All about Food & Insulin

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 stuffOne goal of diabetes care is managing glucoseFLUXdriftHint: It takes TIME and PATIENCE!15 seconds2

Non-diabetic personsIts all about inflammation

180100Pre-meal2 hrglucose140220Pre-meal7%5%6%8%HbA1cVascular systemchronic inflammation

95

115

?Postmeal Blood sugars, A1c and CV RiskGoal: improve post-meal control: BG < 180 mg/dl45 seconds5Insulin action opens the door for sugar (glucose) to leave the bloodstream

IGCellHolding open a door photo here6Diabetes an energy management disorder

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

SugarlevelInOut

Why do blood sugar levels shift all the time?presentpastfutureReactiveProactivereactive vs. proactive diabetes careReactive Actions predeterminedMinimal to no flexibility: RIGIDOutcomes dont immediately affect long term actionsEasy to teach/learnLess time neededFavors concrete thinkingLess motivation needed

ProactiveActions are dependent on situation/circumstanceFlexible and adaptableOutcomes influence subsequent actionsTraining needed, plus ongoing reinforcementMore time intensiveFavors problem-solvingRequires motivationFood = energyCarbohydratesProteinFatGlucose(Glucose production Glucose disposal) = FLUX

Here is a picture of FLUXTo manage fluxEverything becomes a TOOL to understand, use, and masterFoodInsulinExerciseTimingDevices, etc.

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

BecauseMost doctors are not nutrition specialistsDiagnosing and prescribing are what were trained to doOur health care system downplays the role of RDs by not always paying for those servicesPlus WE think were 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 diabetesDiabetes care is not an action, its a processlike a recipe

Why does diabetes seem so slippery?Its like the weatherBut like weather, it can be predicted and prepared forIn the end, its a self managed conditionAnd outcomes are largely driven by choices

Point of diminishing returns?

The good is the enemy of the perfectTools to develop expertise with

Checking BG to fine tune? Or not?

Meters are commodity itemsa commodity is the generic term for any marketable item produced to satisfy wants or needsThe best BG meter is the one youll use$10.41/50 stripsChanges aheadKetone meter

Dont pass up an opportunity to correct a high (or low) BGChoose what you consider actionable?BG above or below chosen thresholdsConsider recent and impending actionsCheck your results with BG levelsRepeat as necessary

Check your targets oftenMake 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 attemptPractice makes betterCurb your liver!The liver makes as well as stores sugarA proper insulin level calms down the liverAim for an in-range sugar level (1 year in duration (mean A1C 8.01.0%) who used insulin:carbohydrate (I:C) ratios for at least one meal per day. The adolescents were asked to assess the amount of carbohydrate in 32 foods commonly consumed by youths. Foods were presented either as food models or as actual food, with some items presented as standard serving sizes and some self-served by study participants. T-tests were used to assess the significance of over- or underestimation of carbohydrate content. For each meal, accuracy was categorized as accurate (within 10 grams), overestimated (by >10 grams), or underestimated (by >10 grams) based on the commonly used I:C ratio of 1 unit of insulin per 10 grams of carbohydrate. Only 23% of adolescents estimated daily carbohydrate within 10 grams of the true amount despite selection of common meals. For dinner meals, individuals with accurate estimation of carbohydrate grams had the lowest A1C values (7.690.82%, P=0.04). The pilot study provides preliminary evidence that adolescents with type 1 diabetes do not accurately count carbohydrates. Further data are needed on carbohydrate counting accuracy and other factors that affect glycemic control.28 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 brain

We have > 60,000 thoughts dailyGroups of thoughts comprise decisionsThe typical non-D person makes ~ 250 decisions a day about foodHow many more food choices does a PWD/CWD make?

What are we doing for dinner, dear?Eat at home

You can delegate authority but you cant delegate responsibilityDo 2 RNs = 1 kid?

=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/CWDs seem to have it easier? It depends on your point of view

HoneymoonType 2MODY?Other?Residual insulinhoneymoon. Early type 2 and weight loss lowers resistancewrong diagnosisMODY34Its more than just food: the role of the gut

The pancreas has an off switch for insulin

and its triggered by exerciseKinetic versus Dynamic Insulin

Kinetic: how fast insulin gets in and outDynamic: time that insulin lowers sugarTime in hoursGlucose infusion rate(mg/kg/minute)

Current insulin pump therapyGet my point?

Early Insulin Pumps

Multi-dose insulin therapy

LantusLevemirHumalogNovologNPH70/30Different tools for different jobs

Think of insulin as a tool

onsetpeakdurationWhat is the 4th dimension?The 3 dimensions of insulin

24 h12 h18 h6 h

And the 4th dimension is: consistency40The final productThe 2013 insulin arsenalLong (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 actionsbasal insulins are not very precise

Figure 2. Within-subject variability of insulin detemir, NPH insulin, and insulin glargine are graphically shown by the width of a prediction interval containing 95% of the predicted values. The prediction intervals illustrating day-to-day variability in the pharmacodynamic response are exemplified for a subject with the same mean response with any given treatment (insulin detemir, NPH insulin, or insulin glargine). A: A subject with a mean GIR over 24 h of 1 mg kg-1 min-1 has a probability to experience an effect of less than half the usual effect (i.e., 4 mg kg-1 min-1) will be 0.1% if the subject uses insulin detemir, 6% with NPH insulin, and 3% with insulin glargine. Note: a linear scale has been used in this figure to improve readability of values, and therefore the prediction intervals are not distributed symmetrically around the mean.

43Levemir variability in 9 subjects

Figure 1. Individual time-action profiles (glucose infusion rates over time) of the first nine patients randomized to insulin detemir (A), NPH insulin (B), or insulin glargine (C). The four clamps in one subject are summarized in one plot. A low within-subject variability is indicated by the four lines in one plot being close to each other (e.g., subject no. 204), whereas major deviations between the time-action profiles in one subject (e.g., subject no. 224) shows a high within-subject variability.44Lantus variability in 9 subjects

Figure 1. Individual time-action profiles (glucose infusion rates over time) of the first nine patients randomized to insulin detemir (A), NPH insulin (B), or insulin glargine (C). The four clamps in one subject are summarized in one plot. A low within-subject variability is indicated by the four lines in one plot being close to each other (e.g., subject no. 204), whereas major deviations between the time-action profiles in one subject (e.g., subject no. 224) shows a high within-subject variability.45

Insulin PensDiscreetDifferent needle sizes unit incrementsDisposableDurable unitsMore popular today

This is why we site-rotate

Timing of Bolus Insulin vs. GI or BG

Timing of Bolus Insulin(humalog/novolog/apidra)High GIModerate GILow GIBG Above Target Range30-40 min. prior15-20 min. prior0-5 min. priorBG Within Target Range15-20 min. prior0-5 min. prior15-20 min. afterBG Below Target Range0-5 min. prior15-20 min. after30-40 min. afterWhy timing matters

Note: Carbs estimated w/pre-meal insulin. Carbs known with post-meal insulin.Source: Clinical Therapeutics 2004; 26:1492-7.Why timing mattersBolusing with meal

Bolusing pre-mealCGMS data

CGMS data

Highs after meals depend on

Size of the bolusHow early bolus is givenHow many carbs eatenActivity level after mealFoods glycemic indexTime to reach 100 mg/dl (at ~ 4 mg/dl/min)

minutesBlood sugar1802603404204 mg/dl/minFixing breakfast highs

Timely insulin factsRapid insulin cant lower BG any sooner than 20 minutesIt peaks on average in about 1 h 15 minIts mostly gone in 2-4 hoursMaximum fall in BG is 4 mg/dl/min (rare)

Beware of delayed-action foodsPizzaPasta/noodlesMexican foodsFried foods

That slowly turn to sugar in bodyFried-food revenge and correction

Fried food earlier in evening @ 8PMBG = 1946 unit correction @ 7AMBG = 115 in 3 hours

Proper meal planning??????58carbohydrate counting

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.

Picture of a complex machine with many working parts capable of failing60Timing and consistency are essential to success

Exercise is the wild card sinceIt can occur suddenly or unexpectedlyIt can last for different periods of timeIntensity can shift up or downIts hard to measureIts impact on blood sugar can vary

Tools you have seen todayThe concept of FLUXInsulin onset, peak, duration, amountMacronutrientsFast, medium and slow carbohydrate effectsThe volatile role of exerciseRole of amount, timing and consistencyIncreasing your assessment and analysis frequencyThe role of choice and persistenceGood control of diabetes is all about the journey, not the destination. Diabetes control exists largely in the momentChart1000800111122223333444455550666

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missed bolusbolus too smalllate bolus or high GI food

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High all nightBasal too low or hi fat/pro mealDawn Phenomenon or Insulin ResistanceOvertreated low

Sheet1High all nightBasal too low or hi fat/pro mealDawn Phenomenon or Insulin ResistanceOvertreated low10:00 PM240110807512:00 AM24013580602:00 AM24016080404:00 AM2401801401006:00 AM2402101801708:00 AM240240240240To resize chart data range, drag lower right corner of range.