Determining the Insulin Requirement

The American Diabetes Association has long promulgated the concept that effective control of diabetes requires an optimum balance between 3 variables: diet, exercise, and insulin. Considering the current state of knowledge of diabetes and its management, the addition of a fourth variable, stress, appears warranted.2 At different points in a person’s life, the 3 forms of stress-psychological, physical, and hormonal-clearly play a major role. Because the body responds to stress by increasing the insulin-secretory response, the daily insulin dose must be increased to compensate for stress in the patient with diabetes.

Whether stress is categorized as mild, moderate, or severe, and whether it is psychological, physical, or hormonal, for patients with type 1 diabetes the 24-hour insulin dose is based on the degree of stress, using the formula outlined in Figure 1. When stress is mild, the constant is 0.7 to 0.8 U/kg, whereas for severe stress (eg, ketoacidosis or life-threatening illness) the constant could be as high as 2 U/kg. The daily insulin requirement is also influenced by a number of other variables such as the changes associated with growth and pregnancy. Suggested constants for a range of patient types are given in Table 1.

Figure 1. Insulin requirement based on degree of stress.

Patient Description Constant (kg/d)
Trained athlete 0.5
Moderately active man; moderately active woman in follicular phase of menstrual cycle 0.6
Sedentary man; woman in luteal phase of menstrual cycle; mildly stressed man or woman; woman in first trimester of pregnancy 0.7
Moderately stressed man or woman; woman in second trimester of pregnancy 0.8
Severely stressed man or woman; woman in third trimester of pregnancy 0.9
Man or woman with systemic bacterial infection; woman at full-term pregnancy 1.0
Severely ill man or woman; adolescent in peak of pubescence; patient receiving steroid treatment; patient with ketoacidosis 1.5-2.0

Table 1. Suggested constants for calculating daily insulin requirement for various patient types

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