Stephen W Ponder MD FAAP CDE Scott amp White Clinic Temple Round Rock and College Station And a bunch of other important stuff One goal of diabetes care is managing glucose FLUX ID: 319792
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Slide1
Everything you wanted to know about food & insulin*
Stephen W. Ponder MD, FAAP, CDEScott & White ClinicTemple, Round Rock and College Station
*
And a bunch of other important stuffSlide2
One goal of diabetes care is managing glucose…
FLUX
drift
Hint: It takes TIME and PATIENCE!Slide3
Non-diabetic personsSlide4
It’s all about inflammationSlide5
180
100
Pre-meal
2 hr
glucose
140
220
Pre-meal
7%
5%
6%
8%
HbA1c
Vascular system
chronic inflammation
95
115
?
Postmeal Blood sugars, A1c and CV Risk
Goal: improve post-meal control: BG < 180 mg/dlSlide6
Insulin action opens the door for sugar (glucose) to leave the bloodstream
I
G
CellSlide7
Diabetes – an energy management disorder
This is T2, but forget about d-type for now.Slide8
Sugar
level
In
Out
Why do blood sugar levels shift all the time?Slide9
present
past
future
Reactive
ProactiveSlide10
reactive vs. proactive diabetes careReactive
Actions predeterminedMinimal to no flexibility: RIGIDOutcomes don’t immediately affect long term actionsEasy to teach/learnLess time neededFavors “concrete” thinkingLess motivation needed
ProactiveActions are dependent on situation/circumstance
Flexible and adaptable
Outcomes influence subsequent actions
Training needed, plus ongoing reinforcement
More time intensive
Favors problem-solving
Requires motivationSlide11
Food = energy
Carbohydrates
Protein
Fat
GlucoseSlide12
(Glucose production – Glucose disposal) = FLUX
Here is a picture of FLUXSlide13
To manage fluxEverything becomes a
TOOL to understand, use, and masterFoodInsulinExerciseTimingDevices, etc….Slide14
If insulin keeps us alive, as does food, then why should one get more attention than the other?Slide15
Because…
Most doctors are not nutrition specialistsDiagnosing and prescribing are what we’re trained to doOur health care system downplays the role of RD’s by not always paying for those servicesPlus WE think we’re all food experts anyway!Slide16
New paradigm: “Insulin keeps us alive while food helps keep us in control”Slide17
“A well trained mind is the greatest weapon against diabetes”Slide18
Diabetes care is not an action, it’s a process…like a recipeSlide19
Why does diabetes seem so slippery?
It’s like the weatherBut like weather, it can be predicted and prepared forIn the end, it’s a self managed conditionAnd outcomes are largely driven by choicesSlide20
Point of diminishing returns?
“The good is the enemy of the perfect”Slide21
Tools to develop expertise withSlide22
Checking BG to fine tune? Or not?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 stripsChanges aheadKetone meterSlide24
Don’t pass up an opportunity to correct a high (or low) BGChoose what you consider “actionable”?BG above or below chosen thresholds
Consider recent and impending actionsCheck your results with BG levelsRepeat as necessary Slide25
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 hoursResults should feedback to the next attempt
“Practice makes better”Slide26
Curb your liver!The liver makes as well as stores sugarA proper insulin level “calms down” the liver
Aim for an in-range sugar level (<120 mg/dl) upon waking up each day Slide27
Why do lows happen at night?Hormonal patternsLower insulin need
Insulin peaks?Post-exercise effectSnacking stacking?
Lower overnight insulin/add snackSlide28
D-teens count carbs POORLY
23%Slide29
clinical dietitian (n.)
A person specializing in medical nutrition therapy.An underappreciated and underpaid
member of the diabetes team.Someone who can help your left brainSlide30
We have > 60,000 thoughts dailyGroups of thoughts comprise decisionsThe 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 homeSlide31
“You can delegate authority but you can’t delegate responsibility”Slide32
Do 2 RN’s = 1 kid?
=
Ok?
Ok to me!Slide33
“Assuming a good working knowledge of the system, diabetes control is generally proportional to the time and attention directed towards it.”Slide34
Why do some PWD/CWD’s seem to have it “easier”? It depends on your point of view
“Honeymoon”Type 2MODY?Other?Slide35
It’s more than just food: the role of the gutSlide36
The pancreas has an “off” switch for insulin
…and it’s triggered by exerciseSlide37
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)Slide38
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”Slide39
onset
peak
duration
What is the 4
th
dimension?
The “3 dimensions” of insulinSlide40
24 h
12 h
18 h
6 h
And the 4
th
dimension is:
“consistency”Slide41
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)Slide42
Comparing insulin actionsSlide43
basal insulins are not very preciseSlide44
Levemir variability in 9 subjectsSlide45
Lantus variability in 9 subjectsSlide46
Insulin Pens
DiscreetDifferent needle sizes½ unit incrementsDisposableDurable unitsMore popular todaySlide47
This is why we site-rotate…Slide48
Timing of Bolus Insulin vs. GI or BGSlide49
Timing of Bolus Insulin
(humalog/novolog/apidra)
High GI
Moderate GI
Low GI
BG Above Target Range
30-40 min. prior
15-20 min. prior
0-5 min. prior
BG Within Target Range
15-20 min. prior
0-5 min. prior
15-20 min. after
BG Below Target Range
0-5 min. prior
15-20 min. after
30-40 min. afterSlide50
Why timing matters…
Note: Carbs estimated w/pre-meal insulin.
Carbs known with post-meal insulin.
Source: Clinical Therapeutics 2004; 26:1492-7.Slide51
Why timing matters…
Bolusing with meal
Bolusing
pre
-meal
CGMS data
CGMS data Slide52
Highs after meals depend on…
Size of the bolusHow early bolus is givenHow many carbs eatenActivity level after meal
Food’s glycemic indexSlide53
Time to reach 100 mg/dl
(at ~ 4 mg/dl/min)
minutes
Blood sugar
180
260
340
420
4 mg/dl/minSlide54
Fixing breakfast highsSlide55
Timely insulin facts
Rapid insulin can’t lower BG any sooner than 20 minutesIt peaks on average in about 1 h 15 minIt’s mostly gone in 2-4 hoursMaximum fall in BG is 4 mg/dl/min (rare)Slide56
Beware of delayed-action foodsPizzaPasta/noodles
Mexican foodsFried foods
That slowly turn to sugar in bodySlide57
“Fried-food revenge” and correction
Fried food earlier in evening @ 8PMBG = 194
6 unit correction @ 7AM
BG = 115 in 3 hoursSlide58
Proper meal planning
?
?
?
?
?
?Slide59Slide60
How does a “basal” insulin work?
Turns off or tones down sugar coming out of the liverAllows a reasonable amount of sugar to enter cellsKeeps sugar levels steady or in balance between meals and snacks.Slide61
Timing and consistency are essential to success Slide62
Exercise is the wild card since…It can occur suddenly or unexpectedlyIt can last for different periods of time
Intensity can shift up or downIt’s hard to measureIt’s impact on blood sugar can varySlide63
Tools you have seen today…
The concept of FLUXInsulin onset, peak, duration, amountMacronutrientsFast, medium and slow carbohydrate effectsThe volatile role of exercise
Role of amount, timing and consistencyIncreasing your assessment and analysis frequency
The role of choice and persistenceSlide64
“Good” control of diabetes is all about the journey, not the destination. Diabetes control exists largely “in the moment”