The correctional environment poses challenges for coordinating insulin administration with food intake, particularly for inmates on short-acting (regular) insulin. The consequences of insulin/food mismatch are, at best, suboptimal control of hyperglycemia; at worst, the result is frequent and potentially severe hypoglycemic episodes. Because of the many factors in a correctional environment that can interfere with the optimal timing of insulin and food, the insulin regimen should be as “forgiving” as possible. The shorter the onset and peak of the insulin, the more critical it is to coordinate food intake with insulin administration. For this reason, rapid-acting insulin is generally not utilized within the BOP. Short-acting (regular) insulin is typically administered two-to-three times per day; ideally, it should be administered prior to a meal to allow some absorption of insulin prior to the rise in blood glucose that occurs during a meal. However, if the timing of meals is uncertain, regular insulin can be administered immediately after eating (rather than before). Although the inmate will have a short period of postprandial hyperglycemia, this approach causes fewer long-term consequences and good diabetic control can still be achieved. Below are questions to consider when planning for optimal insulin/food coordination in BOP facilities:
• Depending on the size of the dining hall, the size of the inmate population, and the type of meal being served, it may take anywhere from one-to-three hours to serve a meal. Is the pill line open during this entire meal period to administer insulin?
• Do inmates have free movement to go to the pill line before they go to the dining hall?
• If insulin is given prior to a meal, and then an institution recall occurs (a lockdown, an emergency count, a fog line, a severe weather incident, etc.), which of these situations would prevent inmates from eating?
• Are there contingency plans to provide food to prevent hypoglycemia?
• Are correctional staff trained to appropriately identify and respond to hypoglycemic episodes in insulin-dependent inmates?
• How quickly could a sack lunch or a snack be provided to inmates who had received their insulin, but were then prevented from eating their usual meal?

The treating physician, with the assistance of other health care providers, should review the initial diabetic treatment plan with the inmate. Involvement of the diabetic inmate in the development of the treatment plan is pivotal to its success, including adequate training to empower the patient to prevent and treat hypoglycemia. The treatment plan should include the following basic components and recommendations:
• Education on diabetes drug treatment options, self-monitoring, recognizing and treating severe hypoglycemic and hyperglycemic episodes, and identifying the signs of diabetic complications such as diseases of the eyes, kidneys, and nervous system.
• Instruction on the inmate’s specific drug treatment regimen and methods for monitoring glucose.
• Necessary lifestyle modifications such as improving food selection, increasing physical exercise, and smoking cessation.
• Importance of annual eye exams (funduscopic) done by an optometrist or ophthalmologist.
• Need for daily self-examination of the feet.
• Need for daily self-examination of the skin, including insulin injection sites.
• Importance of regular dental examinations and treatment.
• Need for regular screenings: fasting blood glucose, A1C, lipid levels, and kidney monitoring (BUN, creatinine, glomerular filtration rate calculation).
• Need for daily aspirin therapy to prevent cardiovascular events.
• Need for annual influenza vaccinations and tuberculosis screening.

Diabetic patients with hypertension should have their blood pressure (BP) lowered to targeted levels, since serious microvascular and macrovascular diabetic complications are strongly linked to hypertension. The optimal treatment goal for non-pregnant diabetics over age 18 is a systolic BP of <130 and a diastolic <80 mmHg. Patients with a systolic BP >140 or a diastolic BP >90 mmHg should receive drug therapy in addition to recommended lifestyle interventions. Those with a systolic pressure of 130–139 or a diastolic of 80–89 mmHg should be prescribed lifestyle interventions for up to three months. If the inmate fails to achieve a systolic BP <130 or a diastolic BP <80 mmHg within three months, drug therapy should be prescribed. All diabetics with hypertension should ordinarily be treated with an ACE inhibitor. If an ACE inhibitor is contraindicated, consider using an angiotensin receptor blocker (ARB). If targets are not achieved, a thiazide diuretic should be added.

Note: ACE inhibitor therapy should also be considered for diabetic inmates, with or without hypertension, who have other cardiovascular risk factors.

Peripheral diabetic neuropathy may result in pain, loss of sensation, and muscle weakness. Autonomic neuropathy may involve the gastrointestinal, cardiovascular, and genitourinary systems, resulting in related symptoms and complications. Diabetic neuropathy is treated by maximizing glycemic control and addressing related symptoms. Pain related to diabetic neuropathy is treated with tricyclic amines and anticonvulsant medications. Titrated doses of nortryptline or carbamazepine are most effective in treating chronic nerve pain associated with diabetic neuropathy. Opioid therapy is not recommended as it is an acute pain management therapy, and NSAIDS (ibuprofen) have no therapeutic benefit with neuropathic pain. Foot ulcers and amputations are complications of diabetes that are frequently related to neuropathy. The risk of amputation is associated with the following conditions: peripheral neuropathy with a loss of sensation, evidence of increased pressure (erythema, hemorrhage under a callus), peripheral vascular disease (absent distal pulses), severe nail disease, and a history of foot ulcers. Screening for diabetic neuropathy should include monofilament testing.

Footwear recommendations for diabetic inmates should consider the following:
• The current version of the BOP standard-issue work shoe addresses most concerns of diabetic and non-diabetic inmates.
• The institution is required to provide an inmate with a properly fitting work shoe. Tennis shoes and other recreational footwear are solely the responsibility of the inmate.
• Inmates with severe neuropathy are best served with protective footwear, such as steel-toed work shoes or boots, that minimize the chance of an incidental foot trauma that could cause a diabetic ulcer. Extra-wide, extra-deep toe boxes will reduce the risk of irritation to feet with deformities and/or impaired sensation. Only rarely will a tennis shoe be the most appropriate choice for a diabetic inmate.
• Medically ordered footwear should be considered in certain circumstances, including the following:
• Inmates with symptomatic foot deformities (e.g., large bunions, pronounced hammertoes, etc.) where regular-issue shoes of the appropriate size and width are causing significant skin irritation or ulceration.
• Inmates with Risk Category 2 or 3 (as determined by the LEAP Diabetes Foot Screen). This includes those with a loss of protective sensation with either high pressure (callous/deformity), or poor circulation; or history of plantar ulceration, neuropathic fracture (Charcot foot) or amputation.
• Inmates with significant vascular disease as suggested by claudication, absent dorsalis pedis or tibialis posterior pulses, or other studies.