Beyond Carbohydrate Counting: What Else Matters? Lorraine Anderson RD, CDE Senior Clinical Manager,...

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Beyond Carbohydrate Counting:What Else Matters?

Lorraine Anderson RD, CDESenior Clinical Manager, Animas Canada2015 CWD Friends for Life Canada Conference – Niagara Falls

Disclosures

Employee, Animas Canada. No other conflicts to disclose.

Objectives

Discuss the importance of post-meal blood glucose management and strategies for children with type 1 diabetes.

Review the latest literature regarding the roles of carbohydrate, fat and protein in diabetes management.

Review strategies for practical application in day to day practice.

Optimizing Post-meal Blood Glucose

Insulin:Carb (I:C) ratio Is it correct?

Insulin Sensitivity Factor (ISF)/Correction Factor Does it work?

Target BG/Duration of Insulin Action (pumps)

Matching Insulin to Food (quantity and quality) Carb Counting Glycemic Index Fat and Protein Content

Others? Timing, Exercise, Stress, Alcohol, More

Recommended Glycemic Targets for Children and Adolescents with Type 1 Diabetes

Wherrett D et al. Can J Diabetes 37 (2013) S153-S162.

* Postprandial monitoring is rarely done in young children except for those on pump therapy for whom targets are not available.

“It’s not just about the carbs”

Carbohydrate

Greatest glycemic impact (time and magnitude) Carbohydrates don’t affect blood glucose equally Some of the potential variables effecting glycemic impact:

Type and amount of CHO (starch, i.e. Basmati rice vs. short grain) Fiber (soluble vs. insoluble) Sugar alcohols Physical form of the food Acidity Temperature Processing Cooking method – degree of gelatinization i.e. al dente pasta

Franz M. Carbohydrate and Diabetes: Is the Source or the Amount of More Importance? Current Diabetes Reports 2001. 1:177-186.

Carbohydrate Counting

Beyond the Basics - 15g carbohydrate exchanges

Carbohydrate Counting Tools

How accurate are we?

Smart CE et al. 102 children, 8-18 years and 110 caregivers estimated CHO content of 17 standardized meals (8-90g)

Most of the time (73%), we estimate to within 10-15 g. The larger the carb content of the meal, the greater the

inaccuracy in carb counting. Large meals are commonly underestimated whereas snacks

are commonly overestimated. Foods in non-standard servings sizes such as rice, pasta, cereal

and fruit most often inaccurately estimated. The longer the children had been carb counting, the greater

the percentage error – need ONGOING education.

Smart, CE et al. Diabet. Med 2009; 26: 279-285.

Two “inputs” when determining meal insulin dose, both have risk of error Carb counting Meter accuracy

And don’t forget adjustment for activity (↑↓), alcohol, stress, high fat, high protein meals…

Inaccurate carbohydrate counting is associated with higher daily blood glucose variability. Though accuracy within 10-20g is NOT correlated

to higher A1C or significant postprandial glucose excursion.

Of all the “inputs” when determining meal insulin dose, which has the greatest risk of error?

Checking the I:C Ratio

Fix the basal first

Test the ratio when the pre-meal blood glucose is in target

Try to do this when it has been at least 4 hours since the last bolus

No recent lows or exercise

Eat a low-fat meal when you know the exact carb count(i.e. Lean Cuisine, or use Salter scale)

Test with ~ 1 g carbohydrate/kg body weight

Test pre-meal, at 2 hr and 4 hr after meals

Checking Insulin:Carb Ratios

What is an acceptable increase in BG at 2 hrs?

Insulin:Carbohydrate Ratio

If set right, the I:C ratio should keep the BG rise between 2.2 and 4.4 mmol/L, 2 hours later

Should bring the BG back close to target at 4-5 hrs.

If adjusting, do so by 1 or 2 g at a time

Walsh J. Pumping Insulin, 5th Ed. San Diego: Torrey Pines Press; 2012.

meal 2 hours 4 hours

Evaluating Carb Bolus

too much

dose just right

too little

Test before meal,every 1-2hr after and

before next meal.

1 hour 3 hoursAdapted - John Walsh

Checking the Insulin Sensitivity Factor (ISF)

When a correction bolus is injected/programmed, how quickly should the BG return to target?

Checking the Insulin Sensitivity Factor (ISF)

BG should return to target 4-5 hours LATER

Should not cause hypoglycemia afterwards

Walsh J. Pumping Insulin, 5th Ed. San Diego: Torrey Pines Press; 2012.

Matching Insulin to Food

The carbohydrate quantity causes the rise in blood glucose after a meal and determines the bolus size.

The carbohydrate quality affects the rate at which blood glucose rises and determines the type of bolus to be used.

Evelyne Pytka 2008

normal/standard bolus

extended or square wave bolus

combination or dual-wave bolus

Types of Boluses

Advanced Bolus Features

Normal bolus Entire bolus delivered immediately

Extended bolus Bolus delivered over an extended period of time

Combination bolus Portion of bolus is delivered immediately and portion is

extended over time Bolus mimics physiological insulin delivery – “first phase

and second phase delivery”

Why Use a Combination Bolus?

Prevents early post meal hypoglycemia (from insulin peaking before blood glucose rises)

Prevents late post-meal high blood sugars (from not having insulin to “cover” the late rise in glucose from carbohydrate)

The more rapidly-absorbed carbohydrate is “covered” now, and the more slowly absorbed carbohydrates are “covered” later

Why Combo Bolus?

Unpredictable eaters, such as young children

Gastroparesis (also pre-meal hyperglycemia slows gastric emptying)

Nutrient composition of meal

Ryan-Turek T. Variable Bolus Features on Insulin Pumps and Practical Applications for Use. On The Cutting Edge. 2005 26:4:16-18.Wolpert H. Smart Pumping: A Practical Approach to Mastering the Insulin Pump. Virginia: ADA; 2002: 128.Walsh J. Pumping Insulin, 5th Ed. San Diego: Torrey Pines Press; 2012.

Nutrient Composition of Meal

“Slow carbs” – low GI, high fat

“Fast carbs” – high GI, little or no fat

High protein/High fat effect Independent and additive

Smart CE et al. Diabetes Care December 2013 vol. 36.12: 3897-3902.

How to Determine a Combination Bolus

Starting point:

Split the bolus: 50% now, 50% over 3-5 hours (maybe longer?)

Check blood glucose at 2, 4, and 6 hours after eating

If “on the low side” at 2 hours, but “on the high side” 4-6 hours later, take less of the bolus up front, and spread more of the bolus over time

Adjust based on individual response

What about injectors?

Adapted from Wolpert H, Smart Pumping, Alexandria VA: American Diabetes Association, 2003,p. 134.

Challenge your knowledge – Missed Boluses

Question 1: True or False

Missing the occasional meal bolus does not impact A1C.

Missed meal boluses

TAKING the bolus is important!!!

“Forgetting” is very common – average of 2 missed meal boluses per week among 7-20 year olds

Burdick, J. et al. Pediatrics Vol. 113, No. 3, March 2004, e221-224.

Forgot to Bolus?

2 missed boluses per week A1C increased 0.5% 4 missed boluses per week A1C increased 1.0% Most common reason: “forgetting”

Missed meal boluses

TAKING the bolus is important!!!

“Forgetting” is very common – average of 2 missed meal boluses per week among 7-20 year olds

Reasons? Privacy/discretion Low pre-meal, decided to wait to bolus “Just forgot”

Bottom Line

MISSED MEAL DOSES ARE A MAJOR REASON FOR SUBOPTIMAL GLYCEMIC CONTROL

Challenge your knowledge – Bolus Timing

Optimal glycemic control can be achieved when meal-time insulin is given during or after the meal.

Studies examining bolus timing

Jovanovic et al. 2004 Clin Ther. Sep; 26(9):1492-7. Cobry et al. 2010 Diab Tech Ther:12:173-7. Scaramuzza et al. 2010 Diab Tech Ther;12:149-52. De Palma et al. 2011 Diab Tech Ther;13(4):483-7 Danne et al. 2003 Diabetes Care;26:2359-64. Ratner et al. 2011 Diabetes Obes Metab. 13(12): 1142-8. Luijf et al. 2010 Diabetes Care; 33(10): 2152-5. Ryan et al. 2008 Diabetes Care;31(8): 1485-90. Liberty, I. et al. Practical Diabetes 2012; 29(3): 98–102.

When to bolus

Cobry et al. 2010 23 subjects aged 12-30, crossover study with three

treatment arms: Delivering a bolus 20 min prior to meal (PRE) Immediately before the meal 20 minutes after the meal

Cobry E, et al. Diab Technol & Therapeutics, 2010

Pre-meal vs start of meal vs post-meal bolusing

20 minutes pre-meal significantly better than start of meal or 20 minutes after

TiBoDi Study – Scaramuzza et al. 2010

30 pts, T1 DM X 8.07 +/- 4.1 years, 6-20 years of age, on pump therapy

Compared glucose response to a standard meal when bolus was given 15 min before, immediately before or immediately after the meal.

Results: No difference if the bolus is given 15 min or immediately before meal HOWEVER, there is a significant rise when the bolus is administered after the meal, even if the BG was in the hypo range pre-meal.

TiBoDi Study – Scaramuzza et al. 2010

If low pre-meal, correct the hypoglycemia, inject the bolus, then eat.

When bolus was given 15 min pre-meal, average post meal levels never exceeded 7.8 mmol/L. 15 min pre-meal bolus best option because it is

associated with smallest standard deviation (SD).

Bottom Line

NO STUDIES FAVOUR POST-MEAL BOLUSING*

If uncertain of the quantity to be eaten: give correction + grams carb likely to eat i.e. 20 g for child, 40 g for adolescent or adult

The higher the pre-meal BG, the earlier the bolus should be given.

Timing is important.

Challenge your knowledge

Although carbohydrate is the primary stimulus for insulin secretion, it is not the only one.

Protein

Many people eat double the recommended amounts for protein

How protein impacts blood glucose is controversial

BG effect difficult to predict Up to 50-60% can be converted to glucose (TAG theory)

Common to see rise in BG 3-5 hours later, after significantly larger than normal portions are consumed.

Franz, M., ed. Diabetes Management Therapies: A Core Curriculum for Diabetes Education, 5h edition. Chicago: American Association of Diabetes Educators, 2001.

*Bao et at. Am J Clin Nutr 2009;90:986-92.

In people without diabetes: Protein ingestion stimulates the endogenous

production of both insulin and glucagon In people with type 1 diabetes:

No endogenous insulin production Production of endogenous glucagon Protein causes a slow rise in BG; 3-5 hours after

eating Occurs after the peak of rapid-acting insulin analogs Cannot be included in meal bolus

Protein

Nutall FQ et al. 1984

Effects on BG Delayed stomach emptying Decreased insulin sensitivity May last for several hours after eating

Minimal fat actually converted to glucose (<10%) Individual’s response needs to be evaluated

Wolpert H. Smart Pumping: A Practical Approach to Mastering the Insulin Pump. Virginia: ADA; 2002: 128.Funnell M., et al. Life with Diabetes: A Series of Teaching Outlines by the Michigan Diabetes Research and Training Center. Alexandria: American Diabetes Association; 2004.

Bolusing for Fat and Protein 100 kcal of fat/protein = 1 FPU = “10 g carb equivalent” Delivered as extended bolus

1 FPU is extended over 3 hours 2 FPU extended over 4 hours 3 FPU extended over 5 hours > 3 FPU extended over 8 hours

For example, a Hot Dog meal 30 g of CHO, 16 g of PRO, 28 g of FAT How many FPU? I:C ratio is 1 unit per 10 g of CHO

The ‘Warsaw School Program’ for dosing mealtime insulin

Answer:

30 g of CHO/10 g per unit = 3.0 units

Hot Dog Example

Answer:

3 FPU ≈ “30 g carb equivalents” = 3.0 units

Hot Dog Example

Answer:

3 FPU ≈ “30 g carb equivalents” = 3.0 units

Therefore, 3 units as a normal bolus and 3 units extended over 5 hours

Hot Dog Example

Pts with A1C < 7.5% (n=295) used this method more often than those with A1C >7.5% 19.5 +/- 18.4 times in 2 weeks vs 12.4 +/- 14.3 times in 2 weeks

For patients using less than 14 S-W boluses during a 2-wk period, basal insulin requirement was 34.3+/- 15.8%, and respectively, in patients using more than 1 S-W bolus/d, the % basal insulin was 27.7+/- 10.2%.

Also minimum of 6 boluses per day found to meet A1C goal.

RESULTS

Wolpert et al (2013):

7 adult patients with type 1 diabetes Compared 2x 18-h periods of closed-loop

glucose control after high fat (HF) and low fat (LF) dinners Identical carbohydrate and protein in each

dinner 10g fat in LF dinner and 60g fat in HF

dinner 15 minute ‘meal priming bolus’ given before

each meal

Wolpert et al. Diabetes Care. April 2013; 36: 810-816.

High fat dinner required more insulin than low fat dinner (12.6 vs. 9.0 units) (ICR 1:9 vs 1:13) Still more hyperglycemia vs. low fat dinner

No hypoglycemia These findings highlight limitations of carb

counting method.

HF dinner increased mean insulin requirement 42%

Marked inter-individual responses (-17% to 108%) ?differences in FFA concentrations, gastric emptying rates, glucagon, incretins Therefore need food records and must evaluate

based on a case by case basis. Dietary fat intake is an IMPORTANT consideration

for type 1’s striving for tight control.

Wolpert et al (2013) Conclusions:

Adults with type 1 diabetes require more insulin coverage for higher fat meals than for lower fat meals with identical carbohydrate content

Fat and Protein ↑ Blood Glucose

33 kids age 8-17 years 4 test breakfasts – same amount of carb

1. Low fat, low protein2. Low fat, high protein3. High fat, low protein4. High fat, high protein

Fat and Protein ↑ Blood Glucose

What did they find?

Smart CE et al. Results Fat and Protein

HP and HF significantly higher 180-300 min than LP/LF meal. This late effect was increased and sustained with

HP/HF meal. HF meal alone reduced glycemic excursion first 90

minutes (likely due to delayed gastric emptying) However addition of protein prevented this

(suggesting that protein may have a protective effect in early pp hypoglycemia)

Smart CE et al. Conclusions

Cause of late, sustained hyperglycemia with HP/HF has been postulated but is currently unknown. Protein may lead to delayed hyperglycemia by gluconeogenesis and ↑

glucagon secretion. Fat FFA impair insulin sensitivity and enhancement of hepatic

glucose production, also delayed gastric emptying

HP/HF (40 g pro, 35g fat) are commonly consumed. Hyperglycemia 3-5 hours after the meal dual/combo Most important with evening meal as potential for prolonged

hyperglycemia vs daytime when awake to correct.

Smart CE et al. Conclusions

Other studies suggest normal bolus for CHO and square wave bolus of supplemental insulin for fat and protein Reduced postprandial hyperglycemia however the

rate of hypoglycemia using this method is unacceptably high (33-35%).

So need further research for appropriate algorithm.

But what about “real life”?

The day-to-day realities….

Received on Tuesday March 18th, 2014

“Hi Lorraine, Are you still coming to the Tues. April 29 meeting as our guest speaker on Pump Tips and Tricks? I was in Mississauga yesterday and saw ________ from the Trillium Centre. Our group is going to the JDRF dinner at Boston Pizza in May. I never eat there...too many carbs, fats and calories!!!! _______ said to go and enjoy. It's a treat dinner.”

Example 1: Boston Pizza Lasagna

Patient has an I:C Ratio of 1:10g and is having 1 order of the lasagna.

CHO: 62g Fat: 49g x 9 kcal/g = 441 kcal Protein: 57g x 4 kcal/g = 228 kcal TOTAL: 669 kcal 6 FPUs equivalent to 60g additional ‘carbs’

Insulin Dose: Normal Bolus: 62/10 6.2 units Extended Bolus: 60 /10 6.0 units x 8h

Final thoughts…

Thank you! Questions?Lorraine Anderson RD, CDESenior Clinical Manager, Animas Canadalanderso@its.jnj.com416-303-0996

Super Bolus

Adapted from John Walsh, 2004

http://www.diabetesnet.com/diabetes_technology/super_bolus.php

11.1 11.1

5.6 5.6

What are we aiming for?

“In all the work with diabetes technology I’ve done, I’ve worn CGM for long periods of time. I don’t have diabetes, but I’ll eat a dessert and go up to 200 mg/dl (11.1 mmol/L). I’ll also drop down to 50 (2.8 mmol/L) or 60 mg/dl (3.3 mmol/L). People with diabetes are comparing themselves to a false standard. The pancreas, for all of the advantages it has, still allows big excursions. It’s crazy to think it’s ideal.”

-Dr. Steven Russell (Massachusetts General Hospital, Boston, MA) urging people with diabetes not to be too hard on themselves at the 14th

North American Conference on Diabetes and Exercise in San Diego, CA, August 17-18.

Beyond Carbohydrate Counting: What Else Matters? Lorraine Anderson RD, CDE Senior Clinical Manager,...

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