.

To prevent low blood sugar check with your provider or diabetes educator for insulin adjustment recommendations.


References1. CommuniCare Health Centers

www.communicarehc.org2. Sweet Success California Diabetes and Pregnancy

Program (CDAPP) 3. www.womenshealth.gov/breastfeeding4. American Diabetes Association www.diabetes.org5. BD Getting started Gestational Diabetes

www.bd.com6. National Diabetes Information Clearing House (NIH)

www.diabetes.niddk.nih.gov7. www.nutritioncaremanual.org8. Medical Management of Pregnancy

complicated by Diabetes, 5th Edition. Edited by Donald R. Coustan. MD. American Diabetes Association. 2013.

9. Joslin’s Diabetes Deskbook; A guide for Primary Care Providers, 3rd Edition, Richard S. Beaser MD & Staff of Joslin Diabetes Center, Joslin Diabetes Center 2014.

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