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Managing diabetes during illness presents unique challenges that require careful attention and evidence-based strategies. When the body fights infection or deals with any form of illness, the physiological stress response can significantly impact blood glucose control, making diabetes management more complex and potentially dangerous. Understanding how to navigate these sick days effectively is essential for preventing serious complications and maintaining optimal health outcomes.
Understanding the Complex Relationship Between Illness and Blood Glucose
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 even when you’re following your normal diabetes management routine and taking your prescribed medications as directed.
The Stress Hormone Response
During stressful situations, epinephrine (adrenaline), glucagon, growth hormone and cortisol play a role in blood glucose levels, with stressful situations including infections, serious illness or significant emotion stress. Insulin levels fall, glucagon and epinephrine (adrenaline) levels rise and more glucose is released from the liver, while at the same time, growth hormone and cortisol levels rise, which causes body tissues (muscle and fat) to be less sensitive to insulin, resulting in more glucose available in the bloodstream.
These hormones also make it hard for insulin or other medicines to lower your blood sugar. This means that 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.
Why Even Minor Illnesses Matter
Even a minor cold can make your diabetes harder to control, and uncontrolled diabetes can lead to more serious health problems. Minor illnesses in people with diabetes (especially children with type 1 diabetes) can lead to very high blood sugar levels and possible emergencies. The combination of elevated stress hormones, potential changes in eating patterns, and the body’s increased energy demands during illness creates a perfect storm for blood glucose instability.
The Dual Risk: High and Low Blood Sugar
While illness typically causes blood sugar to rise, there’s also a risk of hypoglycemia. 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. Feeling sick often makes you not want to eat or drink, which, surprisingly, can lead to a higher blood sugar. This paradoxical effect occurs because the stress response continues to elevate glucose levels even when food intake decreases.
Developing a Comprehensive Sick Day Action Plan
Preparation is the cornerstone of effective sick day management. 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.
Essential Components of Your Sick Day Plan
Your personalized sick day action plan should include several critical elements. This plan 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, and what foods and fluids to take during your illness.
Additionally, your plan needs to address medication adjustments. Work with your healthcare team to understand how to modify your insulin or oral medications if needed during illness. Having a plan for sick days ahead of time will help you manage your diabetes and will make additional complications less likely.
Assembling 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. Your kit should contain blood glucose monitoring supplies, ketone testing strips or meters, a thermometer, your current medication list, emergency contact numbers for your healthcare team, and easy-to-consume foods and beverages appropriate for sick days.
Make sure you have insulin, other diabetes medicines, and easy-to-make foods, enough for several weeks or longer. This preparation ensures you won’t need to make trips to the pharmacy or grocery store when you’re feeling unwell.
Critical Monitoring Strategies During Illness
Blood Glucose Monitoring Frequency
Increased monitoring is essential during illness. Test your blood sugar every 4 hours and keep track of the results. For those with more advanced monitoring capabilities, 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.
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. This detailed record-keeping helps you and your healthcare team identify patterns and make informed decisions about medication adjustments.
Ketone Testing: A Critical Safety Measure
For individuals with type 1 diabetes, ketone monitoring becomes particularly important during illness. If you have type 1 diabetes, check your urine ketones every time you urinate. We recommend testing for ketones every four to six hours when you’re feeling sick.
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. Ketone testing provides early warning of diabetic ketoacidosis, a potentially life-threatening complication.
Additional Vital Sign Monitoring
Beyond blood glucose and ketones, monitor other vital signs. Weigh yourself every day, as losing weight without trying is a sign of high blood sugar. Check your temperature every morning and evening, as a fever may be a sign of infection. These simple measurements provide valuable information about your body’s response to illness and the effectiveness of your management strategies.
Medication Management During Sick Days
The Golden Rule: Don’t Stop Your Medications
One of the most critical aspects of sick day management is continuing your diabetes medications. Take your diabetes medicines as usual, and keep taking your diabetes medicine, even if you vomit and have trouble eating or drinking. Continue taking your insulin and diabetes pills as usual.
If you do not keep taking insulin, you could get very sick and increase the risk for diabetic ketoacidosis (DKA), and also, 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 sugars, which in turn can worsen the underlying illness.
When Medication Adjustments May Be Necessary
If you are vomiting and can’t take your medicine, call your doctor, as you may need to adjust your medicines. During sick days most people (adults and children) with diabetes may require more insulin. Even if you are not eating as much, your blood sugar can still get very high, and if you use insulin, you may even need extra insulin injections or higher doses.
Your healthcare provider may give you specific instructions for adjusting rapid-acting insulin doses based on blood glucose readings and ketone levels. Follow these instructions carefully and document all medication changes in your sick day log.
Special Considerations for Insulin Pump Users
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. Continuous insulin delivery is crucial during illness, and interrupting this delivery can quickly lead to dangerous elevations in blood glucose and ketone production.
Nutrition and Hydration Strategies for Sick Days
The Critical Importance of Hydration
Maintaining adequate fluid intake is essential during illness. Drink plenty of water to prevent dehydration. More specifically, drink at least twelve 8-ounce (oz) cups (3 liters) of fluid a day.
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 approach helps prevent dehydration even when nausea makes drinking difficult.
Choosing Appropriate Fluids
The type of fluids you consume should depend on your blood glucose levels. 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. 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.
When blood sugars are elevated, focus on sugar-free fluids to maintain hydration without further raising glucose levels. Water, sugar-free electrolyte drinks, and clear broths are excellent choices.
Eating During Illness
Try to eat as you normally would. However, when normal eating isn’t possible, if you can’t eat meals, you’ll need to eat or drink about 50 grams of carbohydrates every 4 hours, with some examples including 1½ cup of unsweetened applesauce or 1½ cup of fruit juice.
Eat small meals often. This approach helps maintain some nutritional intake and provides the carbohydrates needed to prevent hypoglycemia, especially if you’re continuing your usual insulin doses. Focus on easily digestible foods that are gentle on your stomach.
Activity Modifications
Do not do vigorous exercise when you are sick. Your body needs energy to fight illness, and exercise during sickness can lead to unpredictable blood glucose changes and may prolong recovery. Rest is an important component of healing.
Recognizing Diabetic Ketoacidosis: A Medical Emergency
Understanding DKA 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). This condition is particularly dangerous and requires immediate medical attention.
Severe DKA that goes untreated can cause coma or death. Understanding the warning signs and seeking prompt treatment can be lifesaving.
Warning Signs Requiring Immediate Medical Attention
The following are warning signs of DKA, and if you experience any of these, contact your doctor immediately. These signs include persistent nausea and vomiting, abdominal pain, fruity-smelling breath, rapid breathing, confusion, and extreme fatigue.
Go to the emergency room right away if 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. Additional emergency situations include losing 5 pounds or more during the illness, blood sugar lower than 60 mg/dl, vomiting and/or severe diarrhea for more than 6 hours, or temperature over 101 degrees F for 24 hours.
When to Contact Your Healthcare Team
Proactive Communication
There are many reasons to call the diabetes team and you shouldn’t hesitate if you are concerned, as healthcare providers would much rather someone call in to ask questions if they are worried than have something bad happen to them. Call our center, if you have any questions or concerns regarding being ill and your diabetes—it is better to contact us, than to wait until you become very ill.
Specific Situations Requiring Medical Guidance
When you are sick, keep a close watch on diabetes warning signs including high blood sugar that will not come down with treatment, and if you have any of these warning signs and cannot treat them yourself, contact your health care provider right away.
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. This underscores the importance of early intervention and not waiting until symptoms become severe.
Ensuring Accessibility to Care
Keep your doctor’s contact information handy, and be sure you know how to reach your doctor at night or on weekends. 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. Having this information readily available eliminates delays in getting help when you need it most.
Special Considerations for Different Populations
Children with Diabetes
When children are sick, watch them closely for signs that they need medical attention right away, and your doctor will tell you what signs to watch for and what blood sugar level they recommend. Children may require more frequent monitoring, with checking your child’s blood sugar every 3 hours, at the first sign of illness, and keeping a record of blood sugar levels and insulin dosing.
Always give basal/long acting insulin (Lantus, Basaglar, Levemir), regardless of whether your child is eating or drinking. This is crucial for preventing ketoacidosis in children with type 1 diabetes.
Type 1 vs. Type 2 Diabetes Considerations
While sick day management principles apply to all types of diabetes, individuals with type 1 diabetes face higher risks of ketoacidosis and require more intensive monitoring. Those with type 2 diabetes should also remain vigilant, as if you don’t take insulin, continue to take your diabetes medications, even if you are sick and have been throwing up.
Prevention Strategies and Proactive Health Management
Vaccination and Preventive Care
You’ll also want to be sure to get your annual flu shot to make getting the flu less likely. Preventive vaccinations reduce the risk of common illnesses that can complicate diabetes management. Discuss with your healthcare provider which vaccinations are recommended for people with diabetes, including annual influenza vaccines, pneumococcal vaccines, and other age-appropriate immunizations.
Maintaining Optimal Baseline Control
Making sure your blood glucose remains in target is one of the best ways to help your body deal with sickness. Good baseline glucose control provides a buffer when illness strikes and may reduce the severity of blood sugar fluctuations during sick days.
Regular Healthcare Team Communication
Hopefully, your clinic or diabetes team will work with you and provide information about what they recommend for sick days and give you guidelines on when to call them for assistance. Regular appointments and open communication with your diabetes care team ensure your sick day plan remains current and appropriate for your individual needs.
The Role of Support Systems
Family and Caregiver Education
Make sure your family members also know the warning signs. Educating those close to you about diabetes sick day management ensures you have support when you’re too ill to manage everything independently. Family members should know where you keep your sick day kit, emergency contact numbers, and your written sick day action plan.
Emergency Preparedness
If you take insulin, you should also have a glucagon emergency treatment kit prescribed by your provider, and always have this kit available. Ensure family members or caregivers know how to use emergency glucagon in case of severe hypoglycemia.
Understanding the Broader Impact of Illness on Diabetes
The Stress-Diabetes Connection
The relationship between stress and diabetes extends beyond acute illness. Stress hormones make blood sugar rise or fall unpredictably, and stress from being sick or injured can make your blood sugar go up. Understanding this connection helps explain why illness affects diabetes management so profoundly.
Long-term Implications
If you do get sick, your blood sugar can be hard to manage. Repeated episodes of poorly controlled blood glucose during illness can contribute to long-term complications. This makes effective sick day management not just about getting through the immediate illness, but also about protecting long-term health.
Practical Tips for Successful Sick Day Management
Documentation and Record-Keeping
Write down the diabetes medicines you’ve been taking and note if you have changed the dose based on your sick-day plan. Detailed records help you and your healthcare team identify patterns and make informed decisions about treatment adjustments. Record blood glucose readings, ketone levels, medications taken, food and fluid intake, and any symptoms you’re experiencing.
Creating a Supportive Environment
After you’ve discussed these topics with your diabetes care team, be sure to write your plan down to reference when you’re feeling sick. Keep this written plan in an easily accessible location, and make sure it’s clear and easy to follow even when you’re not feeling well.
Leveraging Technology and Resources
The Ambulatory Pediatric Safety Learning Lab has developed an excellent online resource that may be helpful for those living with T1D – diabetessickday.org. Online resources, mobile apps for tracking blood glucose and medications, and continuous glucose monitors can all support effective sick day management. Explore these tools with your healthcare team to determine which might be helpful for your situation.
Addressing Common Challenges and Misconceptions
The Myth of Stopping Insulin When Not Eating
A dangerous misconception is that insulin should be stopped when you’re not eating. As discussed earlier, this can lead to ketoacidosis. The body still needs insulin during illness, often more than usual, regardless of food intake. The stress response and hormone changes during illness create insulin resistance that must be overcome with continued or even increased insulin administration.
Managing Nausea and Vomiting
You may have to take less insulin if you are having severe vomiting, drink fluids with carbohydrates, or utilize mini-glucagon to keep blood sugars in the target range. If unable to keep fluids down or blood sugars up, you can go to an emergency room to get intravenous (IV) dextrose fluids (sugar fluids). Don’t hesitate to seek medical care when oral intake becomes impossible.
Balancing Rest and Monitoring
While rest is important for recovery, it must be balanced with the need for frequent monitoring. Set alarms to wake yourself for blood glucose checks if needed, or enlist family members to help with monitoring so you can rest while ensuring safety.
Recovery and Return to Normal Management
Transitioning Back to Routine Care
As you recover from illness, blood glucose patterns may take several days to return to normal. Continue more frequent monitoring even as symptoms improve, and gradually transition back to your usual testing schedule. Stress hormones can remain elevated for some time after the acute illness resolves, continuing to affect blood glucose levels.
Post-Illness Follow-up
Schedule a follow-up appointment with your healthcare team after recovering from a significant illness. Review what worked well and what could be improved in your sick day management. Update your sick day action plan based on lessons learned from the experience.
Replenishing Your Sick Day Kit
After an illness, restock your sick day kit with any supplies that were used. Check expiration dates on medications and testing supplies, and replace items as needed. This ensures you’re prepared for the next time illness strikes.
The Importance of Mental Health During Illness
Emotional Impact of Sick Days
Illness can be particularly stressful for people with diabetes, adding physical challenges to the already demanding task of diabetes management. If you’re stressed, you may not take care of yourself as well as usual, and your blood sugar levels can be affected too. Acknowledge these feelings and seek support when needed.
Preventing Diabetes Burnout
Repeated illnesses and the intensive management they require can contribute to diabetes burnout. When in doubt, reach out to someone for help. Don’t try to manage everything alone. Your healthcare team, family, and diabetes support groups can provide valuable assistance and emotional support.
Evidence-Based Resources and Continuing Education
Staying Informed
Diabetes management recommendations evolve as new research emerges. Stay connected with reputable sources of diabetes information, including the American Diabetes Association, the Centers for Disease Control and Prevention, and your healthcare team. These organizations provide evidence-based guidelines and resources for all aspects of diabetes care, including sick day management.
Diabetes Education Programs
Consider participating in diabetes self-management education and support (DSMES) programs. These programs provide comprehensive education on all aspects of diabetes care, including detailed sick day management training. Many insurance plans cover these services, and they can significantly improve your confidence and competence in managing diabetes during illness.
Online Communities and Support
Online diabetes communities can provide practical tips and emotional support from others who understand the challenges of managing diabetes during illness. While these communities shouldn’t replace professional medical advice, they can offer valuable peer support and shared experiences. Websites like Children with Diabetes provide specialized resources for families managing pediatric diabetes.
Conclusion: Empowerment Through Preparation
Successfully navigating illness with diabetes requires preparation, vigilance, and a willingness to seek help when needed. By developing a comprehensive sick day action plan, assembling necessary supplies, understanding when to contact your healthcare team, and recognizing warning signs of serious complications, you can manage illness safely and effectively.
Remember that illness affects everyone differently, and your sick day management may need to be individualized based on your type of diabetes, medications, overall health status, and personal circumstances. Work closely with your healthcare team to develop strategies that work for your unique situation.
The key principles remain consistent: continue your diabetes medications unless specifically instructed otherwise, monitor blood glucose and ketones more frequently, maintain hydration, consume appropriate foods and fluids, and seek medical attention promptly when warning signs appear. With proper preparation and management, you can minimize the impact of illness on your diabetes control and prevent serious complications.
Your health and safety are paramount. Never hesitate to contact your healthcare team with questions or concerns during illness. Early intervention and proactive management are always preferable to waiting until problems become severe. By taking a proactive, informed approach to sick day management, you can protect your health and maintain the best possible diabetes control even during challenging times.
Key Takeaways for Effective Sick Day Management
- Develop a written sick day action plan with your healthcare team before you get sick
- Assemble a sick day kit with all necessary supplies and keep it easily accessible
- Continue taking your diabetes medications unless specifically instructed otherwise by your healthcare provider
- Monitor blood glucose every 4 hours or more frequently as recommended
- Test for ketones regularly, especially if you have type 1 diabetes
- Maintain hydration by drinking at least 3 liters of fluid daily
- Consume small, frequent meals or carbohydrate-containing fluids to prevent hypoglycemia
- Keep detailed records of blood glucose, ketones, medications, and symptoms
- Know the warning signs of diabetic ketoacidosis and when to seek emergency care
- Contact your healthcare team early with questions or concerns rather than waiting
- Ensure family members know your sick day plan and where to find emergency information
- Get recommended vaccinations to prevent common illnesses
- Rest adequately but maintain necessary monitoring schedules
- Follow up with your healthcare team after recovering from significant illness
- Update and restock your sick day kit regularly
By implementing these evidence-based strategies and maintaining open communication with your healthcare team, you can navigate illness with confidence and minimize the risk of serious complications. Your proactive approach to sick day management is an investment in your long-term health and well-being. For additional information and support, visit the American Diabetes Association’s sick day resources and discuss any questions with your diabetes care team.