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Everything you wanted to know about food & insulin *. Stephen W. Ponder MD, FAAP, CDE Scott & White Clinic Temple, Round Rock and College Station. * And a bunch of other important stuff. One goal of diabetes care is managing glucose…. FLUX. drift. Hint: It takes TIME and PATIENCE!.

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everything you wanted to know about food insulin

Everything you wanted to know about food & insulin*

Stephen W. Ponder MD, FAAP, CDE

Scott & White Clinic

Temple, Round Rock and College Station

*And a bunch of other important stuff

one goal of diabetes care is managing glucose
One goal of diabetes care is managing glucose…

FLUX

drift

Hint: It takes TIME and PATIENCE!

slide5

Postmeal Blood sugars, A1c and CV Risk

chronic inflammation

Vascular system

220

glucose

HbA1c

180

8%

140

7%

100

6%

5%

Pre-meal

2 hr

Pre-meal

Goal: improve post-meal control: BG < 180 mg/dl

95

?

115

diabetes an energy management disorder
Diabetes – an energy management disorder

This is T2, but forget about d-type for now.

slide9

present

Proactive

Reactive

future

past

reactive vs proactive diabetes care
reactive vs. proactive diabetes care

Reactive

Proactive

Actions are dependent on situation/circumstance

Flexible and adaptable

Outcomes influence subsequent actions

Training needed, plus ongoing reinforcement

More time intensive

Favors problem-solving

Requires motivation

  • Actions predetermined
  • Minimal to no flexibility: RIGID
  • Outcomes don’t immediately affect long term actions
  • Easy to teach/learn
  • Less time needed
  • Favors “concrete” thinking
  • Less motivation needed
food energy
Food = energy

Carbohydrates

Protein

Fat

Glucose

to manage flux
To manage flux
  • Everything becomes a TOOL to understand, use, and master
  • Food
  • Insulin
  • Exercise
  • Timing
  • Devices, etc….
because
Because…
  • Most doctors are not nutrition specialists
  • Diagnosing and prescribing are what we’re trained to do
  • Our health care system downplays the role of RD’s by not always paying for those services
  • Plus WE think we’re all food experts anyway!
why does diabetes seem so slippery
Why does diabetes seem so slippery?
  • It’s like the weather
  • But like weather, it can be predicted and prepared for
  • In the end, it’s a self managed condition
  • And outcomes are largely driven by choices
slide23
Meters are commodity items“a commodity is the generic term for any marketable item produced to satisfy wants or needs”
  • The best BG meter is the one you’ll use
  • $10.41/50 strips
  • Changes ahead
  • Ketone meter
don t pass up an opportunity to correct a high or low bg
Don’t pass up an opportunity to correct a high (or low) BG
  • Choose what you consider “actionable”?
  • BG above or below chosen thresholds
  • Consider recent and impending actions
  • Check your results with BG levels
  • Repeat as necessary
check your targets often
Check your targets often
  • Make sure you hit your target “zone” sugar (± 30 mg/dl)
  • Rapid-acting insulin results are best examined at 2-3 hours
  • Results should feedback to the next attempt

“Practice makes better”

curb your liver
Curb your liver!
  • The liver makes as well as stores sugar
  • A proper insulin level “calms down” the liver
  • Aim for an in-range sugar level (<120 mg/dl) upon waking up each day
why do lows happen at night
Why do lows happen at night?
  • Hormonal patterns
  • Lower insulin need
  • Insulin peaks?
  • Post-exercise effect
  • Snacking stacking?

Lower overnight insulin/add snack

clin i cal di e ti tian n
clinical dietitian (n.)
  • A person specializing in medical nutrition therapy.
  • An underappreciated and underpaid member of the diabetes team.
  • Someone who can help your left brain
we have 60 000 thoughts daily
We have > 60,000 thoughts daily

Eat at home

  • Groups of thoughts comprise decisions
  • The typical non-D person makes ~ 250 decisions a day about food
  • How many more food choices does a PWD/CWD make?

“What are we doing for dinner, dear?”

slide33

“Assuming a good working knowledge of the system, diabetes control is generally proportional to the time and attention directed towards it.”

why do some pwd cwd s seem to have it easier it depends on your point of view
Why do some PWD/CWD’s seem to have it “easier”? It depends on your point of view
  • “Honeymoon”
  • Type 2
  • MODY?
  • Other?
the pancreas has an off switch for insulin
The pancreas has an “off” switch for insulin

…and it’s triggered by exercise

kinetic versus dynamic insulin
Kinetic versus Dynamic Insulin

Kinetic: how fast insulin gets in and out

Dynamic: time that insulin lowers sugar

Glucose infusion rate

(mg/kg/minute)

Time in hours

current insulin pump therapy

Early Insulin Pumps

Different tools for different jobs

Multi-dose insulin therapy

Current insulin pump therapy…

“Think of insulin as a tool”

Lantus

Levemir

Humalog

Novolog

NPH

Get my point?

70/30

slide39

The “3 dimensions” of insulin

What is the 4th dimension?

peak

onset

duration

the 2013 insulin arsenal
The 2013 “insulin arsenal”
  • Long (Lantus, Levemir)
  • Intermediate (NPH)
  • Fast (Regular)
  • Rapid (Humalog, Novolog, Apidra)
  • Premixed (75/25 and 70/30)
  • Ultra-rapid? (in development)
  • Ultra-long? (Degludec and others)
insulin pens
Insulin Pens
  • Discreet
  • Different needle sizes
  • ½ unit increments
  • Disposable
  • Durable units
  • More popular today
timing of bolus insulin
Timing of Bolus Insulin

(humalog/novolog/apidra)

why timing matters
Why timing matters…

Note: Carbs estimated w/pre-meal insulin.

Carbs known with post-meal insulin.

Source: Clinical Therapeutics 2004; 26:1492-7.

why timing matters1
Why timing matters…

CGMS data

  • Bolusingwith meal

CGMS data

  • Bolusing pre-meal
highs after meals depend on
Highs after meals depend on…
  • Size of the bolus
  • How early bolus is given
  • How many carbs eaten
  • Activity level after meal
  • Food’s glycemic index
time to reach 100 mg dl at 4 mg dl min
Time to reach 100 mg/dl(at ~ 4 mg/dl/min)

420

4 mg/dl/min

340

260

Blood sugar

180

minutes

timely insulin facts
Timely insulin facts
  • Rapid insulin can’t lower BG any sooner than 20 minutes
  • It peaks on average in about 1 h 15 min
  • It’s mostly gone in 2-4 hours
  • Maximum fall in BG is 4 mg/dl/min (rare)
beware of delayed action foods
Beware of delayed-action foods
  • Pizza
  • Pasta/noodles
  • Mexican foods
  • Fried foods

That slowly turn to sugar in body

fried food revenge and correction
“Fried-food revenge” and correction

BG = 194

6 unit correction @ 7AM

BG = 115 in 3 hours

Fried food earlier in evening @ 8PM

how does a basal insulin work
How does a “basal” insulin work?
  • Turns off or tones down sugar coming out of the liver
  • Allows a reasonable amount of sugar to enter cells
  • Keeps sugar levels steady or in balance between meals and snacks.
exercise is the wild card since
Exercise is the wild card since…
  • It can occur suddenly or unexpectedly
  • It can last for different periods of time
  • Intensity can shift up or down
  • It’s hard to measure
  • It’s impact on blood sugar can vary
tools you have seen today
Tools you have seen today…
  • The concept of FLUX
  • Insulin onset, peak, duration, amount
  • Macronutrients
  • Fast, medium and slow carbohydrate effects
  • The volatile role of exercise
  • Role of amount, timing and consistency
  • Increasing your assessment and analysis frequency
  • The role of choice and persistence
slide64
“Good” control of diabetes is all about the journey, not the destination. Diabetes control exists largely “in the moment”
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