Insulin Therapy for Diabetes Mellitus

1. Insulin Therapy for Diabetes Mellitus Jennifer Morgan

2. Learning ObjectivesAfter this presentation you will be able to: • Understand the distinctions between T1DM and T2DM • Understand the types of insulin available and regimens to monitoring blood glucose levels in diabetics • Summarize the major approaches to managing DM through MNT

3. Incidence and Prevalence of Diabetes • Nearly 26 million (8.3%) children and adults in the U.S. have diabetes • 79 million Americans have prediabetes • The economic cost of diagnosed diabetes in the U.S. is $245 billion per year. • Among adults with diagnosed diabetes,12% take insulin only, 14% take both insulin and oral medication, 58% take oral medication only, and 16% do not take either insulin or oral medication

4. Overview: Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus • (Insulin-Dependent) • Characterized by high blood glucose levels caused by a total lack of insulin • Body’s immune system attacks insulin-producing beta cells and destroys them. • Often begins in late childhood • Characterized by high blood glucose levels caused by insulin deficiency and resistance • Eventually exogenous insulin may be required • T2DM no longer mainly affects older adults

5. Insulin Basics • Can not be taken as a pill • Characteristics: Onset, peak, duration • U-100 is the concentration of insulin available in the U.S. • All insulins have additives

6. Types of Insulin • Rapid-acting: begins to work about 15 minutes after injection, peaks in about 1 hour, continues to work for 3-5 hours. Types: Insulin glulisine (Apidra), insulin lispro (Humalog), and insulin aspart (NovoLog) • Regular or short-acting: usually reaches the bloodstream within 30 minutes after injection, peaks in 2-3 hours, effective for ~ 3-6 hours. Types: Humulin R, Novolin R • Intermediate-acting: reaches bloodstream about 2-4 hours after injection, peaks 4-12 hours later, effective for ~12-18 hours. Types: NPH (Humulin N, Novolin N) • Long-acting: reaches the bloodstream several hours after injection and tends to lower glucose levels fairly evenly over a 24-hour period. Types: Insulin detemir (Levemir) Insulin glargine (Lantus)

7. Insulin Pump Therapy • Delivers precise doses of rapid-acting insulin to closely match your body’s needs • Basal Rate: • Small amounts of insulin delivered continuously (24/7) for normal functions of the body (not including food) • Bolus Dose: • Additional insulin you can deliver “on demand” to match the food you are going to eat or to correct a high blood sugar • Pumps have bolus calculators • Insulin Pens • ADA insulin pump video

8. Insulin Regimens • Normal weight persons with T1DM • Dosage: 0.5-1 unit/kg body wt • Approx. 30-50% of the total daily insulin dose is used to provide for basal or background insulin needs • The remainder (bolus insulin) is divided among meals • Insulin-to-carbohydrate ratio • Proportionally to CHO content • 1-1.5 units/ 10-15g CHO consumed • Higher amount usually needed to cover breakfast carbohydrates • Example: EW is 135lbs (61kg) 1 x 61 = 61 units 61 x .4 = ~24 units basal61-24 = 37 units bolus

9. Insulin Regimens • Persons with T2DM requiring insulin • Dosage: 0.5-1.2 units/kg body weight • Large doses, even more than 1.5 units/ kg body weight daily may be required at least initially to overcome prevailing insulin resistance

10. Meal Scheduling Based on Insulin Regimen • Insulin-to-carbohydrate ratio: 1:15, ratios vary • 1 unit of insulin for every 15g CHO consumed • # grams carbohydrate # units of bolus insulin = 1 unit insulin per __ g CHO • Take a look at sample meal plan • Figure 31-3 • Insulin must be synchronized with food consumption • Taken before or after meals?

12. Carbohydrate Counting • Meal planning technique for managing blood glucose levels • Based on two ideas: • Eating equal amounts of sugar (fruit, candy) or starch (bread pasta) will raise blood sugar about the same amount • Carbohydrate is the main nutrient that effects blood sugar. Within1-2 hours of eating carbs, most of it is changed to blood sugar. • Carbohydrate counting education • Facts about carbohydrates • Primary food sources of carbohydrates • Average and accurate portions • Amount of carbohydrates that should be eaten • Label reading • 1 carbohydrate serving = 15g of carbohydrates

13. MNT for Type 1 Diabetes Mellitus • Integrate insulin regimen into preferred eating and physical activity schedule • Adjust premeal insulin dose based on insulin-to-carbohydrate ratios • Energy intake to prevent weight gain in adults • Adequate energy intake to promote growth in children • Self-monitoring blood glucose (SMBG) 3-8 tests/day • Insulin-to-carbohydrate control

14. Long-Term Uncontrolled Blood Glucose • Macrovascular diseases • Diseases of large blood vessels (CHD, peripheral vascular disease, cerebrovascular disease) • Dislipidemia • Hypertension • Diabetic nephropathy  ESRD • Retinopathy • Most frequent cause of new cases of blindness • Neuropathy • Peripheral • Autonomic

15. Possible PES Statements • Excessive carbohydrate intake compared with insulin dosing related to inaccurate carbohydrate counting as evidenced by the number of carbohydrate servings per meal noted in food record and postmeal glucose levels consistently > 200 mg/dL • Altered blood glucose values related to insufficient insulin as evidenced by hyperglycemia despite very good eating habits

16. Education Materials for Diabetics • http://www.mc.vanderbilt.edu/documents/7north/files/CarbohydrateCounting_FINAL.pdf • https://www.nutritioncaremanual.org/vault/editor/Docs/DiabetesLabelReading_FINAL.pdf

17. References • http://professional.diabetes.org/admin/UserFiles/0%20-%20Sean/FastFacts%20March%202013.pdf • http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insulin-basics.html • http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/advantages-of-using-an-insulin-pump.html#sthash.cVLJlwDp.dpuf • http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/glycemic-index-and-diabetes.html • http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/carbohydrate-counting.html • Carbohydrate Counting http://www.childrenwithdiabetes.com/d_08_d00.htm • http://www.diabetes.org/living-with-diabetes/complications/neuropathy/ • Mahan, L. K., Escott-Stump, S., & Raymond, J. L. Krause's Food and Nutrition Care Process (13th ed., pp. 689-707).