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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!




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 the bloodstream

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


Why do blood sugar levels shift all the time? the bloodstream

Out

In

Sugar

level


present the bloodstream

Proactive

Reactive

future

past


Reactive vs proactive diabetes care
reactive vs. proactive diabetes care the bloodstream

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 the bloodstream

Carbohydrates

Protein

Fat

Glucose


Glucose production glucose disposal flux
(Glucose production – Glucose disposal) = the bloodstreamFLUX

Here is a picture of FLUX


To manage flux
To manage the bloodstreamflux

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

  • Food

  • Insulin

  • Exercise

  • Timing

  • Devices, etc….



Because
Because… 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
New paradigm get more attention than the other?: “Insulin keeps us alive while food helps keep us in control”




Why does diabetes seem so slippery
Why does diabetes seem so slippery? recipe

  • 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” recipe

Point of diminishing returns?




Meters are recipecommodity 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 recipe

  • 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 recipe

  • 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! recipe

  • 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? recipe

  • 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 recipe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 recipe

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?”



Do 2 rn s 1 kid
Do 2 RN’s = 1 kid? responsibility”

Ok?

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
Why do some PWD/CWD’s control is generally proportional to the time and attention directed towards it.”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 control is generally proportional to the time and attention directed towards it.”


The pancreas has an off switch for insulin
The pancreas has an “off” switch for insulin control is generally proportional to the time and attention directed towards it.”

…and it’s triggered by exercise


Kinetic versus dynamic insulin
Kinetic versus Dynamic Insulin control is generally proportional to the time and attention directed towards it.”

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 control is generally proportional to the time and attention directed towards it.”

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


The “3 dimensions” of insulin control is generally proportional to the time and attention directed towards it.”

What is the 4th dimension?

peak

onset

duration


And the 4 control is generally proportional to the time and attention directed towards it.”th dimension is: “consistency”

6 h

12 h

18 h

24 h


The 2013 insulin arsenal
The 2013 “insulin arsenal” control is generally proportional to the time and attention directed towards it.”

  • 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 control is generally proportional to the time and attention directed towards it.”


Basal insulins are not very precise
basal insulins are not very precise control is generally proportional to the time and attention directed towards it.”


Levemir variability in 9 subjects
Levemir variability in 9 subjects control is generally proportional to the time and attention directed towards it.”


Lantus variability in 9 subjects
Lantus variability in 9 subjects control is generally proportional to the time and attention directed towards it.”


Insulin pens
Insulin Pens control is generally proportional to the time and attention directed towards it.”

  • 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… control is generally proportional to the time and attention directed towards it.”


Timing of bolus insulin vs gi or bg
Timing of Bolus Insulin vs. GI or BG control is generally proportional to the time and attention directed towards it.”


Timing of bolus insulin
Timing of Bolus Insulin control is generally proportional to the time and attention directed towards it.”

(humalog/novolog/apidra)


Why timing matters
Why timing matters… control is generally proportional to the time and attention directed towards it.”

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… control is generally proportional to the time and attention directed towards it.”

CGMS data

  • Bolusingwith meal

CGMS data

  • Bolusing pre-meal


Highs after meals depend on
Highs control is generally proportional to the time and attention directed towards it.”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 control is generally proportional to the time and attention directed towards it.”mg/dl(at ~ 4 mg/dl/min)

420

4 mg/dl/min

340

260

Blood sugar

180

minutes


Fixing breakfast highs
Fixing breakfast highs control is generally proportional to the time and attention directed towards it.”


Timely insulin facts
Timely insulin facts control is generally proportional to the time and attention directed towards it.”

  • 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 control is generally proportional to the time and attention directed towards it.”

  • Pizza

  • Pasta/noodles

  • Mexican foods

  • Fried foods

That slowly turn to sugar in body


Fried food revenge and correction
“Fried-food revenge” and correction control is generally proportional to the time and attention directed towards it.”

BG = 194

6 unit correction @ 7AM

BG = 115 in 3 hours

Fried food earlier in evening @ 8PM


Proper meal planning
Proper meal planning control is generally proportional to the time and attention directed towards it.”

?

?

?

?

?

?


How does a basal insulin work
How does a “basal” insulin work? control is generally proportional to the time and attention directed towards it.”

  • 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 control is generally proportional to the time and attention directed towards it.”


Exercise is the wild card since
Exercise is the wild card since… control is generally proportional to the time and attention directed towards it.”

  • 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… control is generally proportional to the time and attention directed towards it.”

  • 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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