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Understanding the Impact of Illness on Blood Sugar Control
Managing diabetes effectively during illness is crucial to prevent complications and maintain optimal health. When you’re sick with the flu or another illness, your body releases hormones to fight infection, and these hormones raise blood sugar levels. This physiological response occurs regardless of whether you have type 1 or type 2 diabetes, making illness management a critical component of comprehensive diabetes care.
When you are sick, insulin does not work as well in your cells and your blood sugar level can be higher, even if you are taking the normal doses of your medicines, including insulin. This phenomenon can be particularly challenging because it creates an unpredictable situation where standard diabetes management protocols may not be sufficient to maintain target blood glucose levels.
Even a minor cold can make your diabetes harder to control, and uncontrolled diabetes can lead to more serious health problems. Understanding this relationship between illness and blood sugar fluctuations is the first step in developing an effective sick day management strategy. The stress response triggered by illness, whether from a common cold, flu, infection, or other medical condition, can significantly impact glucose metabolism and insulin sensitivity.
When you are sick and you have diabetes your stress hormones increase and your blood sugars may rise even if you are not eating, and during sick days most people (adults and children) with diabetes may require more insulin. This counterintuitive situation often surprises people with diabetes who expect their blood sugar to drop when they’re not eating normally.
Creating a Comprehensive Sick Day Action Plan
Preparation is essential for managing diabetes during illness. Work with your doctor to write a sick-day plan for how to help prevent high blood sugar when you’re sick, keep your plan in a handy place, and let your family know where you keep the plan. Having a written plan eliminates confusion and uncertainty during times when you may not be thinking clearly due to illness.
Before you get sick, decide on an action plan with your health care team that should include when to call your doctor (in most cases if you are vomiting or have diarrhea more than three times over 24 hours or have had a fever over 101° for 24 hours), how often to check your blood glucose, what foods and fluids to take during your illness, and how to adjust your insulin or oral medication, if you need to.
Your sick day action plan should be personalized to your specific situation, taking into account your type of diabetes, current medications, typical blood sugar patterns, and any other health conditions you may have. This individualized approach ensures that you have clear, actionable guidance when illness strikes.
Essential Components of Your Sick Day Kit
If you do get sick, it’ll make things easier if you already have a sick-day kit ready to go with the things you’ll need. Assembling this kit before you become ill ensures you have all necessary supplies readily available when you need them most. Your sick day kit should be stored in an easily accessible location and checked periodically to ensure supplies haven’t expired.
Make sure you have insulin, other diabetes medicines, and easy-to-make foods, enough for several weeks or longer. This preparation is particularly important during flu season or when infectious diseases are circulating in your community. Having adequate supplies prevents the stress of running out of critical medications or testing supplies when you’re too ill to leave home.
Your sick day kit should include blood glucose testing supplies, ketone testing strips or meters (especially for type 1 diabetes), a thermometer, your blood glucose meter with extra batteries, contact information for your healthcare team, a list of your current medications and dosages, and easy-to-digest foods and beverages that can help maintain blood sugar levels when you have difficulty eating regular meals.
Intensive Blood Glucose Monitoring During Illness
Regular monitoring of blood glucose becomes even more critical during illness. The current recommendations from the International Society for Pediatric and Adolescent Diabetes (ISPAD) are to either utilize CGM (continuous glucose monitoring) or do finger sticks every 1-2 hours and monitor ketone levels. This increased frequency allows you to detect dangerous trends early and respond appropriately.
Test your blood sugar every 4 hours and keep track of the results. This recommendation applies to most people with diabetes during illness, though some situations may require even more frequent monitoring. Keeping detailed records of your blood sugar readings, along with notes about symptoms, food intake, and medication doses, provides valuable information for both you and your healthcare team.
Patients with T1D should monitor their blood glucose every 4 hours and check their urine for ketones during an acute illness. For individuals with type 1 diabetes, this frequent monitoring is particularly important because of the risk of diabetic ketoacidosis (DKA), a serious and potentially life-threatening complication.
Check your blood sugar every 4-6 hours, at the first sign of illness, and keep a record of your blood sugar levels and insulin dose, if you take insulin. Starting this intensive monitoring at the first sign of illness, rather than waiting until you feel very sick, allows for earlier intervention and may prevent more serious complications.
Understanding Blood Sugar Patterns During Illness
Illness can cause blood sugar levels to rise due to the added stress on the body, however, low blood sugar is also a risk if one cannot keep down food. This dual risk makes monitoring essential, as you need to be prepared to respond to both hyperglycemia and hypoglycemia during illness.
The unpredictability of blood sugar during illness stems from multiple factors working simultaneously. Stress hormones like cortisol and adrenaline increase glucose production in the liver while simultaneously making cells more resistant to insulin. At the same time, reduced food intake, vomiting, or diarrhea can lead to inadequate carbohydrate intake, potentially causing low blood sugar, especially if you continue taking your usual diabetes medications.
More frequent BGM is also needed during acute illness or times of stress. This applies to all people with diabetes, regardless of their usual monitoring routine. Even those who typically check their blood sugar only once or twice daily should increase their monitoring frequency during illness.
Medication Management and Insulin Adjustments
One of the most critical aspects of sick day management is continuing your diabetes medications. Keep taking your diabetes medicine, even if you vomit and have trouble eating or drinking, and if you are vomiting and can’t take your medicine, call your doctor as you may need to adjust your medicines. This guidance often surprises people who assume they should skip medications when not eating normally.
Continue taking your insulin and diabetes pills as usual. This recommendation is fundamental to sick day management and cannot be overstated. Stopping insulin or other diabetes medications during illness can lead to dangerous blood sugar elevations and potentially life-threatening complications like diabetic ketoacidosis.
If you do not keep taking insulin, you could get very sick and increase the risk for diabetic ketoacidosis (DKA), and when your blood sugars stay higher, the infection can worsen as the bacteria or virus feed off the extra sugar and become stronger. This creates a dangerous cycle where stopping insulin leads to higher blood sugar, which in turn makes the illness worse and harder to recover from.
When Insulin Adjustments May Be Necessary
If you use insulin, you may even need extra insulin injections or higher doses. The increased insulin resistance that occurs during illness often means that your usual insulin doses are insufficient to maintain target blood sugar levels. This is why working with your healthcare team to develop specific guidelines for insulin adjustment during illness is so important.
Take your usual dose of insulin or diabetes pills, and you may need more insulin, call your doctor for adjustments. Never attempt to make significant medication adjustments without guidance from your healthcare provider, especially if you’re unfamiliar with sick day management protocols. However, having pre-established guidelines from your doctor about when and how to adjust doses can help you respond quickly to changing blood sugar levels.
For people using insulin pumps, special considerations apply. If you wear an insulin pump, do not take off your pump unless you will be taking insulin shots while you are off the pump. Discontinuing insulin delivery without an alternative method can lead to rapid development of ketoacidosis, particularly in people with type 1 diabetes who produce little or no insulin naturally.
Ketone Testing and Diabetic Ketoacidosis Prevention
Ketone monitoring is a critical component of sick day management, particularly for people with type 1 diabetes. If you have type 1 diabetes, check your urine ketones every time you urinate. This frequent monitoring allows for early detection of ketone accumulation, which can progress rapidly to diabetic ketoacidosis if not addressed promptly.
We recommend testing for ketones every four to six hours when you’re feeling sick. Ketones are produced when the body breaks down fat for energy instead of using glucose, which occurs when there isn’t enough insulin available to move glucose into cells. During illness, the combination of increased insulin resistance and inadequate insulin can lead to ketone production even when blood sugar levels are elevated.
If you have type 1 diabetes check your urine for ketones when your blood sugar is 300 or higher, and call you doctor, if you have moderate to high ketones in your urine or high blood sugars over 300 on two tests in a row that does not respond to insulin and fluids. These specific thresholds provide clear guidance on when medical intervention is necessary.
Understanding Diabetic Ketoacidosis Risk
If your body does not have the proper amount of insulin, you run the risk of your body producing too many ketones, which puts you at risk of developing a serious condition called diabetic ketoacidosis (DKA). DKA is a medical emergency that requires immediate treatment, typically in a hospital setting.
Severe DKA that goes untreated can cause coma or death. This stark reality underscores the importance of vigilant monitoring and early intervention during illness. Understanding the warning signs of DKA and knowing when to seek emergency medical care can be lifesaving.
Warning signs of DKA include persistent high blood sugar levels that don’t respond to insulin, moderate to large ketones in urine or blood, excessive thirst and frequent urination, nausea and vomiting, abdominal pain, fruity-smelling breath, rapid breathing, confusion or difficulty concentrating, and extreme fatigue. If you experience any combination of these symptoms during illness, contact your healthcare provider immediately or seek emergency medical care.
Hydration and Nutritional Strategies During Illness
Maintaining adequate hydration is essential during illness, especially for people with diabetes. Drink at least twelve 8-ounce (oz) cups (3 liters) of fluid a day. This recommendation may seem challenging when you’re feeling unwell, but adequate fluid intake helps prevent dehydration, supports kidney function, and can help lower elevated blood sugar levels.
Drink plenty of water to prevent dehydration. Water should be your primary beverage choice during illness, as it provides hydration without affecting blood sugar levels. However, the type of fluids you consume may need to vary depending on your blood sugar levels and ability to eat.
Be sure you’re getting enough water—so drink plenty of it, and if you’re having trouble keeping water down, have small sips every 15 minutes or so throughout the day. This strategy of frequent small sips can be more tolerable than trying to drink large amounts at once when you’re nauseous or have an upset stomach.
Choosing Appropriate Foods and Beverages
Drink plenty of sugar-free fluids to keep your body from getting dried out (dehydrated). Sugar-free beverages are generally the best choice when blood sugar levels are elevated or in target range. Options include water, sugar-free sports drinks, broth, herbal tea, and diet beverages.
If your blood sugar is less than 100 mg/dL (5.5 mmol/L) or falling quickly, it is OK to drink fluids that have sugar in them. This guidance is important because it addresses the risk of hypoglycemia during illness, particularly when you’re unable to eat solid foods. Beverages containing carbohydrates can help maintain blood sugar levels and prevent dangerous lows.
Having simple carbs handy like regular soda, Jell-O, or popsicles will help keep your blood glucose up if you are at risk for lows. These easily digestible carbohydrate sources are particularly useful when you have nausea or difficulty eating solid foods. They provide quick-acting carbohydrates that can prevent or treat hypoglycemia while being gentle on an upset stomach.
If you can’t eat meals, you’ll need to eat or drink about 50 grams of carbohydrates every 4 hours, and some examples include 1½ cup of unsweetened applesauce or 1½ cup of fruit juice. This specific guidance helps ensure you’re getting enough carbohydrates to prevent hypoglycemia while maintaining some consistency in your carbohydrate intake.
Eat small meals often, and even if you are not eating as much, your blood sugar can still get very high. This counterintuitive fact often confuses people with diabetes who expect their blood sugar to drop when they’re eating less. The stress hormones released during illness can cause blood sugar to rise significantly even with reduced food intake.
Recognizing Critical Warning Signs
Knowing when to seek medical attention is crucial for preventing serious complications. Waiting too long to get medical care when you are sick can lead to getting much sicker, and when you have diabetes, a delay in getting care can be life threatening. Understanding the warning signs that require immediate medical attention can literally save your life.
Go to the emergency room right away if any of the following occurs: You’re having trouble breathing, you have ketones in your urine, or you can’t keep any liquids down for more than 4 hours, or can’t keep food down more than 24 hours. These are clear indicators that your condition requires immediate professional medical intervention.
Emergency Situations Requiring Immediate Care
Several specific situations warrant immediate emergency care. You lose 5 pounds or more during the illness, your blood sugar is lower than 60 mg/dl, you have vomiting and/or severe diarrhea for more than 6 hours, or your temperature is over 101 degrees F for 24 hours. Any of these conditions indicates that your illness has progressed beyond what can be safely managed at home.
Additional warning signs include persistent high blood sugar levels above 250 mg/dL that don’t respond to insulin, moderate to large ketones in urine or blood, signs of severe dehydration such as dry mouth, cracked lips, sunken eyes, or decreased urination, chest pain or pressure, severe abdominal pain, confusion or difficulty thinking clearly, and extreme weakness or inability to stand.
Minor illnesses in people with diabetes (especially children with type 1 diabetes) can lead to very high blood sugar levels and possible emergencies, and when children are sick, watch them closely for signs that they need medical attention right away. Children with diabetes require particularly vigilant monitoring during illness, as they may deteriorate more rapidly than adults and may have difficulty communicating how they’re feeling.
Special Considerations for Different Types of Diabetes
While many sick day management principles apply to all people with diabetes, there are important differences in approach based on diabetes type and treatment regimen. People with type 1 diabetes face unique challenges during illness because they produce little or no insulin naturally, making them particularly vulnerable to diabetic ketoacidosis.
Always give basal/long acting insulin (Lantus, Basaglar, Levemir), regardless of whether your child is eating or drinking. This guidance is critical for type 1 diabetes management during illness. The basal insulin provides the background insulin needed to prevent ketoacidosis, even when food intake is reduced or absent.
For people with type 2 diabetes, sick day management may be somewhat different depending on their treatment regimen. If you don’t take insulin, continue to take your diabetes medications, even if you are sick and have been throwing up. However, certain oral medications may require adjustment during illness, particularly those that can cause hypoglycemia or affect kidney function.
Pediatric Sick Day Management
Check your child’s blood sugar every 3 hours, at the first sign of illness, and keep a record of blood sugar levels and insulin dosing. Children with diabetes require even more frequent monitoring than adults during illness, as their smaller body size means they can develop complications more rapidly.
Check and record urine ketones every time your child urinates (or with a diaper change). This frequent ketone monitoring in children is essential because ketoacidosis can develop quickly, and early detection allows for prompt intervention before the situation becomes critical.
If ketones are moderate or large, contact the Harold Schnitzer Diabetes Health Center immediately for guidance on insulin dosing at 503-494-3273, and if it is an evening or weekend, call 503-494-8311 and request the on-call pediatric endocrinologist. Having clear protocols for when and how to contact medical professionals is particularly important for parents managing a child’s diabetes during illness.
Activity and Exercise Modifications During Illness
Do not do vigorous exercise when you are sick. This recommendation is important because exercise during illness can place additional stress on the body and may worsen dehydration or cause unpredictable blood sugar fluctuations. When you’re ill, your body needs energy to fight infection and heal, and intense physical activity diverts resources away from these critical processes.
Rest is an essential component of recovery from illness, and this is particularly true for people with diabetes. Adequate rest helps your immune system function optimally, reduces stress hormone production, and allows your body to respond better to insulin. While complete bed rest may not be necessary for minor illnesses, significantly reducing your activity level and getting extra sleep can support your recovery.
Once you begin to feel better, gradually resume your normal activity level rather than jumping back into your full exercise routine immediately. Monitor your blood sugar closely as you increase activity, as your insulin sensitivity may change as you recover from illness. Your healthcare provider can give you guidance on when it’s safe to return to your normal exercise routine.
Communication with Your Healthcare Team
There are many reasons to call the diabetes team; you shouldn’t hesitate if you are concerned, and speaking as a certified diabetes care and education specialist and a nurse, I would much rather someone call in to ask questions if they are worried than have something bad happen to them. This perspective from healthcare professionals emphasizes that it’s always better to err on the side of caution when managing diabetes during illness.
Keep your doctor’s contact information handy, and be sure you know how to reach your doctor at night or on weekends. Having this information readily available before you become ill eliminates the stress of searching for contact information when you’re not feeling well. Include phone numbers for your primary care provider, endocrinologist, diabetes educator, and local emergency services in your sick day kit.
You will also want to keep a list of emergency information such as your doctor’s phone number, a list of medications you’re taking, and your insurance information. This comprehensive list ensures that if you need emergency care, healthcare providers have all the information they need to treat you safely and effectively.
When to Contact Your Healthcare Provider
Contact your healthcare provider if you experience vomiting or diarrhea for more than a few hours, fever that persists for more than 24 hours, blood sugar levels consistently above 250 mg/dL that don’t respond to your usual treatment, blood sugar levels below 70 mg/dL that don’t respond to treatment, presence of ketones in urine or blood, inability to eat or drink for more than a few hours, signs of dehydration, or any symptoms that concern you.
Emphasis should be placed on educating the patient on the importance of notifying their primary care provider of any spikes in glucose that do not respond to their medication regimen. This proactive communication allows your healthcare team to provide guidance before the situation becomes critical, potentially preventing emergency room visits or hospitalizations.
Preventing Illness and Preparing for Sick Days
You’ll also want to be sure to get your annual flu shot to make getting the flu less likely. Prevention is always preferable to treatment, and vaccinations are an important tool for reducing your risk of serious illness. People with diabetes should receive recommended vaccinations including annual flu shots, pneumonia vaccines, and COVID-19 vaccines as recommended by their healthcare provider.
While having diabetes does not make you more likely to get a cold or flu, it does raise your chances of getting seriously sick, and having a plan for sick days ahead of time will help you manage your diabetes and will make additional complications less likely. This underscores the importance of preparation and planning before illness strikes.
Good general health practices can help reduce your risk of illness. These include washing hands frequently and thoroughly, avoiding close contact with people who are sick, maintaining good blood sugar control which supports immune function, getting adequate sleep, managing stress, eating a nutritious diet, and staying up to date with dental care to prevent infections.
Monitoring and Recording During Illness
Write down the diabetes medicines you’ve been taking, and note if you have changed the dose based on your sick-day plan. Detailed record-keeping during illness provides valuable information for your healthcare team and helps you track patterns and responses to treatment.
Your illness records should include the date and time of each blood sugar check, blood sugar readings, ketone test results if applicable, medications taken including doses and times, food and fluid intake, symptoms experienced, temperature readings, and any communications with healthcare providers. This comprehensive documentation helps identify trends and provides your healthcare team with the information they need to adjust your treatment plan if necessary.
Weigh yourself every day, as losing weight without trying is a sign of high blood sugar, and check your temperature every morning and evening, as a fever may be a sign of infection. These additional monitoring parameters provide important information about your overall condition and can help identify complications early.
Long-term Implications and Recovery
Recovery from illness when you have diabetes may take longer than for people without diabetes, particularly if blood sugar control was significantly disrupted during the illness. Continue monitoring your blood sugar more frequently than usual for several days after you begin feeling better, as your insulin needs may continue to fluctuate during the recovery period.
Once you’ve recovered from illness, schedule a follow-up appointment with your healthcare provider to review how the illness was managed and whether any adjustments to your sick day plan are needed. This debriefing can help you feel more prepared and confident for managing future illnesses.
If you experienced significant blood sugar fluctuations or complications during your illness, your healthcare provider may recommend checking your A1C level a few months after recovery to assess whether the illness had any lasting impact on your overall blood sugar control. This information can help guide any necessary adjustments to your ongoing diabetes management plan.
Resources and Support for Sick Day Management
The Ambulatory Pediatric Safety Learning Lab has developed an excellent online resource that may be helpful for those living with T1D – diabetessickday.org. This specialized resource provides detailed guidance on managing diabetes during illness, including calculators for insulin dosing adjustments based on ketone levels.
Many diabetes organizations provide sick day management resources, including the American Diabetes Association, which offers comprehensive guides and educational materials. The Centers for Disease Control and Prevention also provides evidence-based information on diabetes management during illness.
Diabetes education programs and certified diabetes care and education specialists can provide personalized instruction on sick day management, including hands-on practice with ketone testing, insulin adjustment calculations, and problem-solving strategies. Many insurance plans cover diabetes education services, making this valuable resource accessible to most people with diabetes.
Support groups, both in-person and online, can provide practical advice and emotional support from others who have experience managing diabetes during illness. Hearing how others have successfully navigated sick days can provide valuable insights and increase your confidence in your ability to manage similar situations.
Technology and Sick Day Management
Continuous glucose monitoring (CGM) systems can be particularly valuable during illness, providing real-time glucose data and trend information without the need for frequent finger sticks. CGM devices can alert you to rapidly rising or falling blood sugar levels, allowing for earlier intervention. Some systems can share data with family members or caregivers, providing an additional safety net when you’re ill.
Smartphone apps can help you track blood sugar readings, medications, food intake, and symptoms during illness. Many apps allow you to share this information electronically with your healthcare team, facilitating remote monitoring and guidance. Some apps also provide reminders for blood sugar checks and medication doses, which can be helpful when you’re not feeling well and may have difficulty remembering your usual routine.
Telemedicine services have become increasingly available and can be particularly useful during illness, allowing you to consult with your healthcare provider without leaving home. This can be especially valuable when you’re too ill to travel to an office visit but need medical guidance beyond what can be provided over the phone.
Conclusion: Empowering Yourself for Successful Sick Day Management
Managing diabetes during illness requires preparation, vigilance, and a clear understanding of when to seek help. By developing a comprehensive sick day action plan with your healthcare team, assembling a well-stocked sick day kit, understanding the principles of intensive monitoring and medication management, and knowing the warning signs that require medical attention, you can navigate illness safely and effectively.
Remember that every illness is different, and what works well for one situation may need to be adjusted for another. The key is to start with evidence-based guidelines, monitor closely, communicate with your healthcare team, and be willing to seek help when needed. With proper preparation and management, you can minimize the impact of illness on your diabetes control and reduce your risk of serious complications.
The investment you make in preparing for sick days—creating your action plan, assembling your kit, learning the warning signs, and establishing clear communication channels with your healthcare team—pays dividends when illness strikes. Rather than facing uncertainty and anxiety, you’ll have a clear roadmap to follow, allowing you to focus your energy on recovery while maintaining safe blood sugar control.
For additional information and support, consult resources from reputable organizations such as the National Institute of Diabetes and Digestive and Kidney Diseases, which provides comprehensive, evidence-based information on all aspects of diabetes management. Your healthcare team remains your most valuable resource, so don’t hesitate to reach out with questions or concerns about managing your diabetes during illness.