Everything you wanted to know about food & insulin *

1. 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

2. One goal of diabetes care is managing glucose… FLUX drift Hint: It takes TIME and PATIENCE!

3. Non-diabetic persons

4. It’s all about inflammation

5. 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

6. Insulin action opens the door for sugar (glucose) to leave the bloodstream Cell I G

7. Diabetes – an energy management disorder This is T2, but forget about d-type for now.

8. Why do blood sugar levels shift all the time? Out In Sugar level

9. present Proactive Reactive future past

10. reactive vs. proactive diabetes care 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

11. Food = energy Carbohydrates Protein Fat Glucose

12. (Glucose production – Glucose disposal) = FLUX Here is a picture of FLUX

13. To manage flux • Everything becomes a TOOL to understand, use, and master • Food • Insulin • Exercise • Timing • Devices, etc….

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

15. Because… • 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!

16. New paradigm: “Insulin keeps us alive while food helps keep us in control”

17. “A well trained mind is the greatest weapon against diabetes”

18. Diabetes care is not an action, it’s a process…like a recipe

19. 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

20. “The good is the enemy of the perfect” Point of diminishing returns?

21. Tools to develop expertise with

22. Checking BG to fine tune? Or not?

23. 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

24. 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

25. 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”

26. 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

27. Why do lows happen at night? • Hormonal patterns • Lower insulin need • Insulin peaks? • Post-exercise effect • Snacking stacking? Lower overnight insulin/add snack

28. D-teens count carbs POORLY 23%

29. clin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

30. We have > 60,000 thoughts daily 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?”

31. “You can delegate authority but you can’t delegate responsibility”

32. Do 2 RN’s = 1 kid? Ok? Ok to me! =

33. “Assuming a good working knowledge of the system, diabetes control is generally proportional to the time and attention directed towards it.”

34. Why do some PWD/CWD’s seem to have it “easier”? It depends on your point of view • “Honeymoon” • Type 2 • MODY? • Other?

35. It’s more than just food: the role of the gut

36. The pancreas has an “off” switch for insulin …and it’s triggered by exercise

37. Kinetic versus Dynamic Insulin Kinetic: how fast insulin gets in and out Dynamic: time that insulin lowers sugar Glucose infusion rate (mg/kg/minute) Time in hours

38. Early Insulin Pumps 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

39. The “3 dimensions” of insulin What is the 4th dimension? peak onset duration

40. And the 4th dimension is: “consistency” 6 h 12 h 18 h 24 h

41. 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)

42. Comparing insulin actions

43. basal insulins are not very precise

44. Levemir variability in 9 subjects

45. Lantus variability in 9 subjects

46. Insulin Pens • Discreet • Different needle sizes • ½ unit increments • Disposable • Durable units • More popular today

47. This is why we site-rotate…

48. Timing of Bolus Insulin vs. GI or BG

49. Timing of Bolus Insulin (humalog/novolog/apidra)

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