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
Vascular system
220
glucose
HbA1c
180
8%
140
7%
100
6%
5%
Pre-meal
95
2 hr
?
Pre-meal
115
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?
present
past
future
reactive vs. proactive diabetes care
Reactive
• 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
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
Food = energy
Carbohydrates
Protein
Glucose
Fat
(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?
Because…
1) Most doctors are not
nutrition specialists
2) Diagnosing and
prescribing are what
we’re trained to do
3) Our health care system
downplays the role of
RD’s by not always
paying for those
services
4) 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
23%
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
We have > 60,000 thoughts daily
Eat at
home
“What are we doing for dinner, dear?”
• 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?
“You can delegate authority
but you can’t delegate
responsibility”
Do 2 RN’s = 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/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
Dynamic: time that insulin lowers sugar
(mg/kg/minute)
Glucose infusion rate
Kinetic: how fast insulin gets in and out
Time in hours
Different
toolsPumps
for different
jobs
Early
Insulin
Current
insulin
pump
therapy…
Multi-dose
“Think insulin
of insulin
therapy
as a tool”
Lantus
Levemir
Humalog
Novolog
NPH
Get my point?
70/30
7
6
The
What
“3 is
dimensions”
the 4th dimension?
of insulin
5
4
peak
3
2
onset
1
0
duration
7
6
5
4
3
And the 4th dimension is: “consistency”
2
1
0
6h
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
Low BG
OK
High BG
Low G.I.
Mod
High G.I.
-30
-15
0
Minutes from meal
15
30
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. after
Why timing matters…
200
150
Pre-Meal
Insulin
Post-Meal
Insulin
100
Note:
4 hrs
3-hrs
2-hrs
1-hr
0
50
Carbs estimated w/pre-meal insulin.
Carbs known with post-meal insulin.
Source: Clinical Therapeutics 2004; 26:1492-7.
Why timing matters…
CGMS data
 Bolusing with 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)
Blood sugar
420
340
260
180
minutes
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
Fried food earlier
in evening @ 8PM
BG = 115
in 3 hours
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”