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Splc Prisoner Diabetes Handbook 2007

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Prisoner Diabetes Handbook
A Guide to Managing Diabetes—
for Prisoners, by Prisoners

published by the southern poverty law center

Why A Handbook for Prisoners With Diabetes?
Diabetes is important.
It is common, chronic, and can cause disabling complications.
What you do for yourself to take care of your diabetes is the most
important factor in your diabetes being well controlled.
Very little diabetes education is provided in prisons.
There are few organized programs for prisoners with diabetes.
Experience has shown that others with diabetes are a good source
of information about the disease. By cooperating and sharing,
diabetics can help each other.
A diabetes support group has been meeting at Great Meadow
Correctional Facility in Comstock, New York since 1997. This
group helps prisoners with diabetes to improve their diabetes
management. People in the
group learn from the experiences of other prisoners with
diabetes. There is a lot of support and good fellowship in
the diabetes group.

Diabetics at Comstock Prison would
be lost without the support group to
help them learn about diabetes.
Jimmie Lee

Sometimes the group chooses
a project to do together. In the fall of 2003 we decided to write
a handbook to share what we learned about diabetes self care
in prison.
This handbook is by prisoners, for prisoners.
Our goal is to help you manage your diabetes better yourself.


Diabetes is not just one disease but several different diseases that
all cause the same basic problem: too much sugar in the blood.
Biology of Diabetes
The sugar in the blood is called glucose.
All cells in the body use glucose to make energy to live.
All sugars and starches we eat are made into glucose.
Glucose moves around the body in the blood to get to the cells
where it is used.
Insulin is a hormone that helps move glucose out of the blood into
the cells. Insulin is made in the pancreas, an organ located behind
and below the stomach.

The more you know about diabetes,
the more you can help yourself

Different types of diabetes result from different problems in
insulin production and insulin

• Type 1: the body makes no insulin at all
• Type 2: the body makes too little insulin, and the insulin doesn’t
work well
• Gestational Diabetes: diabetes during pregnancy
Type 1 Diabetes
Someone with type 1 diabetes must always take insulin because
his/her pancreas makes no insulin at all.
People are usually young when they get type 1 diabetes, often
under 20 years of age, but it can begin at any age.
One out of ten people with diabetes has type 1 diabetes.
There is no cure for type 1 at this time.


Type 2 Diabetes
The pancreas makes too little insulin and the insulin doesn’t
work well.
Type 2 is usually treated with diet and exercise early in the disease. As time goes on, medicines must be added (usually pills)
and eventually most people with type 2 diabetes will also need
insulin. (Although some people with type 2 diabetes may need
insulin soon after diagnosis.)
People are usually middle aged when type 2 starts, but it can
begin in adolescence.
Often many people in the same family have type 2 diabetes.
Type 2 diabetes often occurs in people who are overweight and
losing even 10-20 pounds will really improve the diabetes. Getting weight down to normal (especially early in the disease) may
even cure type 2 diabetes for awhile.
More women than men have type 2 diabetes.
Type 2 is more common among Blacks, Native Americans and
Nine out of ten people with diabetes have
type 2 diabetes.
Many people don’t know they have type
2 diabetes, because they don’t feel sick
and haven’t had a blood sugar test.
Gestational Diabetes
This type of diabetes occurs during pregnancy in a woman who did not have diabetes before.
In gestational diabetes, the pancreas
makes insulin normally but the insulin does not work well in the pregnant
woman’s body.


Gestational diabetes usually goes away when the baby is born,
but it means that the woman is more likely to get type 2 diabetes
later in life.
Which type of diabetes do you have? If you’re not sure, ask
the doctor.
Diabetes Causes Medical Complications
Over years, the high blood sugar of poorly managed diabetes
damages the body in many ways.
There can be damage to eyes, kidneys, nerves and arteries causing
blindness, kidney failure, foot infections, heart attack, stroke, leg
cramps, pneumonia, gum disease and other complications.

Find Out If You Have Diabetes
Many people who have type 2 diabetes don’t know they have it.
They don’t feel sick and may never have had a blood sugar test.
Know who is at risk for diabetes.
If you are at risk, get a blood sugar test.
Tell others so they can get tested too.
Who are at greatest risk? People with one or more of these
risk factors are more likely to get type 2 diabetes:
• Other family members who have diabetes
• Overweight

Importance of Blood Sugar Control
Keeping blood sugar at near normal levels helps prevent the
long-term complications like blindness, kidney failure, foot amputations, heart attacks and strokes.

• Get little or no exercise

You cannot tell how good your blood sugar control is just by
how you feel.

• Female

Feeling good and not peeing a lot is not good enough control to
prevent the long-term complications of diabetes. And if your
blood sugar is often high, you may get used to high blood sugars
and feel fine, even though the sugar is hurting your body.

But anyone can get diabetes, even if they have
none of these risk factors

You must get two kinds of blood tests to know how well your
management is working:
1. Blood sugar tested before a meal is a measure of daily control
and should be between 80 and 130 most of the time.
2. The A-1-C test is a measure of control over the last 3 months
and should be under 7.0%
What is your A-1-C? If you’re not sure, ask the doctor.

• Black, Hispanic, Native American, or Asian/
Pacific Island ethnicity
• Over 40

Symptoms of undiagnosed diabetes:
There may be no symptoms at all. You may
not suspect anything is wrong.

I didn’t even know my
sister and aunt had
diabetes. It was a
hush-hush thing that
was unheard of to talk
about. They only told me
when I started to talk
about my new diagnosis.
Jimmie Lee

Or you may have one or more of the following symptoms:
• Urinating a lot, especially after eating sweets or a big meal.
• Being very thirsty.
• Having blurry vision from time to time
• Feeling tired and not having much energy.
• Losing weight without trying.
• Having numb or tingling feet.



Get Diagnosed
A fasting blood sugar test is used to diagnose diabetes.
When was your last blood sugar test? What was the result? Were
you fasting (nothing to eat or drink for at least 8 hours) when
the blood was drawn?
A fasting blood sugar of 126 or higher indicates someone who
probably has diabetes.
A fasting blood sugar between 100 and 125 indicates someone
who may be developing diabetes. A fasting blood sugar under
100 is normal.
If the fasting blood sugar is 100 or higher, it should be repeated.
Help Others Get Diagnosed
Tell people at risk to get their blood sugar tested.
Tell people about the symptoms.

Get Serious About Your Diabetes
Prison challenges your determination to survive
So does diabetes.
Diabetes can destroy your health slowly while you do your time.
But ignoring diabetes is dangerous. So get diagnosed, learn to
control your blood sugar, and stay healthy.

Losing my feet is my greatest fear. I want to
beat the system and walk out of here on my
own two feet.


Survival in prison requires self-control
Some prisoners survive well in prison by living a highly disciplined life. People with diabetes need to be disciplined too
and manage their blood sugar with knowledge, self-control and
A person who has diabetes needs
to be disciplined in order to be able
to follow consistent daily routines.
This is truer in prison than outside, since choices in prison are
Healthy eating, especially in prison, requires self-control.
Self-control is a necessity that
people who manage diabetes successfully get comfortable with.

Prison will make you or break
you. There are people who can
and people who can’t. We are
here in the diabetes group because we are the people who
can, who have taken charge of
our fate.
Jimmie Lee

The importance of regular daily routines
You need a daily schedule because following a
daily routine is one way people live well with diabetes and achieve good blood sugar control.
Regular meal times and regular physical activity
help control blood sugars.
Daily routines in prison are well established
and consistent so the rigid structure of the correctional day can support your efforts to follow
a regular daily activity plan.
Diabetes is with you all day every day.
Find the right balance for you.
Get serious about blood sugar control
Remember, good blood sugar control prevents complications of
diabetes such as blindness, amputations, kidney failure, heart
attacks and strokes.


Get Right with Yourself
Mental strength
How you feel affects your diabetes plus how you feel influences
what you are able to do for yourself.

Stress, Loneliness and Frustration Can Sabotage
Your Determination
Stress and frustration can cause you to lose focus and your
Hopelessness affects your will power and discipline.

You need mental strength to manage diabetes in prison day after

You may go back to old eating habits, stop testing, skip medicine,
or miss healthcare appointments.

Prison is a highly stressful environment
In prison, it’s hard to relax and hard to feel safe, even locked in
a single cell.

Responding to the stress
Recognize anger and feelings.

Stress affects everything about daily life in prison.

Exercise and music help the body and
mind to relax.

Stress affects your diabetes control physically and emotionally.
You’re never alone, yet always being with strangers is often

Find ways to relax.

Change conditions to reduce stress;
find where there is less noise and
fewer threats.

You need a mellow frame of
mind to handle what we have
to deal with here all the time.
Overcome it mentally. Create
the state of mind. Make it

You’re disconnected from family, friends, and home.

Quiet is better. You need a chance to
get into yourself to relax.

When the letter you are waiting for doesn’t come, when packages
and visits stop, you can feel alone and hopeless.

One person in our diabetes group learned meditation from a
Buddhist volunteer in another prison.

Sometimes people get frustrated and upset about diabetes or
frustrated with other people’s responses.
It is frustrating when sugar stays high even though you have
tried to improve it.
And frustrating when people invade your privacy by saying “You
shouldn’t eat that.”
It is frustrating to feel like a freak and be ashamed and fed up
with the needles.


What You Can Do To
Manage Your Diabetes
Diabetes needs your attention every day.
Successful management is finding the right balance of diet, activity and medicine to control blood sugar and keep your A-1-C
under 7%.
Getting there is a process. It takes time, effort, and monitoring
so you can see how you are doing.


Diabetes management includes:
• Education: Learn about taking care of diabetes

They can give you advice about diabetes and can adjust your
medicines to improve control.

• Eating healthy foods: Choose meals that help control blood
sugar and blood fats

They can give you access to things you need like blood sugar
tests, the medical diet, and specialist referrals. But you have to
convince them to work with you so you can get what you need.

• Being Active: Use regular exercise to help manage blood sugar
• Taking Medicine: Shots or pills replace what is missing from
your body
• Monitoring: Test your blood sugar and notice how you feel
• Health care: Get support from doctors and nurses; get lab
Management is often things you do for yourself
• Education: You educate yourself by seeking out information
• Food: You choose what you eat even though your choices are
• Activity: You choose what you do and how hard and frequently
you do it much of the time
• Medicine: Doctors prescribe medicine, but
you choose to take it
• Monitoring: You monitor yourself the best
you can; you go to medical to get blood sugar
• Health care: You have to know and advocate
for the services you need; you request blood
sugar, A-1-C, other monitoring tests and specialty appointments from the doctor
Nurses and doctors can help with your
diabetes management
Nurses and doctors who care can help you to
improve your diabetes management.


You may have to show them that you are serious about your diabetes.
Diabetes management is harder in prison
There is only limited variety and quality of
foods available in prison and access to blood
sugar testing is limited.
There is also limited availability of important services like diabetes education, medical
nutrition therapy, podiatric care, and dental
Insulin is rarely given more than twice a day
and the timing may not be the best. Plus some medicines and
devices, such as insulin pumps, are not available.
You can’t “shop” for professionals you trust. Furthermore, it’s
hard to get to the specialty appointments you need or hard to do
what you have to in order to get to those appointments.
Set your own diabetes management goals
You need to set your own diabetes goals and work to achieve
You can’t get the A-1-C from 13% to under 7% instantly. It takes
time and effort.
You need realistic short and long-term goals:
Short-term goals for today
Medium-term goals for the next three months
Long-term goals for life


For example:
Goals for today might be: avoid candy; eat more fruit.

Family: Talk to your family about your diabetes. Your mother
and your sister may know a lot about diabetes.

Goals for the next 3 months might be: lower your A-1-C from 13
to 11.

Others with diabetes: Talk to others who have diabetes when
you are in clinic together to get insulin
shots or at meals together.

Goals for life might be: no amputation, no kidney failure, no
Begin with what is most important to you, today, right now.
Improve your diabetes management starting there.
Attitude of staff and friends makes a difference
If someone says, “You’re dumb and you’re doing it all wrong,”
that doesn’t help you at all.

Starting today I can think
more about what I eat to try
to get my A-1-C test below 11.

But when someone says, “Let me
tell you how I do it so you can do
it better,” that supports your own
best efforts.
Success helps too. When you see
the positive results that your selfdiscipline can achieve, it gives you
strength to go on.

Lower blood sugar tests, lower A-1-C, fewer low blood sugar
episodes, or weight loss are good measures of success.

Ignorance creates anxiety.
Learning what to do creates confidence.
Education helps overcome fear.
Knowledge helps you establish control.
How does a prisoner learn about diabetes?
Seek information wherever you can find it:


Professionals: Ask nurses or doctors
about diabetes. Find out who has a
special interest in helping people with

The more you know about the
disease, the more you can
help yourself.

Read: Find pamphlets, books, and
magazines to read about diabetes. Look in the prison library for
health books.

Write: Diabetes organizations will send you information if you
write to them and ask for publications.
Good reading material
Diabetes Forecast: published by the
American Diabetes Association, PO
Box 363, Mount Morris, IL 61054-8303.
Diabetes Health: published by King’s
Publishing, PO Box 15368, N. Hollywood, CA 91615-5368.
Centers for Disease Control and Prevention, Take Charge of Your Diabetes,
3rd edition, Atlanta: U.S. Department
of Health and Human Services, 2002.
(FREE). This and other materials are
available by calling 1-800-232-4636, option 4.
Support Groups
People with diabetes can educate each other.
In a support group, people with diabetes share their experience
and knowledge.
Ask the health staff at your prison to sponsor a diabetes support

Food and Nutrition
Freedom to choose your own food
Choosing what to eat may be one of the last freedoms a prisoner
has left. The restrictions of a medical diet can be hard for people
who are locked up.
A prisoner with diabetes may resist letting diabetes take away
his last freedom. But having diabetes doesn’t mean you can’t
have your favorite foods.
Knowledge about food and nutrition will help you to choose
Be strictly disciplined if you want, or be self indulgent in an
intelligent way if that is what you want.
Diet Goals
The American Diabetes Association recommends:
• Foods containing carbohydrate from whole grains, fruits, vegetables, and low-fat milk should be included in a healthy diet.
• Eat less fat, especially animal fat, to reduce the risk of heart
attack and stroke.
• Eat less salt and sodium to help control blood pressure.
• Eat fewer total calories for weight loss if you are overweight.
There Is No “Diabetic Diet”
There is no “diabetic diet” and there are no “forbidden” foods.
If you are on medicines that lower blood sugar (like insulin and
sulfonylureas), you should eat consistent amounts of starch and
sugar (carbohydrate) at each meal or snack.
If you control your diabetes with exercise and diet, or if you are
on medicines that don’t lower the blood sugar, avoid eating a
large amount of carbohydrate at one time. In other words, spread
your carbohydrates throughout the day.


BUT, many people with diabetes find it is easier to reach their
blood sugar goals when they stop drinking regular soda and large
amounts of fruit juice and stop eating candy and other foods that
are almost entirely sugar.
There are medical nutrition goals based on each person’s needs,
such as carbohydrate controlled meals, reduced fat and cholesterol, reduced salt, high fiber, or weight loss.
You should think about what you eat, and choose foods that
support your goals.
Why low saturated fat and low cholesterol diets?
Animal fat is mostly saturated fat and cholesterol therefore eat
less animal fat because a diet with less saturated fat and less
cholesterol is healthier.
A low saturated fat diet helps prevent heart attacks.
A low saturated fat diet helps prevent strokes.
A low fat diet has fewer calories to prevent weight gain.
How do I eat a low saturated fat, low cholesterol diet?
Eat fewer fatty foods like sausages, bacon, cheeseburgers and
Eat leaner meats like skinless chicken or turkey breast and fish,
if available.
Eat less high cholesterol foods like egg
yolks and liver.
Cream is an animal fat that contributes
to heart disease and stroke.
Because 1% milk or skim milk has less
cream, it is better for you.
Also, eat lower fat cheeses like part
skim milk mozzarella, if available.

You can eat whatever you
want. You just can’t eat as
much as you want, whenever
you want.


Why a low salt diet?
Salt is made of sodium chloride and contributes to high blood
For a lower salt diet use little or no salt from the salt shaker on the
table. Always rinse canned vegetables to remove some of the salt
used in canning. Also limit salty snacks like chips and salted nuts.
And, if you drink tomato or V8 juice, get the low salt kind.
Commissary: If you buy snacks from the “store”:
Read the nutrition labels on packaged foods purchased from the
commissary. Labels tell you how much carbohydrate, saturated
fat, cholesterol and salt are in each packaged food item.
Many prisoners like to eat the whole package all at once. But,
usually there are 2 or 3 “servings” per package.
Figure out how much carbohydrate or saturated fat is in the
whole package.
One fruit pie has almost 500 calories. A whole fruit pie is not a
good choice for a snack at night because it has too many carbohydrates.
But an athlete who has diabetes might need a large snack like a
whole fruit pie before and during an extremely strenuous workout to prevent his blood sugar from dropping too low.

How To Improve Your Diet
What to eat?
Choose healthy foods with less sugar, less fat, less salt, and more
Eat fruit and vegetables, especially raw vegetables, whenever
they are available.
Try to be consistent about the amount of starch or sweet foods
(carbohydrate) that you eat each day and at each meal or


If weight loss is your goal, eat smaller portions.
Learn how to salvage an adequate diet from what they feed you,
by choosing well and trading with others, if allowed, for more
of what you need.
Adjust when you eat to prevent low blood sugar
If possible, spread food out throughout the day in meals and
If you take medicine for diabetes, don’t miss a meal or planned
Eat enough carbohydrates to prevent low blood sugar when
insulin is most active.
It is important to know that there are different kinds of insulin
used in shots and they work at different times during the day:
Morning REGULAR insulin acts after breakfast and lasts through
Morning NPH insulin acts after lunch and lasts through dinner.
Evening REGULAR insulin acts after dinner and lasts until late
evening. Evening NPH acts around midnight and lasts throughout the night.
People who take insulin for diabetes may need 1 or 2 snacks to
prevent low blood sugar. These snacks should be at the times
when their insulin works the hardest, or just before they have
been having the low blood sugar reactions.
Low blood sugars in the middle of the night? Try a snack around
Blood sugar too high at 4PM? Eat less starch at lunch or skip
that afternoon snack.
Adjust diet to anticipated activity:
Muscles use blood sugar for energy during exercise.


So, before a major workout plan to eat a larger lunch with enough
carbohydrate to prevent low blood sugar when exercising.
Eat snacks with some carbohydrate during and after exercise.
However, during times of inactivity, such as watching a movie,
if you plan to eat candy, then eat a smaller meal.
Choose What You Eat
Most prisoners have little choice at mealtime. But, even if you
get one tray, you can choose what to eat off the tray.
Know what is in the food you eat. Use nutrition labels, common
sense, or read books about food and nutrition to learn more.
Remember to eat fewer sweets and fats and eat to satisfaction,
but don’t overeat.

I cheat; I eat less bread when
I want to eat some cake.
(But it’s not “cheating”; it’s
smart eating)

Increase fiber by eating more fresh
or raw fruits and vegetables, whole
grains, beans, bran and oatmeal,
when available.
Try to substitute foods. For example,
if you want syrup on that pancake?
Use sugar free diet syrup. Or can’t
get any diet syrup? Ok then, use a
little sugar syrup, but eat fewer pancakes.

Want a small piece of cake for dessert? It’s ok. Eat less starch
(potato, bread, pasta, rice) with the meal to compensate for the
sugar in the dessert.
Don’t reject foods that are mixtures
At first people in the diabetes group said, “3 bean salad is garbage
all mixed up to hide what’s in it.” But it provides vegetables and
fiber that you need in your diet. The recipe calls for 3 different
beans to be mixed up together. Most of the men were unfamiliar
with this type of salad, so they thought it was all leftovers. Now
many of them eat 3 bean salad to improve their diet.


Don’t reject all foods with dressings
At first people in the diabetes group said,
“The cole slaw is rotten and they’re covering it up with that thick dressing.” But it is
one of the few sources of raw vegetables
which is on the menu frequently. One man
tried it and reported back that it was ok.
Many of them now eat coleslaw as often
as they can.
Don’t get bored with the same fresh fruit
all the time:
One man in the diabetes group said, “They
apple you to death here.”
But apples are the only fresh fruit that is
regularly available on the menu.
Make the most of it in spite of the monotony.
Trade with others, if allowed, to improve your diet:
Trade away high carbohydrate or high fat items in exchange
for fruit, vegetables (especially raw vegetables) and high fiber
Examples of high fiber foods available in some prison menus
and commissary:
General diet: apples, cole slaw, three-bean salad, oatmeal,
Medical diet: raw carrots, raw celery, prunes, non-white breads
Commissary: canned beans, canned vegetables, instant oatmeal,
What About Snacks?
People who take insulin may need a snack (especially before bed)
to prevent low blood sugar. But not everyone who has diabetes
needs to have snacks.


If you are trying to lose weight, snacks may help or hurt your
ability to lose weight.
If it is allowed, you may need to stockpile food for evening and
nighttime snacks. In some places, limited amounts of food may
be carried out of the mess hall: one apple; 4 slices of bread. If you
are able to, collect fruit when you can (apples; unripe bananas)
and eat them as snacks over several days. But you can get a ticket
for a rule violation if you take too much food out of the mess hall
for snacks later.

Exercise and Activity
Benefits of exercise
• Healthy heart
• Healthy blood pressure
• Relax the body and mind
• Control your weight
• Better blood sugar control
Issues related to exercise
Don’t overdo it.
Choose an exercise program that is comfortable for you
Be alert to the risk of low blood sugar during, shortly after, and
hours after a strenuous workout. Plan ahead how you will prevent low blood sugar during and after exercise. Eat more before
and/or while exercising and have some sugar with you.
On the other hand, if your blood sugar is too high, exercise can
bring it down to a better level. You can use exercise to correct
high blood sugar.
The yard can be dangerous, so exercise where you feel safe.
Because access to the gym is limited, take advantage of a gym
if you can.


Learn ways to work out in your cell.
David’s Exercises to Do In Your Cell
1. Push-ups on the floor.
2. Sit-ups: Wrap a belt around the end
of the bed loosely, lock feet through
the belt to hold legs down, then do
3. Pull-ups: Use a towel to pull yourself up on the bars; or stand your bed
straight up and pull yourself up.
4. Crunches can be done on the bed
or on the floor.
5. Dips can be done by standing between the locker and the bed post,
support your weight on your hands
on the locker and bedpost, bend legs
at the knee to move lower legs out of
the way behind you, then do dips up
and down with arms.
6. Do “dead weights” by using water
filled buckets as weights, lifting in unison with both arms.
7. Walk in place.
8. Do stretches by placing feet on
9. Calf exercises: Stand in place while
holding onto bars, move whole body
up and down by standing up on your
toes. Can be done standing with toes
on books, so that the ankle tendons are
stretched when the heel goes down
to the floor while the toes stay up on
the books.

I eat a larger lunch to get
my sugar a little high when
I’m planning a big afternoon
workout. Then I eat a snickers
bar during the workout, and
sometimes another one right
after I finish.
(This works for Paulie because
he has type 1 diabetes, is not
overweight, and works out
strenuously for a long time.)

Mix up the exercises to work
on different muscle groups at
different times. Don’t let it
get boring.
Jimmie Lee

10. Lunges: step forward and bend
knee; repeat on opposite side.

and Nateglinide (Starlix). Possible side effects are low blood
sugar and weight gain.

11. “Cherry picking”: legs about 2 feet
apart; arms reach up high, then down
to shoulder level, then bend down to
touch the toes, repeat.

• Medicine (biguanides) that slows down the amount of sugar
made by the liver called Metformin (Glucophage, Riomet, Glucophage XR, Fortamet, Glumetza). Possible side effects include
diarrhea, nausea, upset stomach, metallic taste in the mouth,
and weight loss.

Oral Medications for Type 2 Diabetes
People who have type 2 diabetes may need to take one or more
medicines to help control their blood sugar, in addition to being
active & choosing healthy food.
The longer a person has type 2 diabetes, the more effort (and
medicine) it takes to control it.
People with type 2 diabetes tend to have two problems:
1. they don’t make enough insulin and
2. the cells of their bodies are unable to use the insulin as
they should
There are different kinds of diabetes pills that work in a variety of ways to help the body deal with these problems. There
is no “best” pill or treatment for type 2 diabetes. You may
need to take more than one type of pill or pills plus insulin.
The different types of diabetes pills are:
• Medicines that help the pancreas make more insulin. These
medicines are called sulfonylureas and include Glyburide
(Diabeta, Micronase, Glynase Prestab) Glipizide (Glucotro1,
Glucotrol XL) and Glimepiride (Amaryl). Possible side effects
include low blood sugar, weight gain, upset stomach, skin rash,
and itching.
• Other medicines (meglitinides) help the pancreas make more
insulin, especially after meals. They are Repaglinide (Prandin)


• Medicines that help your body use its own insulin better. These
medicines (thiazolidinediones) are not used in people who have
active liver disease or those who have had congestive heart
failure. These medicines are Rosiglitazone (Avandia) and Pioglitazone (Actos). Possible side effects include liver problems,
weight gain, and swelling of the feet and legs. These medicines
take 2-4 weeks to begin to work when you start the medicine
and to stop working when the medicine is stopped.
• Medicines that slow the digestion of carbohydrates (sugar and
starches) in the small intestines are called alpha-glucosidase
inhibitors. These include Acarbose (Precose) and Miglitol
(Glyset). Side effects are common and include bloating, diarrhea, and gas.
• Because the medicines work in different ways to lower blood
glucose, they are often used together. Some combination drugs
are Glucovance, Avandamet, Metaglip and ActoPlus Met.
Injected Medicines for Type 2 Diabetes
• Insulin is a hormone that lowers blood glucose by moving
glucose from the bloodstream into the body’s cells. If you have
type 2 diabetes you may need to start taking insulin based on
several factors – how long you have had diabetes, how high
your blood glucose levels are, what other medicines you take
and your overall health. Taking insulin does not mean that you
now have type 1 diabetes. Many people with type 2 diabetes
need to take insulin sooner or later.
• Scientists are developing new medicines for diabetes all the
time. In 2006, two new injectable medicines became available.
The first is an “incretin memetic” called Exenatide (Byetta). It

boosts insulin release when the blood glucose is high, prevents
the body from releasing too much sugar from the liver, and
slows emptying of the stomach after meals. It often leads to
weight loss. The second is called Pramlintide (Symlin). This is
a copy of a human hormone called amylin and is only used in
combination with insulin. It slows stomach emptying, stops the
liver from producing too much sugar, and stimulates feelings
of “fullness” after eating.
Medicines to treat Type I Diabetes
• Insulin is ALWAYS used to treat type 1 diabetes. Pills are not
useful or effective in type 1 diabetes.

Type & Name

Onset after injection



Aspart (Novolog)
Lispro (Humalog)

About 5-10 minutes
(inject immediately
before a meal – do not
delay eating)

About 1 hour later

2-4 hours


About 30 minutes

2-3 hours later

3-6 hours


About 2-4 hours

4-10 hours later

10-16 hours

Glargine (Lantus)
Detemir (Levemir)

About 1 hour

No peak; works the
same throughout

20-24 hours

70/30 (70% intermediate & 30% short
or rapid acting)
50/50 (50% N &
50% R)
75/25 (75% intermediate with 25% rapid

Combines rapid-acting or short-acting
mealtime insulin and
insulin. Designed
to be taken before

• To treat type 1 diabetes, insulin may be given from 2-4 times
a day.
• There are three characteristics of insulin – Onset (when the
insulin starts to work), Peak (when the insulin is working the
hardest) and Duration (how long the insulin works).
• If you take rapid, short, or intermediate-acting insulin, you need
to eat on time and match your meals (and possibly snacks) and
your insulin injections. Your insulin should peak at the same
time blood sugar levels from meals are also peaking.
• You may need extra insulin to lower your blood sugar if it is
• Pramlintide (Symlin) (see above) is also used, in combination
with insulin in type 1 diabetes.
Insulin can cause low blood sugar reactions.
• Insulin already injected can’t be stopped from working.
• If you take insulin, don’t skip meals.
• If your sugar is too low, you may suddenly feel shaky, sweaty,
weak, confused. You need some sugar to raise your blood sugar
(for example, ½ cup of juice, 5-7 pieces of chewable candy, 3-5
glucose tablets, 1 tube of liquid glucose, ½ cup of regular — nondiet — soft drink)



Self-Injection of Insulin
Some prisoners with diabetes want to give their own injections.

Self-monitoring: You already do it — you just don’t know it
Read your body’s signs and pay attention to what it is telling you.

However, there is no self-injection of insulin at some prisons.

Learn to recognize your feelings associated with highs and lows.

Choosing where to inject and how to inject is very personal.
Sometimes nurses fill syringes before patients come in for their
shot. Some prisoners with diabetes worry about the accuracy of
the dose and type of insulin. They
would prefer to draw up the dose
themselves and inject themselves.
If that’s not allowed, do what you
can to make sure you are getting the
right kind and amount of insulin.

I always say, ‘Now that’s 10
units of Regular and 38 units
of NPH, right?
Jimmie Lee

One man described how he didn’t
want to have two insulin shots a day because he hated the
needle. But, finally he agreed to try it. In less than two weeks,
he was feeling a lot better in general, so he agreed to keep the
two shots after that.

What is monitoring?
Monitoring is what you do to assess how well you are managing
your diabetes. There is the monitoring you do yourself, and there
are other types of monitoring that doctors and nurses have to
do for or with you.
It helps you know when something has to change to get better
blood sugar control.
Blood sugar testing and the A-1-C test give you feedback about
how you are doing with your diabetes management. If these tests
are not as good as you want them to be, something needs to be
changed in your management plan to improve control.
Also, lab tests can identify complications of diabetes so they can
be treated.


Any person who has diabetes can
have high blood sugar.
People treated with insulin and some
pills can have low blood sugars.
High Blood Sugar (hyperglycemia):
If your blood sugar is high, you might
notice you have blurred vision, leg
cramps, headache, fatigue, thirst, frequent urination.
But your sugar may be too high even
if you feel fine.

I can tell my sugar is ok by
how my body feels; I don’t
have to get up at night; I
don’t have to drink a lot of
water; it’s not bothering me.
If I’m peeing a lot I know my
sugar is too high.

You need to test your blood sugar
regularly to see if it is “in target” or
under 140 most of the time. You need
to test your blood sugar more than
once a day to fine tune sugar to the
normal range.
Low Blood Sugar (hypoglycemia):
If your blood sugar is low, you might
notice feeling shaky, sweaty, dizzy,
confused, or aggressive. You might
have nightmares, have a seizure, or
go unconscious. The quickest way
to raise your blood glucose is with
some form of sugar, such as 3-5 glucose tablets, ½ cup of fruit juice or
5-7 pieces of hard candy or ½ cup of
regular — not diet — soft drink .


Blood sugar testing lets you know how well you are doing
Keep a log of your blood sugar tests. Include date, time, any
unusual activities or meals over the last four hours before the
Note changes from your usual routine on the log, such as extra
exercise or missed meals, which may explain unexpected lows,
or extra food or sweets you may have eaten that may explain an
unexpected high blood sugar.
Look for patterns of highs or lows:
Always low in the morning? Maybe you need a late night
Always high before dinner? Maybe you need more medicine.
Unexpected low before dinner? Was there an extra hard workout
that afternoon?
Always high after pizza lunch? Eat fewer slices next time.
Use your Blood Sugar Monitoring to Help You Make Better
Food Choices
Notice how much food makes your next sugar test too high.
Learn how to eat from observing the effect of particular foods
on the blood sugar.
Eat less or eat something else the next time that meal is on the
Professional monitoring
• Doctors and nurses should do clinical assessments like blood
pressure measurement to assess for hypertension (high blood
pressure) and foot exams to assess for numbness, injury or
• Doctors should order lab tests to monitor the effectiveness of
blood sugar control. Lab tests to monitor blood sugar control
include the A-1-C test every 3-6 months and fasting blood sugar


• Other lab tests monitor for complications of diabetes.
Blood lipids like cholesterol and triglycerides assess risk for heart
attack and strokes.
Urine protein or microalbumin test assesses for early signs of kidney damage.
• Doctors should order specialty consultations to assess for complications in the eyes and feet.
Prisoners with Type 2 Diabetes who take pills for diabetes
often don’t get monitored as much as those with Type 1
Prisoners with type 2 diabetes often
have trouble getting regular blood
sugar tests. There is often more
concern by health staff for those on
insulin who are seen every day for

If I could measure my blood
sugar I could know what to
eat and what not to eat.

Management of Diabetes
During Lockdowns
People with diabetes have a particularly hard time during
facility lockdowns
During lockdown, the usual routines are disrupted.
Very limited meals such as cold cereal and milk or cheese sandwiches may be provided in cells. Plus, it might be difficult to get
medicine and go to sick call.
If you are prepared, you have confidence.
It feels good if you don’t have to ask
anyone for things you need.

I’m prepared for it, and I’m
in control of my situation.


During lockdown, the trip to medical for injections could occur
Insulin may be given at different times every day and not be
coordinated with meals at all.
Be aware that there is a greater risk of bad low blood sugars when
insulin is not coordinated with meals.
During lockdown, you may not get as much food and meals may
not be well-balanced.
You will probably get enough carbohydrate from the meals they
give you.
But, you can’t trade with others to get more fruit and vegetables.
You may need to provide your own snack and supplement with
protein (canned tuna or mackerel) and fruit (canned fruit).
If possible, stockpile carbohydrate and protein foods in the event
you have lows during lockdowns.
Some examples of carbohydrates are ramen noodles, rice, and
Some examples of proteins are peanut butter, canned fish or
seafood, nuts and beans.
During lockdown, because usual daily activities are disrupted,
you need to be active in the cell.
Learn to exercise all muscle groups alone in the cell with sit-ups,
dips and pull-ups off the bed. If you can, stand up bed frame on
end next to sink to make room to exercise.


Medical Care
Successful diabetes management requires good self-care. But it
also requires good health care from professionals familiar with
Be serious
Be serious about your medical problems.
If they see that you are concerned about your blood sugar and
really serious about your health, they are more likely to do things
for you.
You have to be sincere. Stand out from the crowd as someone
special, not someone who is always complaining or trying to
con them.
Don’t ever refuse to go to a medical appointment; if you later
complain about medical care, they will point out your missed
Be informed
Information empowers you as a patient.
Get as much information as you can about diabetes.
Doctors and nurses may assume you are ignorant about your
disease and dismiss you, unless you show them you know what
is going on. Then they treat you differently.
Be active
Don’t be afraid to ask.
A passive convict is unlikely to get care because the medical
programs are usually passive too, waiting for the prisoner to
ask for care.
Find out if tests are abnormal, what do they mean? Ask the doctor
what changes in therapy he/she is recommending and what you
should do to improve your diabetes management.


Together, passive patients and passive health staff equals inadequate care.

• Dental cleanings

Be positive
Advocate for yourself and learn how to present yourself to health
staff effectively.

• Pneumococcal vaccine

When a diabetic patient is
serious and informed about
his disease, health staff have
to be on their toes. They pay
more attention.

Think about what your health issues
are and practice describing them.
Learn to take advantage of the services that are available.
Don’t be afraid to ask questions about
your symptoms: why is this happening? You have to ask for what you
need. If you don’t stand up for yourself, they will keep putting you off.

Be focused at each visit
What is bothering you the most about your diabetes today?
Professional Monitoring
What you should be getting from medical:
• Blood sugar tests
• Blood pressure
• A-1-C test
• Lipid profile (LDL-cholesterol, HDL cholesterol,

• Flu shots

I want these things because I
am diabetic and I am entitled
to them.
Jimmie Lee

How to get the care you need when
you are turned down
Don’t give up. Go up the chain of command to take your needs to
the people who have the authority to address the problem.

Use the grievance system. Go to sick call and request medical
care. Wait 2 weeks for the medical call out. If it doesn’t come, go
back to sick call and ask again. Wait some more.
If you are still not seen, write to the warden or whoever is the right
person in your prison to request necessary medical attention.

When they know you know the rules and who to
write to, they respect you.
Jimmie Lee

Consultations with
Medical Specialists
Outside trips are difficult
The indignity of it all: up early, miss meals, chained up all day,
traveling and waiting for hours for just a “3 minute” consult.
Then it takes days for your wrists to stop hurting from the handcuffs.

• Dilated eye exams
• Urine microalbumin (test
for very small amounts of
protein in the urine)

Prepare well for the trip:
Go to the bathroom before you leave and dress warmly and wear
clean clothes.

• Foot exams



Try to bring your own snack, a candy bar, stick of gum, glucose
tablets, anything, in case you miss a meal and have to support
your blood sugar.

Introduction to Diabetes

Specialists Help with Diagnosis and Management
You might need a specialist consultant for:

There are day-to-day complications, called short-term or acute

Complicated diabetes — an endrocrinologist can evaluate difficult
to control diabetes.

There are complications that accumulate over years, called longterm or chronic complications.

To assess and treat long-term damage to other organs — eye,
nerve, or kidney specialist would be seen.

Good blood sugar control helps prevent both types of complications.

Maintenance procedures — a podiatrist cuts nails, or shaves corns
and calluses on feet.

Day-to-day complications
Low blood sugar is the most common acute complication.

Specialist referrals maybe for appointments at clinics on-site or
to outside doctor offices.

Other acute complications are uncommon and likely to occur
only when type 1 diabetics don’t get any insulin at all.

Approval for special or costly tests and procedures — specialist
“gatekeepers” need to make determinations.
Be smart: don’t refuse to go to the consult or any medical appointment
Remember, the appointment is in response to your request for
care or the doctor’s referral. If you refuse to go, they have an
excuse to never give you another chance.
Use your self-control and be patient throughout the process.
Make the most of the consultant’s opinion
Ask the consultant questions: What is the diagnosis? What treatment does he recommend?

Long-term complications include:
Eye disease: Diabetic damage to the retina (retinopathy), the
lens (cataract), and the optic nerve (glaucoma) can cause blurred
vision, cloudy vision, halos or blindness.
Kidney disease: Diabetic kidney disease first shows up as protein
in the urine and can progress to kidney failure and dialysis. There
are no early symptoms of kidney disease.
Nerve damage: Diabetic nerve damage can effect sensory nerves
(tingling, numbness, or pain); motor nerves (weakness); or autonomic nerves (dizziness, slow digestion).

Get a copy of the consultant report and study it.

Diseases of arteries: Diabetics have more diseases caused by
blocked arteries, such as heart attacks, strokes, and cramps in
leg muscles occurring during activity.

Go to sick call after the consult and ask your facility doctor questions so you can understand the consultant’s report.

Foot problems: Diabetics have more foot problems, like sores and
wounds that won’t heal, infections and amputations.

Demand the treatment that was recommended by the specialist.



Attitude of staff and friends makes a difference:
“He got kidney failure because he didn’t take care of himself”
is a common attitude.
Punitive attitudes like that don’t help people do better.
“He got kidney failure in spite of every thing he could do,” is
more supportive.
Working together, we can all do better.

Acute Complications:
Low Blood Sugar
Recognize low blood sugar when it happens to you. Often you
can feel it.
Recognize low blood sugar in others. You may see it before he
or she feels it.
Know how to help, especially when someone has a seizure from
extreme low blood sugar.
Know the causes of low blood sugar:
Low blood sugar can be caused by:
• too much insulin
• too much exercise without attention to supporting the blood
• too little food such as missing a meal
• poor coordination of diet and exercise with insulin peak

Carry glucose, crackers, or candy to use when you feel low.
Be alert to the symptoms of low blood sugar so you can act to
treat it early.
Know how to help a diabetic who has low blood sugar
Early: he’s feeling shaky, sweaty: feed him.
Later: he’s confused, dull witted: convince him to eat candy or
glucose tablets right away.
Severe: he’s out of his head: try glucose gel between the lips and
gums if you have it; try sugar packet between lips and gums if
that is all you have.
Emergency: he’s seizing or unconscious: he needs an emergency
glucagon shot from medical. Once he wakes up, he needs to eat
a large snack with both protein and carbohydrate.

Chronic Complications: Feet
The Feet of People with Diabetes Are In Danger
Feet become vulnerable after you have had diabetes for a few
years. Diabetic nerve damage causes numbness and injuries
occur due to the lack of a pain warning system.
Poor circulation causes slow healing and poor resistance to infection. A minor injury may become an infected sore. If infection
spreads out of control, amputation may become necessary.
Foot care is focused on preventing sores and infections from
starting, and, finding sores early when they do occur so treatment
can be started before the problem gets out of hand.

Know how to avoid lows:
Never skip meals.

Self examination and hygiene
Wash feet daily and inspect feet daily for sores, blisters, cuts, or
tender spots.

Eat planned small snacks throughout the day and plan ahead to
support your blood sugar.

You need prompt treatment of foot sores and infections so get
medical attention if you find any of those symptoms.



Foot exams at every medical visit
The feet of people with diabetes should
be examined by the doctor or nurse at
every visit.
You can help make sure this happens by
taking your shoes and socks off before
the doctor comes in to see you.
They should test sensation with a stiff
plastic filament or tuning fork at least
once a year.
Nail care
Try to get an experienced professional to cut your nails.
Don’t cut nails too close because if feet are numb, you can’t feel
the painful warning when cutting too close. An injured nail bed
is a possible source of infection.

Foot fungus
Foot fungus and toe fungus are often not paid attention to.
But, there are lots of athlete’s foot and toenail fungus in prisons.
Always wear closed toe sandals in showers and locker rooms
because walking barefoot can expose you to fungus.
Treatment of Foot Infections
Treatment of foot infections in diabetics can be difficult.
Get professional help as soon as a
blister or sore is found on your daily
foot inspection. Management of serious infections often requires a lot
of nursing care and attention: like
dressing changes or soaks several
times a day.

I put athlete’s foot powder in
my socks once a day to prevent
those sore cracks between my
toes from athlete’s foot. A
bad infection could start there.

It may require infirmary care or plastic surgery.
Corns and calluses
Don’t try to shave them yourself. Get an experienced health
professional, like a podiatrist, to shave them for you.

My foot infection started
as a blister.

Foot wear
Don’t wear shoes that don’t fit and never
go barefoot.

Empty shoes before putting them on. A
pebble in the shoe can cause a terrible sore
if you walk on it all day. This could easily happen when the feet
are numb from diabetic nerve damage.
Dry skin
Nerve damage reduces natural oils in the skin of the lower legs
and feet. This causes dry, cracked skin that can result in infection.

It may be hard to get all the care you need, even in an infirmary,
even when ordered by a consultant or facility physician.
Don’t let it go. Do as much as you can for yourself, but try to get
professional help as soon as you can.
Foot ulcers take a long time to heal
Foot ulcers heal better if you don’t walk on them. If you have a
foot ulcer, you need to be off programs and resting off your feet
as much as possible.
A health professional needs to remove dead skin or callus from
the edges of the ulcer weekly. The ulcer has to be kept clean and
dry with daily dressing changes.
If you have an infection or a foot ulcer, it is even more important
to keep your blood sugar as normal as possible.

Skin creams and moisturizers can help prevent cracking.



Chronic Complications: Eyes
Diabetes is the most common cause of blindness in adults.

Know the risk
Dilated eye exams should be done annually by an eye specialist.

The lower the A-1-C the lower the risk of diabetic eye disease.

Get specialist treatment before vision is noticeably damaged
because damage may occur before you are aware of vision problems.

Control eye damage with early diagnosis. Get an annual dilated
eye exam by an eye specialist.

Chronic Complications: Kidneys

Three types of eye disease occur with diabetes: cataract; glaucoma; retinal disease.

Diabetes is the most common cause of kidney failure, dialysis
and transplant.

Cataract is a cloudy spot in the lens in
the front of the eye and cataract causes
blurred vision or halos around lights.

Know the risk and remember that good blood sugar control
prevents kidney damage.

Glaucoma is increased pressure in the
front part of the eye.

Serious damage is occurring without any symptoms at all
The first evidence of kidney damage is when protein starts leaking into the urine. Eventually the damage gets so severe it causes
kidney failure, dialysis and a transplant is needed.

Prevent eye complications with good blood sugar control.

Eventually the pressure damages the optic nerve, causing blindness.
Diabetic diseases of the retina begin with
excess growth of blood vessels on the
retina in the back of the eye. Bleeding and
scarring eventually can cause detachment of the retina and blindness.

Screen annually for microalbumin, a small
amount of protein leaking into the urine
Treatment with medicine called “ACE Inhibitors” or “ARBs” slows the progress of diabetic
kidney disease.

Treat eye complications
Treat eye complications early, before serious damage has already
occurred. Start treatment before you have any symptoms that
would warn you. The only way to make an early diagnosis is to
have a dilated eye exam by an eye professional every year.

Control your blood pressure to preserve
your kidneys
Diabetic kidney disease gets worse much faster
when you have both diabetes and hypertension.
Remember that a low salt diet and medicine
help control blood pressure.

Treatment depends on what the examination shows
Possible treatments for eye problems are:
Medicated drops to treat glaucoma.
Laser surgery to treat overgrowth of blood vessels on the retina.

Diabetics need tighter control of their blood
pressure than other people do because of the
greater risk to the kidneys and blood vessels.
Your blood pressure should be less than 130 for the top or first
number and less than 80 for the bottom or second number.

Cataract removal when vision is seriously effected.


Chronic Complications: Arteries

Chronic Complications: Infections

Diabetics are at greater risk for heart attack, stroke and other
problems related to poor circulation like cramps in the legs.

The prison environment can become easily contaminated with
infectious diseases due to overcrowding and poor hygiene.

Control all risk factors including cholesterol, smoking, hypertension, blood sugar, and inactivity.
Do you know your lipid profile?
Your lipid profile includes: Total cholesterol, LDL cholesterol,
HDL cholesterol, Triglycerides.
Improve lipid profile with a low saturated fat, low cholesterol
Add medicine (“statins”) if diet doesn’t get lipids into target

Greater risk of infection in diabetics
Lung infections more common in prison include influenza, bacterial pneumonia, and tuberculosis. Because tuberculosis is more
common in prisons, get screened annually.
Poor circulation, numbness and high
sugar all contribute to foot infections.
Don’t use needles for tattooing or shooting up because contaminated needles in
prison are more likely to transmit HIV,
hepatitis C and hepatitis B.

Target total cholesterol is below 200.
Target LDL-cholesterol is below 100.
What to do to reduce the risk of heart attack and stroke
Stop smoking.
Exercise regularly.
Eat less animal fat like butter, cream, poultry skin, fatty meats
and sausage products.
Eat less cholesterol, which is in foods like eggs and liver.
Eat more fruits and vegetables, especially raw vegetables.
Eat more high fiber foods like whole grains and oats.
Get blood tests to measure the fats in the blood so you know if
you have a problem.
Take medicine to reduce fats in the blood if they are too high
and cannot be controlled with diet and activity.


Protect yourself by maintaining good
personal hygiene
Don’t touch the handrails.
Wash hands frequently and always wash
hands when you come back to your cell
before you touch anything.
Floors, especially in showers, are contaminated with foot fungus. So never go
barefoot and always wear closed toe sandals in the shower.
Protect yourself by getting immunized
Influenza is common in winter. Get the flu vaccine when it is
Diabetics are more prone to bacterial pneumonia. Get the pneumovax vaccine when it is offered.
Prisoners are more likely to be exposed to hepatitis A and B. Get
the hepatitis A vaccine and the hepatitis B vaccine series of three
shots if they are offered.


Chronic Complications:
Teeth and Gums
Diabetics are at greater risk for gum disease
and need meticulous oral hygiene and more
frequent cleanings.
If you can’t get dental hygienist care? Do better self-care.
Make sure to do prolonged brushing twice a
day and if available, use an electric toothbrush,
floss regularly twice a day, and use an antiseptic

Chronic Complications: Nerves
Symptoms of nerve damage:
Stomach fullness
Erectile dysfunction
Different types of nerves can be involved
Motor nerves: Causes weakness.
Sensory nerves: Causes pain, numbness or tingling.
Autonomic nerves: Causes dizziness right after standing up, stomach fullness for hours after meals, inability to have an erection.















































































































You can take charge of your life with diabetes. Ask your health care provider about these tests and record the results here.






__ /__ mm Hg







How to Use the Blood Sugar Diary
Make copies of these pages and write your blood sugar results in
the box marked “Blood Sugar.” List the amount and any changes in
insulin taken in the box marked “Insulin.” Write down any types
of special or unusual foods you have eaten, the times and types of
exercise, and also any sickness, in the comments section. Describe
your feelings, low blood sugar reactions and general health.



































The Legal Right to Medical Care
The Eighth Amendment to the U. S. Constitution gives convicted inmates the right to adequate medical care; the Due
Process Clause gives this same right to pretrial detainees.
This means that, as a person with diabetes, you probably
have the right to the following, which is minimally adequate
medical care: (See also the American Diabetes Association’s
“Diabetes Management in Correctional Institutions” which
is reprinted at the end of this booklet.)
• If you use insulin, at least twice-daily finger sticks to check
your blood sugar levels; if you do not use insulin, finger sticks
as often as necessary for adequate diabetes control;
• A treatment plan which includes treatment targets for blood
sugar and A1C;
• A1C testing every three to six months, depending on how well
your blood sugar is controlled;
• Insulin and other medications needed to help control your
• Referral to specialists when necessary to treat complications
resulting from your diabetes (like an eye doctor, kidney doctor, etc.);
• Access to prompt treatment for hypoglycemia (low blood
• Access to prompt treatment in the event of high blood sugar
and ketosis;
• Annual dilated eye exams;
• Foot exams as part of regular diabetes chronic care appointments and special footwear when medically necessary;
• Annual urine protein testing (microalbumin test) for kidney
• Lipid level testing;


• Annual dental examination and cleaning;
• Regular, scheduled, chronic care appointments with a doctor
or specially trained nurse;
• Annual flu shot.
If you are not getting this care, you may want to file a grievance or, if necessary, a lawsuit to protect your rights under
the Eighth Amendment. To bring a lawsuit based on the
Eighth Amendment, you need to know the following:
The Four Elements of an Eighth Amendment
Medical Care Claim
There are four things you must prove in order to win a
medical care claim: (1) a serious medical need; (2) the prison
official’s actual knowledge of your serious medical need; (3)
that prison official’s failure to reasonably respond by providing you adequate treatment (this is called “deliberate indifference”); and (4) that the official’s “deliberate indifference”
caused you an injury or is likely to injure you in the future.
1. Serious Medical Need
The Constitution gives inmates a right to treatment only for
medical needs that are “serious.” Many medical conditions
endanger a person’s life and are clearly serious, such as diabetes, HIV/AIDS, tuberculosis, cancer, broken bones, open
wounds. But a medical condition does not have to be lifethreatening to be considered serious. A medical need is serious when it “has been diagnosed by a physician as mandating
treatment or . . . is so obvious that even a lay person would
easily recognize the necessity for a doctor’s attention.”
2. Official’s Knowledge of Need
If you become sick or injured, you need to do everything you
can to tell officials about your problem, such as filing written
grievances. You have no right to medical treatment if no one
knows about your problem.


3. Failure to Provide Treatment
Once officials know about your serious medical need, they
must respond reasonably. What kind of response does the
Constitution require? Ideally, you should be promptly examined by qualified medical personnel, prescribed or ordered
the necessary treatment, given that treatment properly, and
then provided follow-up attention as needed. As you know,
however, life in jail or prison is sometimes far from ideal.
According to the Supreme Court, officials only violate the
Constitution when they intentionally deny or delay access to
medical care, provide grossly inadequate treatment, or intentionally interfere with prescribed treatment.
4. Causation And Injury
Finally, to win a medical care claim, you must show that the
officials’ deliberate indifference caused you, or is likely to
cause you, an injury or serious medical harm, such as blindness, amputation, or kidney failure.
For more information, you can order a book published by the
Southern Poverty Law Center, called Protecting Your Health
and Safety: A Litigation Guide for Inmates. To order a copy,
send a check or money order for $10.00 (this covers postage
and handling) to:
Protecting Your Health & Safety
Prison Legal News
2400 NW 80th Street #148
Seattle, WA 98117
Be sure to include your name, prison identification number,
mailing address, and any other necessary information for getting the book to you.

This handbook is a summary of the ideas and experiences
discussed during the approximately ten years of regular
meetings of the diabetes support group at Great Meadow
Correctional Facility in Comstock, NY. Many people contributed to this handbook. The most important contributors are
the past and present group participants. Prisoners at Great
Meadow joined the group for various reasons. Some had
diabetes themselves and wanted to learn more about how
to take care of themselves. Others had family members with
diabetes and wanted to understand more about their family
members’ health needs. Through their willingness to share
their stories, concerns, and lessons learned, they taught us a
lot about how to live with diabetes in very difficult circumstances.
To write the handbook, we started with notes taken by Michael Cohen during the group sessions, sorted the ideas by
subject, and ordered them logically for presentation. Then,
each section of the handbook was reviewed, discussed and
improved in the diabetes support group.
We are also deeply grateful to Rhonda Brownstein and Rosi
Smith of the Southern Poverty Law Center, who not only
wrote the section on legal rights, but responded with immediate enthusiasm and support for publishing the handbook.
—Michael D. Cohen, MD
and Kathryn Godley, MS, RN, CDE
For additional FREE copies of the Prisoner Diabetes
Handbook please write to:
Prison Legal News
2400 NW 80th Street #148
Seattle, WA 98117
Be sure to include your name, prison identification number, mailing address, and any other necessary information for getting the book to you.



Diabetes Management in
Correctional Institutions

Originally approved 1989. Most recent review, 2006.
Abbreviations: CBG, capillary blood glucose; DKA, diabetic ketoacidosis; GDM, gestational
diabetes mellitus; MNT, medical nutrition therapy.
DOI: 10. 2337/dc07-S077
Copyright ©2007 American Diabetes Association.
From Diabetes Care® Vol. 30, 2007; S77-S84
Reprinted with permission from The American Diabetes Association

At any given time, over 2 million people are incarcerated in prisons and
jails in the U.S. (1). It is estimated that nearly 80,000 of these inmates have
diabetes, a prevalence of 4.8% (2). In addition, many more people pass
through the corrections system in a given year. In 1998 alone, over 11 million people were released from prison to the community (1). The current
estimated prevalence of diabetes in correctional institutions is somewhat
lower than the overall U.S. prevalence of diabetes, perhaps because the
incarcerated population is younger than the general population. The prevalence of diabetes and its related comorbidities and complications, however,
will continue to increase in the prison population as current sentencing
guidelines continue to increase the number of aging prisoners and the
incidence of diabetes in young people continues to increase.
People with diabetes in correctional facilities should receive care that
meets national standards. Correctional institutions have unique circumstances that need to be considered so that all standards of care may be
achieved (3). Correctional institutions should have written policies and
procedures for the management of diabetes and for training of medical
and correctional staff in diabetes care practices. These policies must take
into consideration issues such as security needs, transfer from one facility to another, and access to medical personnel and equipment, so that
all appropriate levels of care are provided. Ideally, these policies should
encourage or at least allow patients to self-manage their diabetes. Ultimately, diabetes management is dependent upon having access to needed
medical personnel and equipment. Ongoing diabetes therapy is important
in order to reduce the risk of later complications, including cardiovascular
events, visual loss, renal failure, and amputation. Early identification and
intervention for people with diabetes is also likely to reduce short-term
risks for acute complications requiring transfer out of the facility, thus
improving security.
This document provides a general set of guidelines for diabetes care in
correctional institutions. It is not designed to be a diabetes management
manual. More detailed information on the management of diabetes and
related disorders can be found in the American Diabetes Association (ADA)
Clinical Practice Recommendations, published each year in January as the
first supplement to Diabetes Care, as well as the “Standards of Medical Care
in Diabetes” (4) contained therein. This discussion will focus on those areas
where the care of people with diabetes in correctional facilities may differ,
and specific recommendations are made at the end of each section.


Diabetes Care, volume 30, Supplement 1, January 2007

Diabetes Care, volume 30, Supplement 1, January 2007


Reception screening
Reception screening should emphasize patient safety. In particular, rapid
identification of all insulin-treated persons with diabetes is essential in
order to identify those at highest risk for hypo-and hyperglycemia and
diabetic ketoacidosis (DKA). All insulin-treated patients should have a
capillary blood glucose (CBG) determination within 1–2 h of arrival. Signs
and symptoms of hypo- or hyperglycemia can often be confused with intoxication or withdrawal from drugs or alcohol. Individuals with diabetes
exhibiting signs and symptoms consistent with hypoglycemia, particularly
altered mental status, agitation, combativeness, and diaphoresis, should
have finger-stick blood glucose levels measured immediately.
Intake screening
Patients with a diagnosis of diabetes should have a complete medical history
and physical examination by a licensed health care provider with prescriptive authority in a timely manner. If one is not available on site, one should
be consulted by those performing reception screening. The purposes of this
history and physical examination are to determine the type of diabetes, current therapy, alcohol use, and behavioral health issues, as well as to screen
for the presence of diabetes-related complications. The evaluation should
review the previous treatment and the past history of both glycemic control
and diabetes complications. It is essential that medication and medical
nutrition therapy (MNT) be continued without interruption upon entry
into the correctional system, as hiatus in either medication or appropriate
nutrition may lead to either severe hypo- or hyperglycemia that can rapidly
progress to irreversible complications, even death.
Intake physical examination and laboratory
All potential elements of the initial medical evaluation are included in
Table 5 of the ADA’s “Standards of Medical Care in Diabetes,” referred to
hereafter as the “Standards of Care” (4). The essential components of the
initial history and physical examination are detailed in Fig. 1. Referrals
should be made immediately if the patient with diabetes is pregnant.

Within 1-2 hrs.

• Identify all inmates with diabetes currently using insulin
therapy or at high risk for hypoglycemia
• ALL insulin treated patients: screening CBG and urine ketone
test (as clinically indicated)
• Any patient exhibiting signs/symptoms consistent with hypoglycemia: immediate CBG
• Continue usual meal schedule and medication administration

Within 2-24 hrs.

• Type and duration of diabetes
• Confirm current therapy
• Presence of complications
• Family history
• Pregnancy screen in all female patients of childbearing age
with diabetes
• Assess alcohol use
• Identify behavioral health issues such as depression, distress,
suicidal ideation
• Assess prior diabetes education
All subjects with diabetes should have physician evaluation.
If no physician available, physician should be consulted.

2 hrs. – 2 weeks

Complete exam including:

Laboratory studies:

• Height, weight

• A1C and glucose

• Blood pressure

• Lipid Profile

• Eye (retinal) exam

• Microalbumin screen (Alb/Cr ratio)

• Cardiac

• Urine ketones (as clinically indicated)

• Patients with diagnosis of diabetes should have a complete medical
history and undergo an intake physical examination by a licensed
health professional in timely manner. (E)
• Insulin-treated patients should have CBG determination within
1–2 h of arrival. (E)
• Medications and MNT should be continued without interruption upon
entry into the correctional environment. (E)

Figure 1—Essential components of the initial history and physical examination.
Alb/Cr ratio, albumin-to-creatinine ratio; ALT, alanine amino-transferase;
AST, aspartate aminotransferase.


Diabetes Care, volume 30, Supplement 1, January 2007

Diabetes Care, volume 30, Supplement 1, January 2007

• Peripheral pulses

• AST/ALT (as clinically indicated)

• Foot and neurologic exam

• Creatinine (as clinically indicated)


Consistent with the ADA Standards of Care, patients should be evaluated
for diabetes risk factors at the intake physical and at appropriate times
thereafter. Those who are at high risk should be considered for blood glucose
screening. If pregnant, a risk assessment for gestational diabetes mellitus
(GDM) should be undertaken at the first prenatal visit. Patients with clinical
characteristics consistent with a high risk for GDM should undergo glucose
testing as soon as possible. High-risk women not found to have GDM at the
initial screening and average-risk women should be tested between 24 and
28 weeks of gestation. For more detailed information on screening for both
type 2 and gestational diabetes, see the ADA Position Statement “Screening
for Type 2 Diabetes” (5) and the Standards of Care (4).

Glycemic control is fundamental to the management of diabetes. A management plan to achieve normal or near-normal glycemia with an A1C goal of
<7% should be developed for diabetes management at the time of initial
medical evaluation. Goals should be individualized (4), and less stringent
treatment goals may be appropriate for patients with a history of severe
hypoglycemia, patients with limited life expectancies, elderly adults, and
individuals with comorbid conditions (4). This plan should be documented
in the patient’s record and communicated to all persons involved in his/her
care, including security staff. Table 1, taken from the ADA Standards of Care,
provides a summary of recommendations for setting glycemic control goals
for adults with diabetes.
People with diabetes should ideally receive medical care from a physician-coordinated team. Such teams include, but are not limited to, physicians, nurses, dietitians, and mental health professionals with expertise
and special interest in diabetes. It is essential in this collaborative and
integrated team approach that individuals with diabetes assume as active
a role in their care as possible. Diabetes self-management education is an
integral component of care. Patient self-management should be emphasized,
and the plan should encourage the involvement of the patient in problem
solving as much as possible.
It is helpful to house insulin-treated patients in a common unit, if this
is possible, safe, and consistent with providing access to other programs
at the correctional institution. Common housing not only can facilitate
mealtimes and medication administration, but also potentially provides
an opportunity for diabetes self-management education to be reinforced
by fellow patients.


Diabetes Care, volume 30, Supplement 1, January 2007

Table 1—Summary of recommendations for adults with diabetes
Glycemic control

<7. 0%*

Preprandial capillary plasma glucose

90–130 mg/dl (5. 0–7. 2 mmol/l)

Peak postprandial capillary plasma glucose†

<180 mg/dl (<10. 0 mmol/l)

Blood pressure

<130/80 mmHg


<100 mg/dl (<2. 6 mmol/l)


<150 mg/dl (<1. 7 mmol/l)


>40 mg/dl (>1. 0 mmol/l)§

Key concepts in setting glycemic goals:
• A1C is the primary target for glycemic control
• Goals should be individualized
• Certain populations (children, pregnant women, and elderly) require special
• More stringent glycemic goals (i. e., normal A1C, <6%) may further reduce
complications at the cost of increased risk of hypoglycemia
• Less intensive glycemic goals may be indicated in patients with severe or frequent hypoglycemia
• Postprandial glucose may be targeted if A1C goals are not met despite reaching
preprandial glucose goals
*Referenced to a nondiabetic range of 4. 0–6. 0% using DCCT-based assay. †Postprandial
glucose measurements should be made 1–2 h after the beginning of the meal, generally peak
levels in patients with diabetes. ‡Current NCEP/ATP III guidelines suggest that in patients
with triglycerides ≥200 mg/dl, the “non-HDL cholesterol” (total cholesterol minus HDL) be
utilized. The goal is ≤130 mg/dl (121). §For women, it has been suggested that the HDL goal
be increased by 10 mg/dl.

Nutrition counseling and menu planning are an integral part of the multidisciplinary approach to diabetes management in correctional facilities. A
combination of education, interdisciplinary communication, and monitoring
food intake aids patients in understanding their medical nutritional needs
and can facilitate diabetes control during and after incarceration.

Diabetes Care, volume 30, Supplement 1, January 2007


Nutrition counseling for patients with diabetes is considered an essential component of diabetes self-management. People with diabetes
should receive individualized MNT as needed to achieve treatment goals,
preferably provided by a registered dietitian familiar with the components
of MNT for persons with diabetes.
Educating the patient, individually or in a group setting, about how
carbohydrates and food choices directly affect diabetes control is the first
step in facilitating self-management. This education enables the patient
to identify better food selections from those available in the dining hall
and commissary. Such an approach is more realistic in a facility where the
patient has the opportunity to make food choices.
The easiest and most cost-effective means to facilitate good outcomes
in patients with diabetes is instituting a heart-healthy diet as the master
menu (6). There should be consistent carbohydrate content at each meal,
as well as a means to identify the carbohydrate content of each food selection. Providing carbohydrate content of food selections and/or providing
education in assessing carbohydrate content enables patients to meet the
requirements of their individual MNT goals. Commissaries should also
help in dietary management by offering healthy choices and listing the
carbohydrate content of foods.
The use of insulin or oral medications may necessitate snacks in order
to avoid hypoglycemia. These snacks are a part of such patients’ medical
treatment plans and should be prescribed by medical staff.
Timing of meals and snacks must be coordinated with medication administration as needed to minimize the risk of hypoglycemia, as discussed
more fully in the MEDICATION section of this document. For further
information, see the ADA Position Statement “Nutrition Principles and
Recommendations in Diabetes” (7).

All patients must have access to prompt treatment of hypo- and hyperglycemia. Correctional staff should be trained in the recognition and treatment
of hypo- and hyperglycemia, and appropriate staff should be trained to
administer glucagon. After such emergency care, patients should be referred
for appropriate medical care to minimize risk of future decompensation.
Institutions should implement a policy requiring staff to notify a physician of all CBG results outside of a specified range, as determined by the
treating physician (e.g., <50 or >350 mg/dl).


Diabetes Care, volume 30, Supplement 1, January 2007

Severe hyperglycemia in a person with diabetes may be the result of intercurrent illness, missed or inadequate medication, or corticosteroid therapy.
Correctional institutions should have systems in place to identify and refer
to medical staff all patients with consistently elevated blood glucose as well
as intercurrent illness.
The stress of illness in those with type 1 diabetes frequently aggravates
glycemic control and necessitates more frequent monitoring of blood glucose
(e.g., every 4–6 h). Marked hyperglycemia requires temporary adjustment
of the treatment program and, if accompanied by ketosis, interaction with
the diabetes care team. Adequate fluid and caloric intake must be ensured.
Nausea or vomiting accompanied with hyperglycemia may indicate DKA,
a life-threatening condition that requires immediate medical care to prevent complications and death. Correctional institutions should identify
patients with type 1 diabetes who are at risk for DKA, particularly those
with a prior history of frequent episodes of DKA. For further information
see “Hyperglycemic Crisis in Diabetes” (8).
Hypoglycemia is defined as a blood glucose level <60 mg/dl. Severe hypoglycemia is a medical emergency defined as hypoglycemia requiring
assistance of third party and is often associated with mental status changes
that may include confusion, incoherence, combativeness, somnolence,
lethargy, seizures, or coma. Signs and symptoms of severe hypoglycemia
can be confused with intoxication or withdrawal. Individuals with diabetes
exhibiting signs and symptoms consistent with hypoglycemia, particularly
altered mental status, agitation, and diaphoresis, should have their CBG
levels checked immediately.
Security staff who supervise patients at risk for hypoglycemia (i.e., those
on insulin or oral hypoglycemic agents) should be educated in the emergency
response protocol for recognition and treatment of hypoglycemia. Every
attempt should be made to document CBG before treatment. Patients must
have immediate access to glucose tablets or other glucose-containing foods.
Hypoglycemia can generally be treated by the patient with oral carbohydrates. If the patient cannot be relied on to keep hypoglycemia treatment on
his/her person, staff members should have ready access to glucose tablets
or equivalent. In general, 15–20 g oral glucose will be adequate to treat
hypoglycemic events. CBG and treatment should be repeated at 15-min
intervals until blood glucose levels return to normal (>70 mg/dl).
Staff should have glucagon for intramuscular injection or glucose for
intravenous infusion available to treat severe hypoglycemia without requiring transport of the hypoglycemic patient to an outside facility. Any

Diabetes Care, volume 30, Supplement 1, January 2007


episode of severe hypoglycemia or recurrent episodes of mild to moderate hypoglycemia require reevaluation of the diabetes management plan
by the medical staff. In certain cases of unexplained or recurrent severe
hypoglycemia, it may be appropriate to admit the patient to the medical
unit for observation and stabilization of diabetes management.
Correctional institutions should have systems in place to identify the
patients at greater risk for hypoglycemia (i.e., those on insulin or sulfonylurea
therapy) and to ensure the early detection and treatment of hypoglycemia.
If possible, patients at greater risk of severe hypoglycemia (e.g., those with
prior episode of severe hypoglycemia) may be housed in units closer to the
medical unit in order to minimize delay in treatment.
• Train correctional staff in the recognition, treatment, and appropriate
referral for hypo-and hyperglycemia. (E)
• Train appropriate staff to administer glucagon. (E)
• Train staff to recognize symptoms and signs of serious metabolic
decompensation, and immediately refer the patient for appropriate
medical care. (E)
• Institutions should implement a policy requiring staff to notify a physician of all CBG results outside of a specified range, as determined by
the treating physician (e.g., <50 or >350 mg/dl). (E)
• Identify patients with type 1 diabetes who are at high risk for DKA.

Formularies should provide access to usual and customary oral medications and insulins necessary to treat diabetes and related conditions. While
not every brand name of insulin and oral medication needs to be available,
individual patient care requires access to short-, medium-, and long-acting
insulins and the various classes of oral medications (e.g., insulin secretagogues, biguanides, α-glucosidase inhibitors, and thiazolidinediones)
necessary for current diabetes management.
Patients at all levels of custody should have access to medication at dosing frequencies that are consistent with their treatment plan and medical
direction. If feasible and consistent with security concerns, patients on
multiple doses of short-acting oral medications should be placed in a “keep
on person” program. In other situations, patients should be permitted to
self-inject insulin when consistent with security needs. Medical department nurses should determine whether patients have the necessary skill
and responsible behavior to be allowed self-administration and the degree


Diabetes Care, volume 30, Supplement 1, January 2007

of supervision necessary. When needed, this skill should be a part of patient
education. Reasonable syringe control systems should be established.
In the past, the recommendation that regular insulin be injected 30–45
min before meals presented a significant problem when “lock downs” or
other disruptions to the normal schedule of meals and medications occurred.
The use of multiple-dose insulin regimens using rapid-acting analogs can
decrease the disruption caused by such changes in schedule. Correctional
institutions should have systems in place to ensure that rapid-acting insulin
analogs and oral agents are given immediately before meals if this is part
of the patient’s medical plan. It should be noted however that even modest delays in meal consumption with these agents can be associated with
hypoglycemia. If consistent access to food within 10 min cannot be ensured,
rapid-acting insulin analogs and oral agents are approved for administration
during or immediately after meals. Should circumstances arise that delay
patient access to regular meals following medication administration, policies and procedures must be implemented to ensure the patient receives
appropriate nutrition to prevent hypoglycemia.
Both continuous subcutaneous insulin infusion and multiple daily insulin injection therapy (consisting of three or more injections a day) can be
effective means of implementing intensive diabetes management with the
goal of achieving near-normal levels of blood glucose (9). While the use of
these modalities may be difficult in correctional institutions, every effort
should be made to continue multiple daily insulin injection or continuous
subcutaneous insulin infusion in people who were using this therapy before
incarceration or to institute these therapies as indicated in order to achieve
blood glucose targets.
It is essential that transport of patients from jails or prisons to off-site
appointments, such as medical visits or court appearances, does not cause
significant disruption in medication or meal timing. Correctional institutions
and police lockups should implement policies and procedures to diminish
the risk of hypo-and hyperglycemia by, for example, providing carry-along
meals and medication for patients traveling to off-site appointments or
changing the insulin regimen for that day. The availability of prefilled insulin
“pens” provides an alternative for off-site insulin delivery.
• Formularies should provide access to usual and customary oral medications and insulins to treat diabetes and related conditions. (E)
• Patients should have access to medication at dosing frequencies that
are consistent with their treatment plan and medical direction. (E)

Diabetes Care, volume 30, Supplement 1, January 2007


• Correctional institutions and police lock-ups should implement policies and procedures to diminish the risk of hypo-and hyperglycemia
during off-site travel (e.g., court appearances). (E)

All patients with a diagnosis of diabetes should receive routine screening
for diabetes-related complications, as detailed in the ADA Standards of
Care (4). Interval chronic disease clinics for persons with diabetes provide
an efficient mechanism to monitor patients for complications of diabetes.
In this way, appropriate referrals to consultant specialists, such as optometrists/ophthalmologists, nephrologists, and cardiologists, can be made on
an as-needed basis and interval laboratory testing can be done.
The following complications should be considered.
• Foot care: Recommendations for foot care for patients with diabetes
and no history of an open foot lesion are described in the ADA Standards of Care. A comprehensive foot examination is recommended
annually for all patients with diabetes to identify risk factors predictive
of ulcers and amputations. Persons with an insensate foot, an open
foot lesion, or a history of such a lesion should be referred for evaluation by an appropriate licensed health professional (e.g., podiatrist or
vascular surgeon). Special shoes should be provided as recommended
by licensed health professionals to aid healing of foot lesions and to
prevent development of new lesions.
• Retinopathy: Annual retinal examinations by a licensed eye care professional should be performed for all patients with diabetes, as recommended in the ADA Standards of Care. Visual changes that cannot be
accounted for by acute changes in glycemic control require prompt
evaluation by an eye care professional.
• Nephropathy: An annual spot urine test for determination of microalbumin-to-creatinine ratio should be performed. The use of ACE
inhibitors or angiotensin receptor blockers is recommended for all
patients with albuminuria. Blood pressure should be controlled to
<130/80 mmHg.
• Cardiac: People with type 2 diabetes are at a particularly high risk of
coronary artery disease. Cardiovascular disease risk factor management
is of demonstrated benefit in reducing this complication in patients
with diabetes. Blood pressure should be measured at every routine
diabetes visit. In adult patients, test for lipid disorders at least annually
and as needed to achieve goals with treatment. Use aspirin therapy


Diabetes Care, volume 30, Supplement 1, January 2007

(75–162 mg/day) in all adult patients with diabetes and cardiovascular
risk factors or known macrovascular disease. Current national standards for adults with diabetes call for treatment of lipids to goals of
LDL <_100, HDL >40, triglycerides <150 mg/dl and blood pressure to
level of <130/80 mmHg.

Monitoring of CBG is a strategy that allows caregivers and people with
diabetes to evaluate diabetes management regimens. The frequency of
monitoring will vary by patients’ glycemic control and diabetes regimens.
Patients with type 1 diabetes are at risk for hypoglycemia and should have
their CBG monitored three or more times daily. Patients with type 2 diabetes on insulin need to monitor at least once daily and more frequently
based on their medical plan. Patients treated with oral agents should have
CBG monitored with sufficient frequency to facilitate the goals of glycemic
control, assuming that there is a program for medical review of these data
on an ongoing basis to drive changes in medications. Patients whose diabetes is poorly controlled or whose therapy is changing should have more
frequent monitoring. Unexplained hyperglycemia in a patient with type 1
diabetes may suggest impending DKA, and monitoring of ketones should
therefore be performed.
Glycated hemoglobin (A1C) is a measure of long-term (2- to 3-month)
glycemic control. Perform the A1C test at least two times a year in patients
who are meeting treatment goals (and who have stable glycemic control)
and quarterly in patients whose therapy has changed or who are not meeting glycemic goals.
Discrepancies between CBG monitoring results and A1C may indicate
a hemoglobinopathy, hemolysis, or need for evaluation of CBG monitoring
technique and equipment or initiation of more frequent CBG monitoring
to identify when glycemic excursions are occurring and which facet of the
diabetes regimen is changing.
In the correctional setting, policies and procedures need to be developed
and implemented regarding CBG monitoring that address the following.
• Infection control
• Education of staff and patients
• Proper choice of meter
• Disposal of testing lancets
• Quality control programs
• Access to health services
• Size of the blood sample

Diabetes Care, volume 30, Supplement 1, January 2007


• Patient performance skills
• Documentation and interpretation of test results
• Availability of test results for the health care provider (10)
• In the correctional setting, policies and procedures need to be developed and implemented to enable CBG monitoring to occur at the
frequency necessitated by the individual patient’s glycemic control
and diabetes regimen. (E)
• A1C should be checked every 3–6 months. (E)

Table 2—Major components of diabetes self-management education
Survival skills
• Hypo-/hyperglycemia

Daily management issues
• Disease process

• Sick day management

• Nutritional management

• Medication

• Physical activity

• Monitoring

• Medications

• Foot care

• Monitoring
• Acute complications


• Risk reduction

Self-management education is the cornerstone of treatment for all people
with diabetes. The health staff must advocate for patients to participate
in self-management as much as possible. Individuals with diabetes who
learn self-management skills and make lifestyle changes can more effectively manage their diabetes and avoid or delay complications associated
with diabetes. In the development of diabetes self-management education
program in the correctional environment, the unique circumstances of the
patient should be considered while still providing, to the greatest extent
possible, the elements of the “National Standards for Diabetes Self-Management Education” (11). A staged approach may be used depending on
the needs assessment and the length of incarceration. Table 2 sets out the
major components of diabetes self-management education. Survival skills
should be addressed as soon as possible; other aspects of education may be
provided as part of an ongoing education program.
Ideally, self-management education is coordinated by a certified diabetes educator who works with the facility to develop polices, procedures,
and protocols to ensure that nationally recognized education guidelines
are implemented. The educator is also able to identify patients who need
diabetes self-management education, including an assessment of the patients’ medical, social, and diabetes histories; diabetes knowledge, skills,
and behaviors; and readiness to change.

• Goal setting/problem solving

Policies and procedures should be implemented to ensure that the health
care staff has adequate knowledge and skills to direct the management and
education of persons with diabetes. The health care staff needs to be involved
in the development of the correctional officers’ training program. The staff
education program should be at a lay level. Training should be offered at
least biannually, and the curriculum should cover the following.


Diabetes Care, volume 30, Supplement 1, January 2007

• Psychosocial adjustment
• Preconception care/pregnancy/
gestational diabetes management

• What is diabetes
• Signs and symptoms of diabetes
• Risk factors
• Signs and symptoms of, and emergency response to, hypo- and
• Glucose monitoring
• Medications
• Exercise
• Nutrition issues including timing of meals and access to snacks
• Include diabetes in correctional staff education programs. (E)

Patients with diabetes who are withdrawing from drugs and alcohol need
special consideration. This issue particularly affects initial police custody
and jails. At an intake facility, proper initial identification and assessment
of these patients are critical. The presence of diabetes may complicate
detoxification. Patients in need of complicated detoxification should be
referred to a facility equipped to deal with high-risk detoxification. Patients
with diabetes should be educated in the risks involved with smoking. All
inmates should be advised not to smoke. Assistance in smoking cessation
should be provided as practical.

Diabetes Care, volume 30, Supplement 1, January 2007


Patients in jails may be housed for a short period of time before being
transferred or released, and it is not unusual for patients in prison to be
transferred within the system several times during their incarceration.
One of the many challenges that health care providers face working in the
correctional system is how to best collect and communicate important
health care information in a timely manner when a patient is in initial police
custody, is jailed short term, or is transferred from facility to facility. The
importance of this communication becomes critical when the patient has
a chronic illness such as diabetes.
Transferring a patient with diabetes from one correctional facility to
another requires a coordinated effort. To facilitate a thorough review of
medical information and completion of a transfer summary, it is critical for
custody personnel to provide medical staff with sufficient notice before
movement of the patient.
Before the transfer, the health care staff should review the patient’s
medical record and complete a medical transfer summary that includes the
patient’s current health care issues. At a minimum, the summary should
include the following.
• The patient’s current medication schedule and dosages
• The date and time of the last medication administration
• Any recent monitoring results (e.g., CBG and A1C)
• Other factors that indicate a need for immediate treatment or management at the receiving facility (e.g., recent episodes of hypoglycemia,
history of severe hypoglycemia or frequent DKA, concurrent illnesses,
presence of diabetes complications)
• Information on scheduled treatment/appointments if the receiving facility is responsible for transporting the patient to that appointment
• Name and telephone/fax number of a contact person at the transferring
facility who can provide additional information, if needed

The sending facility must be mindful of the transfer time in order to
provide the patient with medication and food if needed. The transfer summary or medical record should be reviewed by a health care provider upon
arrival at the receiving institution.
Planning for patients’ discharge from prisons should include instruction
in the long-term complications of diabetes, the necessary lifestyle changes
and examinations required to prevent these complications, and, if possible,
where patients may obtain regular follow-up medical care. A quarterly
meeting to educate patients with up coming discharges about community
resources can be valuable. Inviting community agencies to speak at these
meetings and/or provide written materials can help strengthen the community link for patients discharging from correctional facilities.
Discharge planning for the patients with diabetes should begin 1 month
before discharge. During this time, application for appropriate entitlements
should be initiated. Any gaps in the patient’s knowledge of diabetes care
need to be identified and addressed. It is helpful if the patient is given a
directory or list of community resources and if an appointment for follow-up
care with a community provider is made. A supply of medication adequate
to last until the first postrelease medical appointment should be provided
to the patient upon release. The patient should be provided with a written
summary of his/her current heath care issues, including medications and
doses, recent A1C values, etc.
• For all interinstitutional transfers, complete a medical transfer summary to be transferred with the patient. (E)
• Diabetes supplies and medication should accompany the patient during transfer. (E)
• Begin discharge planning with adequate lead time to insure continuity
of care and facilitate entry into community diabetes care. (E)


The medical transfer summary, which acts as a quick medical reference
for the receiving facility, should be transferred along with the patient. To
supplement the flow of information and to increase the probability that
medications are correctly identified at the receiving institution, sending
institutions are encouraged to provide each patient with a medication card
to be carried by the patient that contains information concerning diagnoses,
medication names, dosages, and frequency. Diabetes supplies, including
diabetes medication, should accompany the patient.

Practical considerations may prohibit obtaining medical records from
providers who treated the patient before arrest. Intake facilities should
implement policies that 1) define the circumstances under which prior
medical records are obtained (e.g., for patients who have an extensive
history of treatment for complications); 2) identify person(s) responsible
for contacting the prior provider; and 3) establish procedures for tracking
Facilities that use outside medical providers should implement policies
and procedures for ensuring that key information (e.g., test results, diagnoses,


Diabetes Care, volume 30, Supplement 1, January 2007

Diabetes Care, volume 30, Supplement 1, January 2007


physicians’ orders, appointment dates) is received from the provider and
incorporated into the patient’s medical chart after each outside appointment. The procedure should include, at a minimum, a means to highlight
when key information has not been received and designation of a person
responsible for contacting the outside provider for this information.
All medical charts should contain CBG test results in a specified, readily
accessible section and should be reviewed on a regular basis.

Children and adolescents with diabetes present special problems in disease
management, even outside the setting of a correctional institution. Children and adolescents with diabetes should have initial and follow-up care
with physicians who are experienced in their care. Confinement increases
the difficulty in managing diabetes in children and adolescents, as it does
in adults with diabetes. Correctional authorities also have different legal
obligations for children and adolescents.
Nutrition and activity
Growing children and adolescents have greater caloric/nutritional needs
than adults. The provision of an adequate amount of calories and nutrients
for adolescents is critical to maintaining good nutritional status. Physical
activity should be provided at the same time each day. If increased physical activity occurs, additional CBG monitoring is necessary and additional
carbohydrate snacks may be required.
Medical management and follow-up
Children and adolescents who are incarcerated for extended periods should
have follow-up visits at least every 3 months with individuals who are experienced in the care of children and adolescents with diabetes. Thyroid
function tests and fasting lipid and microalbumin measurements should be
performed according to recognized standards for children and adolescents
(12) in order to monitor for autoimmune thyroid disease and complications
and comorbidities of diabetes.
Children and adolescents with diabetes exhibiting unusual behavior
should have their CBG checked at that time. Because children and adolescents are reported to have higher rates of nocturnal hypoglycemia (13),
consideration should be given regarding the use of episodic overnight blood
glucose monitoring in these patients. In particular, this should be considered in children and adolescents who have recently had their overnight
insulin dose changed.


Diabetes Care, volume 30, Supplement 1, January 2007

Pregnancy in a woman with diabetes is by definition a high-risk pregnancy.
Every effort should be made to ensure that treatment of the pregnant
woman with diabetes meets accepted standards (14,15). It should be noted
that glycemic standards are more stringent, the details of dietary management are more complex and exacting, insulin is the only antidiabetic agent
approved for use in pregnancy, and a number of medications used in the
management of diabetic comorbidities are known to be teratogenic and
must be discontinued in the setting of pregnancy.

People with diabetes should receive care that meets national standards.
Being incarcerated does not change these standards. Patients must have
access to medication and nutrition needed to manage their disease. In
patients who do not meet treatment targets, medical and behavioral plans
should be adjusted by health care professionals in collaboration with the
prison staff. It is critical for correctional institutions to identify particularly
high-risk patients in need of more intensive evaluation and therapy, including pregnant women, patients with advanced complications, a history of
repeated severe hypoglycemia, or recurrent DKA.
A comprehensive, multidisciplinary approach to the care of people with
diabetes can be an effective mechanism to improve overall health and delay
or prevent the acute and chronic complications of this disease.

The following members of the American Diabetes Association/ National Commission on Correctional Health Care Joint Working Group on Diabetes Guidelines
for Correctional Institutions contributed to the revision of this document: Daniel
L. Lorber, MD, FACP, CDE (chair); R. Scott Chavez, MPA, PA-C; Joanne Dorman,
RN, CDE, CCHP-A; Lynda K. Fisher, MD; Stephanie Guerken, RD, CDE; Linda B.
Haas, CDE, RN; Joan V. Hill, CDE, RD; David Kendall, MD; Michael Puisis, DO;
Kathy Salomone, CDE, MSW, APRN; Ronald M. Shansky, MD, MPH; and Barbara
Wakeen, RD, LD.

Diabetes Care, volume 30, Supplement 1, January 2007


1. National Commission on Correctional Health Care: The Health Status of Soonto-Be Released Inmates: A Report to Congress. Vol. 1. Chicago, NCCHC, 2002
2. Hornung CA, Greifinger RB, Gadre S: A Projection Model of the Prevalence of
Selected Chronic Diseases in the Inmate Population. Vol. 2. Chicago, NCCHC,
2002, p. 39–56
3. Puisis M: Challenges of improving quality in the correctional setting. In Clinical Practice in Correctional Medicine. St. Louis, MO, Mosby-Yearbook, 1998, p.
4. American Diabetes Association: Standards of medical care in diabetes—2007
(Position Statement). Diabetes Care 30 (Suppl. 1):S4–S41, 2007
5. American Diabetes Association: Screening for type 2 diabetes (Position Statement). Diabetes Care 27 (Suppl. 1):S11–S14, 2004
6. Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ,
Erdman JW Jr, Kris-Etherton P, Goldberg IJ, Kotchen TA, Lichtenstein AH,
Mitch WE, Mullis R, Robinson K, Wylie-Rosett J, St Jeor S, Suttie J, Tribble
DL, Bazzarre TL: American Heart Association Dietary Guidelines: revision
2000: a statement for healthcare professionals from the Nutrition Committee
of the American Heart Association. Stroke 31:2751–2766, 2000
7. American Diabetes Association: Nutrition recommendations and interventions
for diabetes (Position Statement). Diabetes Care 30 (Suppl. 1):S48–S65, 2007
8. American Diabetes Association: Hyperglycemic crisis in diabetes (Position
Statement). Diabetes Care 27 (Suppl. 1):S94– S102, 2004
9. American Diabetes Association: Continuous subcutaneous insulin infusion
(Position Statement). Diabetes Care 27 (Suppl. 1):S110, 2004
10. American Diabetes Association: Tests of glycemia in diabetes (Position Statement). Diabetes Care 27 (Suppl. 1):S91–S93, 2004
11. American Diabetes Association: National standards for diabetes self-management education (Standards and Review Criteria). Diabetes Care 30 (Suppl. 1):
S96-S103, 2007
12. International Society for Pediatric and Adolescent Diabetes: Consensus Guidelines 2000: ISPAD Consensus Guidelines for the Management of Type 1 Diabetes Mellitus in Children and Adolescents. Zeist, Netherlands, Medical Forum
International, 2000, p. 116, 118
13. Kaufman FR, Austin J, Neinstein A, Jeng L, Halyorson M, Devoe DJ, Pitukcheewanont P: Nocturnal hypoglycemia detected with the continuous glucose monitoring system in pediatric patients with type 1 diabetes. J Pediatr
141:625–630, 2002
14. American Diabetes Association: Gestational diabetes mellitus (Position Statement). Diabetes Care 27 (Suppl. 1):S88-S90, 2004
15. Jovanovic L (Ed. ): Medical Management of Pregnancy Complicated by Diabetes.
3rd ed. Alexandria, VA, American Diabetes Association, 2000

Edited by
Michael D. Cohen, MD
Kathryn Godley, MS, RN, CDE
Contributing Editors
Rhonda Brownstein
Rosi Smith
Design Director
Russell Estes

Created by the Diabetes support group at
Great Meadow Correctional Facility
Comstock, New York

Diabetes Care, volume 30, Supplement 1, January 2007

Scott Phillips
Illustrations by
Masi B. Gedney



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