To minimize the effects of your diabetes, you need to make sure that your blood sugar is not too high or too low, so there are as few hypos and hypers as possible. If you have had diabetes for some time or know someone with diabetes, you know that this is a very difficult task. Fortunately, you are not alone; your parents, your diabetes nurse and your doctor are there to help you. They can teach you how best to handle your diabetes.

Treatment of diabetes Type 1:

Make sure you regularly measure your blood sugar and administer insulin. In addition, there are some important attention points, such as:

• your diet
• your lifestyle and exercise routines
• regular monitoring by a diabetes team

Administering insulin:

Insulin exists only as an injection fluid, so you need to inject it. This can be done in two ways: inject yourself with an insulin pen or by using a continuous insulin pump. The choice of an insulin pen or a pump is made after consulting you, your parents and the diabetes team. The diabetes team determines which therapy will be the best for you. They will take your age, home situation and your physical and mental state into account.

Insulin pen:

An insulin pen is a syringe filled with insulin in the shape of a fountain pen. The tip contains a thin needle. The pen has a special cartridge containing insulin that you can easily replace when empty. On the pen, you can set how many units you need to inject, so you always inject the right amount of insulin.

The place where you inject should vary. You can choose your upper legs, buttocks, belly and upper arms, preferably a place where you can easily grab a skin fold. It is important to change the places regularly to avoid local irritation.

Insulin pump:
An insulin pump is a small computer in which an ampoule of insulin is placed. The ampoule has a thin tube with a very thin needle at the end. Insert the needle under the skin of your stomach, buttock or leg (you may choose) and put a plaster on straight away. The needle and plaster remain in place for a few days. It’s good to put the needle in a different place every two or three days, or if there is redness, swelling or sensitivity. At that time the tube should also be replaced. The pump works on a battery. Make sure it is replaced or recharged on time, so you don't end up with an empty battery.

The pump ensures a small amount of insulin is administered day and night. This is called the basal position of the pump. At the point when you eat or drink, you can use the pump to give yourself a bolus of insulin. You can easily do this using the buttons on the pump itself, or a remote control. With an insulin pump, you can respond very accurately to the amount of food you ingest and the amount of energy you consume. Using the pump regulates your blood sugar levels, preventing highs and lows. The effect of the insulin pump is most comparable to the functioning of a healthy pancreas. It also continuously delivers insulin and regulates its level.

The pump should always be carried with you-you must get used to wearing it. However, because the pump helps to reduce the number of times to inject during the day, children often get used to wearing it very quickly. It can be disconnected so you can exercise, swim and shower. You can cover the needle after disconnecting the pump

	Insulin pen	Insulin pump
Dosage	3 times short-acting insulin around meal time; 1 time long-acting insulin before bedtime. A different schedule is possible.	Continuous administration (basal position) with boluses.
Number of time to inject	2 to 4 times a day, or more.	Every 2 to 3 days.
Pros	You don't carry anything with you, there's nothing attached to your body (like an insulin pump). You know exactly how much insulin you've injected, the amount you inject goes inside.	You can regulate your blood sugar level even better and adjusting is easy. Less frequent injections. You can easily adapt to spontaneous actions or changes (extra food, sports or illness), you always have your insulin with you. During swimming, showering and sports, the pump can be disconnected.
Cons	You need to inject several times every day If you inject long-acting insulin, you can adjust less well to spontaneous actions (such as extra sports activities). Fluctuation of your blood sugar level can occur more frequently.	You always carry something with you, the pump is attached to your body. You need to learn to deal with it and give yourself extra boluses during meals. Your blood sugar can quickly deregulate (level too high) if the pump cannot do its job, for example if the tube is clogged.

There are several types of insulin:

Short-acting insulin:

• insulin aspart (Novorapid®), Insulin glulisine (Apidra SoloStar®), insulin lispro (Humalog®).
  Working within 10 to 20 minutes, maximum effect after 1 to 3 hours, the total working time is 3 to 5 hours.
• regular insulin (Actrapid®, Humulin Regular®, Insuman Infusat®, Insuman Rapid®). Working within 30 minutes, total working time is 7 to 9 hours.

Intermediate-acting insulin:
Isofaan Insulin (Humulin NPH®, Insulatard®, Insuman Basal®).
Working within 1.5 hours, maximum effect after 4 to 12 hours, total working time is 24 hours.

Long-acting insulin:
Insulin detemir (Levemir®), insulin glargine (Lantus®).
Starts working slowly (so the insulin is slowly absorbed), maximum effect after 6-8 hours, total working time is 24 hours.

Insulinemix:
Combination of short-acting and medium-acting insulin:
insulin aspart/insulin aspart prot Amine (Novomix®), insulin lispro/insulin lispro prot Amine (Humalog Mix®).
Working within 10-20 minutes, maximum effect after 1 to 4 hours, the total working time is 24 hours.

Glucagon administering

It’s dangerous if your blood sugar level drops too low because you can lose consciousness. It’s important to prevent hypo’s, but if they do occur, you need to know what to do. If you experience a hypo, you need to eat and drink something. You need to choose foods that release sugars into your bloodstream quickly, for example, Dextrose tablets (which contain glucose) and sugary lemonade. If you don’t have that with you then biscuits, a sandwich, a banana or fruit juice are also good, but these take longer for the sugars to enter your bloodstream. Sometimes you just can’t eat anything because you feel queasy, need to vomit, or because you are lightheaded or unconscious. Then you need to be treated differently, namely with glucagon (tradename GlucaGen®) is needed at such a moment.

Glucagon is a hormone which your body produces itself and causes your blood sugar levels to rise. Glucagon helps the glycogen in your liver to be converted into glucose and enter your bloodstream. If the correct amount of glucagon is injected during a hypo, then your blood sugar levels will rise within 5 to 20 minutes. The glucagon injections are wrapped in a sturdy packaging (casing/purse) making it easy to keep with you wherever you go. The package contains a syringe, sterilized water and glucagon in powder form. To prepare the injection: inject the sterilized water using the syringe into the bottle with glucagon powder and shake well until the powder has dissolved. Then suck the liquid back up into the syringe, and its ready to inject. It's important to have the technique explained properly to you by someone from your diabetes team. You and your parents need to practice enough so that if ever an emergency does occur, you know what to do straight away. The glucagon can be injected into your arm, leg, stomach or buttock. It’s important to inject the fluid slowly to prevent nausea and the need to vomit. Glucagon injections should be kept cool in the fridge. If you’re out for a few hours, for example at school or on a visit somewhere, it’s also important to keep the injections cool there too. Make sure you keep an eye on the expiry date and replace it on time.

Treating diabetes Type 2

Most children who have diabetes Type 2 are overweight. If you make sure that you exercise enough, eat well, and keep your weight under control your sensitivity to insulin will increase. You can ask for help from a nutritionist and your diabetes nurse. They can tell you exactly what you should be careful of, and how you can achieve your goal. You can also increase your sensitivity to insulin by using medicine, for example, metformin. Metformin increases not only your sensitivity to insulin but also prevents the production of glucose by the liver. It is available in the form of tablets that you need to take 2 to 3 times a day. In the beginning, you might experience side effects such as queasiness, stomach ache and loss of appetite (not wanting to eat). Sometimes the measures you take are not enough and eventually, you may need to start injecting insulin.

You can find more information about injecting insulin in the chapter “Treatment of diabetes Type 1”.

Diet

Your body needs food every day, preferably healthy, sensible food, even when you have diabetes. You don’t have to follow a special diet or strict rules. A sugar-free diet is not necessary either, but you should not drink sweet drinks such as lemonade, fruit drinks or fizzy drinks. If you really want to, sugar-free soft drinks are ok. Furthermore, you can eat normally, but follow a varied and healthy diet. It is important to eat regularly throughout the day. Regularity is crucial. For example, have 3 main meals a day, and 3 snack moments. Then, the amount of insulin you need per day, can be regulated more easy depending on the amount of energy (glucose) you get from the food you eat.

Can you get diabetes from eating too many sweet things?
The risk of being diagnosed with diabetes Type 1 is not increased by eating too many sweet foods. However, for diabetes Type 2 it’s a different story. It’s not the sweet food itself, but the large number of calories (energy) you consume by eating sweets or for example junkfood that increase the risk. The excess calories are stored as fat, which causes overweight or obesitas. If you are obese, don’t exercise enough and have the genetical predisposition, you can develop diabetes Type 2.

Your activities and use of energy

Children use lots of energy. Your blood sugar level and insulin requirement change just by doing your daily activities, such as playing, taking part in sports and going to school, even by growing and developing! Luckily, you learn how to take all these things into account. If you play sports, cycle to school or have exams, for example, you will learn, bit by bit, to recognize how your body reacts to different types of activity.
Coping with the changes that happen during puberty can be more difficult. Managing blood sugar levels during this period is more difficult and sometimes you can barely get a grip on it. Your diabetes team has lots of experience managing diabetes during puberty. They can help teach you the necessary tips and tricks.

When you are sick
When you are sick, for example, because of an infection and you have a temperature, all sorts of things can happen with your blood sugar. Hormones (cortisol and glucagon) are released, causing your blood sugar level to increase. Because of this, you need more insulin. You can notice this at moments you won’t feel like eating and your blood sugar level remains high. That’s why you still need to take your insulin, even when you are sick and have lost your appetite.

But if you have the stomach flu, and are vomiting and have diarrhoea, then you might need less insulin because you’re losing glucose.
Being sick, having a temperature, not eating and working out how much insulin you need is difficult. You must learn to deal with this. Your diabetes team can give you advice. When you are sick and have questions, don’t hesitate to contact them because they can help you work through your problems.

Interpreting the feeling of nausea and throwing up can be difficult. It’s not always obvious why you feel sick. Children who are ill, often feel nausea or need to throw up, not just when they have stomach flu, but for example also if they have a urine infection. However, feeling nausea and throwing up can be a sign that you don’t have enough insulin. That’s why it’s important to determine the blood sugar level and ketones. If your blood sugar level is too high, and ketones are found in your urine or blood, you probably don’t have enough insulin which explaines your nausea. Is your blood sugar level low, then you are probably feeling sick because of the illness itself. Meanwhile, ketones in your blood or urine can be present, caused by not eating enough.

Ketones are released when your body has a shortage of glucose and needs to create energy in a different way. The shortage of glucose can be caused when you don’t consume enough because you haven’t eaten enough or because you don’t have enough insulin to help get the glucose into your cells.

Check-ups by the diabetes team

If you have a chronic illness, such as diabetes, it is important that the doctors and nurses know you well and know how your illness is progressing. That's why each hospital has a diabetic team with a paediatrician, a diabetic nurse, a dietitian and a child psychologist. In almost all hospitals, the diabetes team is available 24 hours a day, so that you can also contact them with problems and emergencies at night. The frequency of your check-ups depends on your situation. Usually, this is once every three or four months. If you are doing well they will be less often, if you are having problems you will come in more often.
During a check-up, you and your parents are asked how you are doing. Are there any complaints, do you have many hypo's or hypers, are there any problems? A lot of attention is given to blood sugar levels and insulin use, but also to how you feel and how you develop. Practical matters are also discussed in detail. The proper diet and enough exercise are important parts of diabetes treatment, so these topics will also be discussed. During a physical examination, your height, weight, blood pressure and injection spots will be examined. When you enter puberty, this development is also checked.

You also get regular blood and urine tests. In the blood, the HbA1c (explanation below) and the amount of fats are measured. Your urine is examined for proteins, glucose and ketones. Because diabetes is an autoimmune disease, you are also checked on other autoimmune diseases, such as celiac disease (gluten hypersensitivity), thyroid disorders or a dysfunctional adrenal gland.

Your diabetes team will also guide you gradually in taking your own responsibility for your disease. If you have acquired diabetes at a young age, your parents usually have taken on all responsibility, but as you get older you must take over more and more yourself. After all, it is your body and future. But even if you organize and check everything yourself, your diabetes team is ready to help you. This gradual change of responsibility is called transition.

The amount of HbA1c in your blood gives an impression of the average blood sugar level in the last two to three months. Hb stands for haemoglobin, which is a protein in your red blood cells. It ensures that oxygen can be transported in your blood. Glucose likes to adhere to the protein haemoglobin, and once it is attached it will not release it. If glucose is attached to haemoglobin, this is called haemoglobin HbA1c. If you are managing well and you have had few high blood sugar levels for the last 2 to 3 months, then the HbA1c will be within the desired values. If you have a lot of hypers and you are not regulated well, the value will be higher. Usually, an HbA1c between 53 and 58 mmol/L is ok, an HbA1c lower than that, is ideal and an HbA1c higher than that, gives more chance of complications. Therefore, a high HbA1c is always a reason to look critically at what can be improved, to prevent the risk of damage to your body in the future by excessive blood sugar levels.

Control by the ophthalmologist

If you have diabetes, ophthalmic controls are also needed. With regular checks of the retina, small changes can be detected and treated at an early stage.