Everything you wanted to know about food insulin
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Everything you wanted to know about food & insulin * PowerPoint PPT Presentation

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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*

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…



Hint: It takes TIME and PATIENCE!

Non-diabetic persons

It’s all about inflammation

Postmeal Blood sugars, A1c and CV Risk

chronic inflammation

Vascular system












2 hr


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




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




Diabetes – an energy management disorder

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

Why do blood sugar levels shift all the time?










reactive vs. proactive diabetes care



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





(Glucose production – Glucose disposal) = FLUX

Here is a picture of 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?


  • 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”

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

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

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

“The good is the enemy of the perfect”

Point of diminishing returns?

Tools to develop expertise with

Checking BG to fine tune? Or not?

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

  • 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

  • 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!

  • 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?

  • Hormonal patterns

  • Lower insulin need

  • Insulin peaks?

  • Post-exercise effect

  • Snacking stacking?

Lower overnight insulin/add snack

D-teens count carbs POORLY


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

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”

Do 2 RN’s = 1 kid?


Ok to me!


“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

  • “Honeymoon”

  • Type 2

  • MODY?

  • Other?

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

The pancreas has an “off” switch for insulin

…and it’s triggered by exercise

Kinetic versus Dynamic Insulin

Kinetic: how fast insulin gets in and out

Dynamic: time that insulin lowers sugar

Glucose infusion rate


Time in hours

Early Insulin Pumps

Different tools for different jobs

Multi-dose insulin therapy

Current insulin pump therapy…

“Think of insulin as a tool”






Get my point?


The “3 dimensions” of insulin

What is the 4th dimension?




And the 4th dimension is: “consistency”

6 h

12 h

18 h

24 h

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

basal insulins are not very precise

Levemir variability in 9 subjects

Lantus variability in 9 subjects

Insulin Pens

  • Discreet

  • Different needle sizes

  • ½ unit increments

  • Disposable

  • Durable units

  • More popular today

This is why we site-rotate…

Timing of Bolus Insulin vs. GI or BG

Timing of Bolus Insulin


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 matters…

CGMS data

  • Bolusingwith meal

CGMS data

  • Bolusing pre-meal

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)


4 mg/dl/min



Blood sugar



Fixing breakfast highs

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

  • Pizza

  • Pasta/noodles

  • Mexican foods

  • Fried foods

That slowly turn to sugar in body

“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







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

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…

  • 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

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

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