Everything you wanted to know about food insulin
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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 *

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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!


Everything you wanted to know about food insulin

Non-diabetic persons


It s all about inflammation

It’s all about inflammation


Everything you wanted to know about food insulin

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


Insulin action opens the door for sugar glucose to leave the bloodstream

Insulin action opens the door for sugar (glucose) to leave the bloodstream

Cell

I

G


Diabetes an energy management disorder

Diabetes – an energy management disorder

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


Everything you wanted to know about food insulin

Why do blood sugar levels shift all the time?

Out

In

Sugar

level


Everything you wanted to know about food insulin

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


Glucose production glucose disposal flux

(Glucose production – Glucose disposal) = FLUX

Here is a picture of FLUX


To manage flux

To manage flux

  • Everything becomes a TOOL to understand, use, and master

  • Food

  • Insulin

  • Exercise

  • Timing

  • Devices, etc….


If insulin keeps us alive as does food then why should one get more attention than the other

If insulin keeps us alive, as does food, then why should one get more attention than the other?


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!


New paradigm insulin keeps us alive while food helps keep us in control

New paradigm: “Insulin keeps us alive while food helps keep us in control”


Everything you wanted to know about food insulin

“A well trained mind is the greatest weapon against diabetes”


Diabetes care is not an action it s a process like a recipe

Diabetes care is not an action, it’s a process…like a recipe


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


Point of diminishing returns

“The good is the enemy of the perfect”

Point of diminishing returns?


Tools to develop expertise with

Tools to develop expertise with


Checking bg to fine tune or not

Checking BG to fine tune? Or not?


Everything you wanted to know about food insulin

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


D teens count carbs poorly

D-teens count carbs POORLY

23%


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?”


You can delegate authority but you can t delegate responsibility

“You can delegate authority but you can’t delegate responsibility”


Do 2 rn s 1 kid

Do 2 RN’s = 1 kid?

Ok?

Ok to me!

=


Everything you wanted to know about food insulin

“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?


It s more than just food the role of the gut

It’s more than just food: the role of the gut


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


Everything you wanted to know about food insulin

The “3 dimensions” of insulin

What is the 4th dimension?

peak

onset

duration


Everything you wanted to know about food insulin

And the 4th dimension is: “consistency”

6 h

12 h

18 h

24 h


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)


Comparing insulin actions

Comparing insulin actions


Basal insulins are not very precise

basal insulins are not very precise


Levemir variability in 9 subjects

Levemir variability in 9 subjects


Lantus variability in 9 subjects

Lantus variability in 9 subjects


Insulin pens

Insulin Pens

  • Discreet

  • Different needle sizes

  • ½ unit increments

  • Disposable

  • Durable units

  • More popular today


This is why we site rotate

This is why we site-rotate…


Timing of bolus insulin vs gi or bg

Timing of Bolus Insulin vs. GI or BG


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


Fixing breakfast highs

Fixing breakfast highs


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


Proper meal planning

Proper meal planning

?

?

?

?

?

?


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.


Timing and consistency are essential to success

Timing and consistency are essential to success


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


Everything you wanted to know about food insulin

“Good” control of diabetes is all about the journey, not the destination. Diabetes control exists largely “in the moment”


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