Slide 1

Slide 2 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 Slide 3 One goal of diabetes care is managing glucose Hint: It takes TIME and PATIENCE! Slide 4 Non-diabetic persons Slide 5 Its all about inflammation Slide 6 180 100 Pre-meal2 hr glucose 140 220 Pre-meal 7% 5% 6% 8% HbA1c Vascular system 95115? Postmeal Blood sugars, A1c and CV Risk Goal: improve post-meal control: BG < 180 mg/dl Slide 7 Insulin action opens the door for sugar (glucose) to leave the bloodstream Slide 8 Diabetes an energy management disorder This is T2, but forget about d-type for now. Slide 9 Why do blood sugar levels shift all the time? Slide 10 present past future Slide 11 reactive vs. proactive diabetes care Reactive Actions predetermined Minimal to no flexibility: RIGID Outcomes dont immediately affect long term actions Easy to teach/learn Less time needed Favors concrete thinking Less motivation needed 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 Slide 12 Food = energy CarbohydratesProteinFat Glucose Slide 13 (Glucose production Glucose disposal) = FLUX Here is a picture of FLUX Slide 14 To manage flux Everything becomes a TOOL to understand, use, and master Food Insulin Exercise Timing Devices, etc. Slide 15 If insulin keeps us alive, as does food, then why should one get more attention than the other? Slide 16 Because 1)Most doctors are not nutrition specialists 2)Diagnosing and prescribing are what were trained to do 3)Our health care system downplays the role of RDs by not always paying for those services 4)Plus WE think were all food experts anyway! Slide 17 New paradigm: Insulin keeps us alive while food helps keep us in control Slide 18 A well trained mind is the greatest weapon against diabetes Slide 19 Diabetes care is not an action, its a processlike a recipe Slide 20 Why does diabetes seem so slippery? Its like the weather But like weather, it can be predicted and prepared for In the end, its a self managed condition And outcomes are largely driven by choices Slide 21 Point of diminishing returns? The good is the enemy of the perfect Slide 22 Tools to develop expertise with Slide 23 Checking BG to fine tune? Or not? Slide 24 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 youll use $10.41/50 strips Changes ahead Ketone meter Slide 25 Dont 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 Slide 26 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 Slide 27 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 ( Slide 28 Why do lows happen at night? Hormonal patterns Lower insulin need Insulin peaks? Post-exercise effect Snacking stacking? Lower overnight insulin/add snack Slide 29 D-teens count carbs POORLY 23% Slide 30 clin i cal di e ti tian (n.) 1.A person specializing in medical nutrition therapy. 2.An underappreciated and underpaid member of the diabetes team. 3.Someone who can help your left brain Slide 31 We have > 60,000 thoughts daily 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? Eat at home Slide 32 You can delegate authority but you cant delegate responsibility Slide 33 Do 2 RNs = 1 kid? = Ok?Ok to me! Slide 34 Assuming a good working knowledge of the system, diabetes control is generally proportional to the time and attention directed towards it. Slide 35 Why do some PWD/CWDs seem to have it easier? It depends on your point of view Honeymoon Type 2 MODY? Other? Slide 36 Its more than just food: the role of the gut Slide 37 The pancreas has an off switch for insulin and its triggered by exercise Slide 38 Kinetic versus Dynamic Insulin Kinetic: how fast insulin gets in and out Dynamic: time that insulin lowers sugar Time in hours Glucose infusion rate (mg/kg/minute) Slide 39 Current insulin pump therapy Get my point? Early Insulin Pumps Multi-dose insulin therapy Lantus Levemir Humalog Novolog NPH 70/30 Different tools for different jobs Think of insulin as a tool Slide 40 onset peak duration What is the 4 th dimension?The 3 dimensions of insulin Slide 41 24 h12 h18 h6 h And the 4 th dimension is: consistency Slide 42 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) Slide 43 Comparing insulin actions Slide 44 basal insulins are not very precise Slide 45 Levemir variability in 9 subjects Slide 46 Lantus variability in 9 subjects Slide 47 Insulin Pens Discreet Different needle sizes unit increments Disposable Durable units More popular today Slide 48 This is why we site-rotate Slide 49 Timing of Bolus Insulin vs. GI or BG Slide 50 Timing of Bolus Insulin (humalog/novolog/apidra) High GIModerate GILow GI BG Above Target Range30-40 min. prior15-20 min. prior0-5 min. prior BG Within Target Range15-20 min. prior0-5 min. prior15-20 min. after BG Below Target Range0-5 min. prior15-20 min. after30-40 min. after Slide 51 Why timing matters Note: Carbs estimated w/pre-meal insulin. Carbs known with post-meal insulin. Source: Clinical Therapeutics 2004; 26:1492-7. Slide 52 Why timing matters Bolusing with meal Bolusing pre-meal CGMS data Slide 53 Highs after meals depend on Size of the bolus How early bolus is given How many carbs eaten Activity level after meal Foods glycemic index Slide 54 Time to reach 100 mg/dl (at ~ 4 mg/dl/min) minutes Blood sugar 180 260 340 420 4 mg/dl/min Slide 55 Fixing breakfast highs Slide 56 Timely insulin facts Rapid insulin cant lower BG any sooner than 20 minutes It peaks on average in about 1 h 15 min Its mostly gone in 2-4 hours Maximum fall in BG is 4 mg/dl/min (rare) Slide 57 Beware of delayed-action foods Pizza Pasta/noodles Mexican foods Fried foods That slowly turn to sugar in body Slide 58 Fried-food revenge and correction Fried food earlier in evening @ 8PM BG = 194 6 unit correction @ 7AM BG = 115 in 3 hours Slide 59 Proper meal planning ? ? ? ? ? ? Slide 60 Slide 61 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. Slide 62 Timing and consistency are essential to success Slide 63 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 Its hard to measure Its impact on blood sugar can vary Slide 64 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 Slide 65 Good control of diabetes is all about the journey, not the destination. Diabetes control exists largely in the moment