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es t e d b a an i D ng nd 1 e nti eyo p Ty Cou B rb a C March 10 2014 Karen Y. Warman M.S.R.D
Opponent is Diabetes Our team is the Pancreas
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Benefits of Diabetes Control • • • • • • • •
Increased energy More restful Sleep Improved Physical Performance Appetite Reduction Brain Power Stable moods/ emotions Fewer sick days Healthier skin and gums
Longer term benefits • Healthy – Eyes – Kidneys – Heart – Feet • Improved blood flow • Nerve Function • Flexible Joints • Mental Health • Successful Pregnancy • Sexual Performance
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Insulin
Accurate carbohydrate counts
Exercise
Meet your Team
What food and beverages are chosen
Stress, illness, climate, travel, rebounds from lows, weight change, medication, pump malfunction
Who are my assistants coaches?
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How to keep score • • • •
A1c Glucose excursions % of time in target Standard deviation from the mean • Assessment of Skills • Growth and development and general health
Insulin Action
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Carbohydrate 1 to 2 hours
Protein 2 to 4 hours Fat 4 to 6 hours
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Fixed Dose insulin • Doses of insulin are keep “fixed” or the same daily • Because the dose stays the same, the student is required to eat the same amount of carbohydrate at each meal and snack. • Over or under eating will result in hyper or hypo glycemia and thus an extra “bolus of insulin or snack.
Basal
Bolus
• Referred to as • Meal-associated background insulin Carbohydrate disposal • Role of basal insulin • Taken as a correction is to keep blood glucose levels when hyperglycemia consistent during is identified periods of fasting • Bolus insulin must act • Allows for cells to take quickly up glucose being released from the liver
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What is Carbohydrate Counting? • Accurately determining the carbohydrate content of food so that you can adjust your insulin dose to match the amount of carbohydrate you eat. 1 gram of CHO raises the BG 3 to 7 (mg/dl) points!
Insulin is given to lower your blood glucose
Constant Carbohydrate (meal plan) Plan Morning Snack
9:30
Gram Carb
30
Lunch
Grams Carb
11:45
2 slices Roman Meal Bread (2.2 oz) 2 oz. Of sara Lee Turkey 1 oz. Baked Tortilla Chips 1 Clementine orange (3 oz) ½ cup 1% milk
60
Afternoon Snack 2:45
Grams Carb
10 Units Sample NPH 7 AM (2 ½ inch) (3.6 oz) 1 small apple 1 oz. Mozzarella cheese 1 nature valley crunchy peanut butter granola bar (0.7 oz)
45
Carbohydrate 15 0.8 15 30.8 30 0 21 9 60
1 banana small (3.5oz) 3/4 cup Breyers Light Ice cream
23 22 45
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Match Your Carbs With Insulin • Accounts HALF the day’s control! • Keeps blood sugar normal after meals • Requires accurate carb counting and an accurate carbohydrate to insulin ratio
Definitions • Insulin to Carbohydrate ratio: the amount of insulin (in units) needed to “cover” a measured amount of Carbohydrate • Insulin sensitivity factor (ISF) or “correction factor”: the amount of insulin (in units) needed to “correct” a high blood sugar by a defined number • Exercise Carbs: ExCarbs
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How accurate is CHO counting among Adolescents • 2009 study found that only 23% of adolescent (ages 12 to 18 years) estimated daily carbohydrate within 10 grams of the true amount • They also found that those with the most accurate CHO counts had lowest A1 C • They used a combination of actual food and food models to assess Bishop et al Diabetes Spectrum Volume 22, Number 1, page 56, 2009
Test your visual Estimation Skills
• http://www.figwee.com/ • Carbs and Cals
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Methods for Counting Carbs Accurately • • • •
Label Reading Measuring and weighing foods Carb factors (requires weight) Visual Estimation of Portion sizes
Nutrition Facts Label • Good resource for carbohydrate counting • Pay attention to:
– Serving Size – Total Carbohydrate – Fiber – Sugar Alcohol
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Sugar Alcohols on Food Labels Total Carbohydrate = 21 grams 1 gram dietary fiber < 1 gram sugar 18 grams sugar alcohol 2 grams other carb Deduct ½ the sugar alcohol from the total Carbohydrate 21-9= 12 grams from this item:
Volume ≠ Weight 1 cup of rice by volume 6.6 ounces by weight or 187 grams by weight
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Measuring for Accuracy • Measuring foods is determining portions by volume – – – –
Cups Teaspoons Tablespoons Fluid ounces
Disadvantage: Requires that you pull out and dirty several measuring cups one for each item that you eat.
Weighing for Accuracy This method uses the weight of foods 1. Easy to use, only requires one tool to clean 2. Information on label is always by weight with the exception of fluids 3. A digital scale reports in grams and ounces which is important because food labels are in grams
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What to Weigh and Measure • Measure or Weigh: mashed potatoes, popcorn, pasta, rice, vegetables, fruit juice
• Weigh: Bread, rolls, bagels, fruits, baked potatoes, chips, breaded meats
Measuring and Weighing Foods • You can’t accurately count carbohydrate without weighing and measuring periodically • How often you need to pull out the scales and measuring cups depends upon whether glycemic goals are being met. • Usually recommend at least weekly
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Portion Estimation Method Long Sandwiches
8g per inch
Pizza
30g per adult hand-sized piece (fingers together)
Cookies
20g per adult-sized palm
Breaded meat/veg/cheese
4g small (“thumb/nugget sized”) 10g large (“patty/palm-sized”)
Portion Estimation Method • Examples of 1-cup Carb Estimates: Potato: 40g
Corn: 30g
Pasta: 40g
Peas: 30g
Rice: 50g
Beans: 40g
Rolls: 25g
Pretzels: 25g
Cereal: 25g
Chips: 15g
Fruit: 20g
Popcorn: 5g
Cooked Veggies: 10g
Ice Cream: 35g
Salad Veggies: 5g
Cake: 45g
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Portion estimation FIGWEE Portion explorer
Show me how you carbohydrate count • Have them review a label that is slightly tricky ie cereal that portion size is 2/3 cup • Have them show how accurate they are a visual estimates: visualize an apple, then weigh in front of them • Visualize cereal that they pour into a bowl, then measure/weigh to assess accuracy
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Recommended CHO for age Boys
< 5 years 30 to 45 grams CHO per meal
5 to 12 years Teens 45 to 60 grams CHO per 60 to 75 + grams meal of CHO per meal
Girls
< 5 years 30 to 45 grams CHO per meal
5 to 12 years Teens 45 to 60 grams CHO per 45 to 75 grams meal CHO per meal
Snacks if needed 15 to 30 grams of Carbohydrate
• Choose lowest GI grain/cereal/bread or starch veg. acceptable • Add fruit or non-starch vegetable • Add lean meat • Add healthy fat • Add low fat dairy product
Carbohydrate 45 to 55% Protein: 15 to 20% Fat: 25 to 30%
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After-Meal Highs: Immediate Problems • Tiredness • Difficulty Concentrating • Impaired Athletic Performance • Decreased desire to move • Mood Shifts • Enhanced Hunger
Summary of after-meal BG targets (glucose excursions) Group/Age
Post-meal goal
Post-meal Rise
Preschool/Toddlers < 250 mg/dl
< 120 mg/dl rise
School-age
< 225 mg/dl
< 100 mg/dl rise
Adolescents
< 200 mg/dl
< 80 mg/dl rise
Adults
< 180 mg/dl
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Meter Test Example Breakfast Pre 1h Post 117 281 90 302 151 264
Lunch Pre 1h Post 157 166 58 247 77 152
Dinner Pre 1h Post 191 204 89 147 235 222
Interpretation: Excessive after-meal peak following breakfast; not after lunch or dinner
Dietary Intervention • Use of Glycemic Index
Fastest
– Lower GI foods digest & convert to glucose more slowly – High-fiber slower than low – Hi-fat slower than low – Solids slower than liquids – Cold foods slower than hot Slowest – Type of sugar/starch affects GI
Glucose Dextrose Starch (branched-chain) Sucrose/Corn Syrup Fructose Starch (straight-chain) Lactose Galactose Sugar Alcohols
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Mini muffins Mini donuts
Gave correction 1 hour 15 minutes after breakfast
Juice box
“sandwich” with chips, cookies and juice
I:CHO 12-6a
20
6a-9a
12
9a-5p
20
5p-12a
15
SF
70
Basal
Meatballs with sweet and sour sauce and cucumbers
Granola bar
12a
0.4
3a
0.6
4a
0.7
7a
0.6
10a
0.5
Turkey 7 grain bread Chicken noodle soup (large frozen yogurt 7 grain bread Peanut butter
Juice and 1slice of pizza
HI protein bar Juice Balance bar Peanut butter crackers
Milk
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Seen on 3/31: breakfast of cereal and milk
Low
Glycemic Index of a food item <56
Email on 4/1 Changed Breakfast to 2 slices of whole wheat toast with egg and milk
Glycemic Load of a meal <11
Medium 56-70
11-20
High
> 20
Ø 70
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Glycemic Index
Glycemic Load
Low
<56
<11
Medium
56-70
11-20
High
Ø 70
> 20
High Glycemic Load Pancakes( 6 inches) by weight 81 grams Maple Syrup
Glycemic Load grams CHO Glycemic Index Glycemic Load Calories 3 66 67 44 2 tablespoons 27 54 14
Total Low Glycemic Load Old Fashioned Oatmeal Milk , skim Banana Hard Boiled egg
93
1/2 cup 15 1 cup 13 1/2 medium banana (66 g15rams) 1 0
Total
THE EQUATION Food
Skim Milk Jelly Beans Doughnut Ice cream Vanilla Wafers Banana Orange Apple Juice Pears, raw Apples, raw raisins Watermelon White Bread Cornflakes Puffed Rice French Fries Saltine Crackers Table Sugar
46 32 51 0
43
157 105
59
262
7 4 8 0
65 90 60 80
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295
Glycemic Load Glycemic IndexMultiplied by (x) Grams of CHO/100 = per serving Glycemic Grams Carbohydrate Glycemic Load Index Serving Size per serving per serving
32 78 76 62 80 51 42 40 38 38 67 73 73 81 78 75 74 68
8 fl ounces 1 oz (10 large) 1 medium ( 1.7 oz) 1 cup 5 each 1/2 large 1 medium (5 oz.) 1/2 cup 1/2 medium (3 oz) 1/2 medium (3.2 oz) 1/2 Small box .75 oz 1 1/3 cups ( 7 oz) 1 large s lice (1 oz.) 1 cup 1 cup (.5 oz) Small (3 oz.) 4 crackers 2 teaspoons
15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15 15
5 12 11 9 12 8 6 6 6 6 10 11 11 12 12 11 11 10
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Protein • Protein often eaten in excess • Rate of digestion and conversion to glucose depends on state of insulinization and glycemic control • BG effect difficult to predict – Up to 50 to 60% can be converted to glucose
• Evidence suggests more glycemic impact in poorly controlled diabetes, less impact when patient is adequately insulinized and controlled
Protein • Persons without Diabetes – Protein stimulates the endogenous production insulin and glucagon • Persons with Type 1 Diabetes – No endogenous insulin production – Production of endogenous glucagon – Protein causes a slow rise in BG; 3 to 5 hour after eating • Occurs after the peak of rapid-acting insluin analogs • Cannot be included meal bolus • Meals that are 100% protein will need some insulin coverage.
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Fat • Effects on Blood Glucose – Delayed stomach emptying – Decreased insulin sensitivity – Increased insulin resistance – May last for hours after eating
• Minimal fat actually converts to glucose < 10% • Individual's response needs to be evaluated
When is important
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Does Timing Matter? • Bolus w/meal
• Bolus pre-meal
Gary Scheiner MS, CDE
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Types of Insulin Bolus Available for Pumpers • Regular: For most food situations • Extended: For special situations/Low glycemic index foods or grazing • Combination: for special foods • The secret to bolusing is the timing!
Combination Bolus • The pizza bolus – A 2005 study indicates that the best way to keep BG’s in target range after pizza is to deliver the insulin in a 50/50 split spread out over 8 hours
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Pump Bolus Features • Often discussed approximately 3 months after pump initiation • Can help deliver the insulin to match the carbohydrate absorption more closely • Help to improve glycemic control • Review the effect of Protein and Fat on carbohydrate absorption and metabolism • A group in Poland has proposed a equation that factors fat and protein to determine dual time and if additional insulin is recommended
Different meal, different bolus
Carbohydrate
Normal/Standard
Protein Meal Square / Extended
Mixed Meal
Dualwave / Multiwave
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Physical Performance
Best athletic performances when blood glucose is in the range of 80 to 140 mg/dl
Just a Few Factors that affect Blood Glucose During Exercise • • • • • •
Active Insulin Infusion Site What You Ate When You Ate Emotional State Temp/Humidity
• Familiarity w/Activity • Amt. Of Prior Activity • Size/Number of Muscles Involved • Duration • Intensity
Sources: Walsh J et al: Using Insulin, Torrey Pines Press, San Diego, 2003. Scheiner, Gary: Think Like A Pancreas, Da Capo Press 2011
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Adrenaline Raises BG! Activities that often produce a shortterm blood glucose rise include: æ Weight lifting (high weight, low reps)
æ Sports w/ “bursts” of activity (golf, baseball, martial arts) æ Sprints (running, swimming) æ Judged performances (gymnastics, skating) æ Events in which WINNING is the primary objective Sources: Colberg, Sheri: The Diabetic Athlete, Human Kinetics, Champaign, IL, 2001.
Hypoglycemia • One of the most feared complication of Diabetes • Often cited as a reason for not giving recommended insulin dose • Physiological definition < 70 mg/dl • Patients with higher A1c feel symptoms at higher blood glucose levels • Repeated bouts of hypoglycemia can result in hypoglycemic unawareness
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Hypoglycemia/exercise • Can occur 1 to 2 hours after or up to 17 hours after exercise • Aerobic exercise results in an increase in both insulin and non-insulin medicated glucose uptake • Non-diabetic 40 to 60% reduction in endogenous insulin secretion.
Factors difficult to control Will /Can Decrease Blood Glucose
Will/Can Increase Blood glucose Caffeine
Prior Heavy Exercise
High Altitude
Weight Loss
Gastroparesis
Brain Work
Warm weather and Humidity
Stress Protein without carbohydrate intake
Fatty Foods
Medications (steroids)
Couch potato for the weekend Growth Hormone/Dawn
Up and down Alcohol: Initially blood glucose will rise, may then result in low blood glucose as it impairs release of glucose from the liver.
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