Balancing carbohydrate intake and insulin treatment January 2014 Job code: UKDBT01551 Prescribing information is available at the end of this presentation

Balancing carbohydrate intake and insulin treatment

January 2014 Job code: UKDBT01551Prescribing information is available at the end of this presentation

Introduction: Why is carbohydrate awareness in diabetes important?

For a person with diabetes, the insulin regimen alone will not control blood glucose levels

Postprandial glucose levels matter This means that the total amount of carbohydrate consumed is

important Carbohydrate amount is not just important for people on basal–bolus

insulin regimens

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Insulin secretion and postprandial glucose levels

Type 1 diabetes is characterised by a lack of endogenous insulin secretion

Type 2 diabetes is characterised by delayed and ineffective insulin secretion

Postprandial glucose levels depend on the amount, timing and composition of food, and the insulin available

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Food considerations

Appetite Timing and frequency of meals Snacks Amount eaten Carbohydrate content Glycaemic index and glycaemic load Work and lifestyle patterns Variety of food eaten

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1. Franz MJ (2000) Diabetes Spectrum 13: 132–41; 2. Gillespie SJ et al (1998) J Am Diet Assoc 98; 897–905

Food groups and their effect on blood glucose levels (1)

The main nutrient in food that affects blood glucose levels is carbohydrate1

Most foods contain a mixture of fat, protein and carbohydrate, but foods containing mainly protein and fat have a minimal effect on blood glucose levels compared with carbohydrate-containing foods1

Carbohydrates are digested into glucose and appear in the bloodstream 15 minutes to 2 hours or more after eating2

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Food groups and their effect on blood glucose levels (2)

Carbohydrates – have the most immediate effect on blood glucose levels1,2

Fat – slows down the rate of digestion and so delays the rate of carbohydrate absorption3

61. Rabasa-Lhoret R et al (1999) Diabetes Care 22: 667–73; 2. Franz MJ (2000) Diabetes Spectrum13: 132–41; 3. Collier G et al (1984) Diabetologia 26: 50–4

Foods containing carbohydrate (1)

Starchy carbohydrates– Bread– Potatoes– Rice, pasta and noodles – Breakfast cereals and oats– Foods made from flour, e.g. crackers, pitta bread, pastry and Yorkshire

puddings

7Diabetes UK (2012) Starchy carbohydrates. Available at: http://bit.ly/IUKt0e (accessed 18.12.2013)


Sugary carbohydrates – sucrose– Sugar– Sugary drinks– Jam and marmalade– Chocolates, sweets, toffees and mints– Cakes and biscuits– Ice cream, desserts and sweet puddings

8Diabetes UK (2012) Fatty and Sugary Foods. Available at: http://bit.ly/1e08tbD (accessed 18.12.2013)

1. Diabetes UK (2012) Fruit and vegetables. Available at: http://bit.ly/1cwHna4 (accessed 18.12.2013); 2. Cabálková J et al (2004) Electrophoresis 25: 487–93


Fruit sugar – fructose– Fruit – fresh, tinned and dried fruit contains the natural sugar fructose.

However, fructose does not have an immediate effect on blood glucose levels1

– Fruit and fruit juice contain other sugars (glucose and sucrose) in addition to fructose.2 Therefore, “natural” or “unsweetened” fruit juices can raise blood glucose quickly1

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Diabetes UK (2012) Milk and dairy foods. Available at: http://bit.ly/18LOk6j (accessed 18.12.2013)


Milk and yoghurt contain natural sugar – lactose– All milk, whether full-cream, semi-skimmed, skimmed, pasteurised,

homogenised or long-life– Products made from milk – e.g. custard, yoghurts and ice cream

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Foods and food groups containing little or no carbohydrate

Protein – meat, fish, cheese and eggs

Fat – butter, margarine, vegetable oils and cream

Most vegetables and salads

Although nuts contain a small amount of carbohydrate, they may not need to be matched to insulin as it is slowly absorbed

11Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)

Are there any benefits in keeping carbohydrate portions the same each day?

People with diabetes may take the same doses of antidiabetes agents each day, so is it best to keep the amounts of carbohydrates at different meals about the same in a similar manner?

This should result in consistent blood glucose levels post-meals However, how practical is this on a day-to-day basis?

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How can the factors affecting blood glucose levels be balanced?

Carbohydrate intake and treatment Matching lifestyles and food patterns with treatment “Eating normally” Weight management

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How much carbohydrate should a person eat?

Carbohydrate need varies from person to person depending on activity levels, gender, age and weight

50% of energy should come from carbohydrates (no more than 35% from fat and 10–20% from protein)1

Total amount of carbohydrate ingested is the primary determinant of post-prandial blood glucose response2

Calories per day (kcal)

Carbohydrates per day (g; based on 50% of calories)

1500 190

2000 250

2500 315

3000 375

14Table adapted from: Cheyette C, Balolia Y (2010) Carbs & Cals (4th Edition). Chello Publishing, UK:4–12; 1. Toeller M (2010) in Holt RIG et al (eds). Textbook of Diabetes 4th Edition. Wiley-Blackwell, Chichester, UK: 346–57; 2. Franz MJ (2000) Diabetes Spectrum 13: 132–41

Half of our time is spent in the postprandial state

Postprandial state

Postabsorptive state

Fasting state

Breakfast Lunch Dinner

06:00 10:00 14:00 18:00 22:00 02:00 06:00

15Monnier L (2000) Eur J Clin Invest 30(Suppl 2): 3–11

www.idf.org

© International Diabetes Federation, 2011ISBN 2-930229-81-0

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What are the targets for post-meal glycaemic control and how should they be assessed?

Evidence statements– Post-meal plasma glucose levels seldom rise above 7.8 mmol/L

(140 mg/dL) after food ingestion in healthy non-pregnant people [Level 2++]

– Self-monitoring of blood glucose is currently the optimal method for assessing plasma glucose levels [Level 2++]

Recommendations– Post-meal plasma glucose should be measured 1–2 hours after a meal– The target for post-meal glucose is 9.0 mmol/L (160 mg/dL) as long as

hypoglycaemia is avoided– Self-monitoring of blood glucose should be considered because it is

currently the most practical method for monitoring post-meal glycaemia

17International Diabetes Federation (2011) 2011 Guideline for the management of post-meal glucose in diabetes. Available at: http://bit.ly/1bS6aYB (accessed: 18.12.2013)

Postprandial control depends on achieving a balance between carbohydrate eaten and insulin available

Structured blood glucose monitoring

Blood glucose levels should be tested pre-meal and 2 hours post-meal

Would expect levels to be 2–3 mmol/L higher 2 hours post-meal– This is based upon targets for fasting and postprandial blood glucose

levels which are <7.2 mmol/L (<130 mg/dL) and <10 mmol/L (<180 mg/dL), respectively1

Discovery sheets may aid structured blood glucose monitoring

19Inzucchi SE et al (2012) Diabetes Care 35 1364–79

A “blank” discovery sheet

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Why carbohydrate count?

Carbohydrate counting is a method of matching insulin requirements with the amount of carbohydrate a person eats and drinks

This can give more choice and flexibility in both the type of food eaten and in meal timing


Establishing the carbohydrate content of food (1): Weighing food

Food can be weighed using kitchen scales and carbohydrate worked out using food charts or tables

This system is useful for foods such as breakfast cereals, potatoes, pasta and rice as portion sizes can vary a lot between different people


Establishing the carbohydrate content of food (2): Carbohydrate counting reference books

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Establishing the carbohydrate content of food (3): Nutrition labels

Most food manufacturers supply this information. It is important to count the total carbohydrate and not just sugars or starches

Foods can be considered to be high or low in sugar depending upon the sugar content

– High sugar >15 g per 100 g– Low sugar <5 g per 100 g

24Diabetes UK (2012) Understanding labels. Available at: http://bit.ly/1gBJzUO (accessed 18.12.2013)

Food label example

25NHS Choices (2013) Food labels. Available at: http://bit.ly/1bKKSvY (accessed 18.12.2013)

Carbohydrate counting and snacks

Carbohydrate counting means a person can decide to have snacks based upon personal choice

If a snack contains more than 10 g carbohydrate, additional insulin will be necessary to cover this


Carbohydrate content of snacks

27Diabetes UK (2011) Carbohydrate Reference List. Available at: http://bit.ly/1cCgXnt (accessed 18.12.2013)

Snack Carbohydrate content (g)

Banana 19–28

Teacake 38

Crumpet 18

Digestive biscuit 9

Example of a food diary

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Breakfast Mid morning

Lunch Mid afternoon

Evening meal

Before bed

None None Cooked egg and bacon and

two slices of bread

None Fish and chips Biscuits

Porridge with milk and slice of

wholemeal toast

Banana Soup, a bread roll and a piece

of fruit

Small slice of cake

Meat, veg and potatoes, and a

yoghurt

Piece of fruit

None Fruit Salad Fruit Pasta Fruit

Two Weetabix and fruit

Biscuits None Toast Takeaway curry None

Carbohydrate quiz

Match method to treatment

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CARBOHYDRATE BUDGET PER

MEAL

CARBOHYDRATE BUDGET

EXACT CARBOHYDRATES

PER MEAL

CONSTANT CARBOHYDRATES

ADJUST INSULIN FOR

CARBOHYDRATES EATEN

CARBOHYDRATE COUNTING

Source: Diabetes Management and Training Centers, Inc.

Carbohydrate budgeting

Choose the “right” person with diabetes– No medications, oral agents or basal insulin only

Establish budget– Use actual intake as a guide, or average intake e.g. female 45–60 g per

meal and male 60–75 g per meal Judge results by post-meal blood glucose and alter carbohydrate

budget as necessary to reach goals

31Source: Diabetes Management and Training Centers, Inc.

32

= 2.5 g

= 50 gTotal

Source: DAFNE Food Plate Models

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= 3 g

= 90 gTotal

Source: DAFNE Food Plate Models

Teaching patients to eat “under the curve”

Blood glucose level pre-meal: 6.1 mmol/L

Blood glucose level post-meal: 16.1 mmol/LConsider options ?

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The constant carbohydrate method

Choose the “right” person with diabetes– Static meal doses, e.g. with premixed insulin

Establish carbohydrate level for each meal– Use actual carbohydrate intake or average as for carbohydrate budget

Judge result by post-meal blood glucose level– Adjust insulin or carbohydrate to reach goal

35Source: Diabetes Management and Training Centers, Inc.

• Aim of intermediate-acting insulin is to manage the body’s natural glucose production, keeping blood glucose levels steady. Ideally blood glucose levels should drop no more than 2 mmol/L overnight

• Aim of rapid-acting insulin is to manage the glucose from the meals so that post-meal blood glucose levels are no more than about 2 mmol/L greater than pre-meal levels1

50 UNITS

12.5 units rapid acting

37.5 units intermediate acting

Activity profile of premixed insulin analogues (25:75)

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6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4

Insu

lin a

ctiv

ity

Time

30 UNITS



These diagrams are theoretical representations based on known pharmacological profiles (e.g. Heise T et al [1998] Diabetes Care 21:800–3); 1. Inzucchi SE et al (2012) Diabetes Care 35 1364–79

Blood glucose targets4–7 mmol/L pre-meals1



50 UNITS




37

6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4

Insu

lin a

ctiv

ity

Time

30 UNITS







50 UNITS




38

6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4

Insu

lin a

ctiv

ity

Time

30 UNITS





Counting carbohydrates

Choose the “right” person with diabetes Basal–bolus regimens Set initial insulin:carbohydrate ratio

– Based on current total daily dose,1 unit per 10 g or the “500 rule”1

Judge result by post-meal blood glucose and alter ratio as required

391. Unger J (2013) In: Schwartz Z (ed). Diabetes Management in Primary Care (2nd Edition). Lippincott Williams & Wilkins, PA, USA: 62–112

Long-acting insulin

Rapid-acting insulin

Fixed doses of rapid-acting insulin in a basal–bolus regimen

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6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3

Insu

lin a

ctiv

ity

Time


• Aim of long-acting insulin is to manage the body’s natural glucose production, keeping BG levels steady• Ideally BG levels should drop no more than 2 mmol/L overnight

• Aim of rapid-acting insulin is to manage the glucose from the meals • Ideally post-meal BG levels should be no more than ~2 mmol/L greater than pre-meal levels1

BG=blood glucose; These diagrams are theoretical representations based on known pharmacological profiles (e.g. Heise T et al [1998] Diabetes Care 21:800–3); 1. 1. Inzucchi SE et al (2012) Diabetes Care 35 1364–79

• Check BG level before breakfast• Check BG levels 2 hours after meal

• This person eats a similar amounts of carbohydrate at each meal• Inject same dose of rapid-acting insulin at each meal

1 unit per 10 g of carbohydrate

Varying doses of rapid-acting insulin in a basal–bolus regimen

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6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3

Insu

lin a

ctiv

ity

Time

BG=blood glucose; These diagrams are theoretical representations based on known pharmacological profiles (e.g. Heise T et al [1998] Diabetes Care 21:800–3); 1. Inzucchi SE et al (2012) Diabetes Care 35 1364–79


Long-acting insulin

Rapid-acting insulin

• Aim of long-acting insulin is to manage the body’s natural glucose production, keeping BG levels steady• Ideally BG levels should drop no more than 2 mmol/L overnight

• Aim of rapid-acting insulin is to manage the glucose from the meals • Ideally post-meal BG levels should be no more than ~2 mmol/L greater than pre-meal levels1

• Check BG level before breakfast• Check BG levels 2 hours after meal

• This person eats different amounts of carbohydrate at each meal• Inject same dose of rapid-acting insulin at each meal

Conclusion: Carbohydrate counting or awareness is important

Insulin alone will not control blood glucose levels, whether this is endogenous production or injected insulin

Postprandial glucose levels matter Total carbohydrate amount consumed is important Carbohydrate awareness and the amount of carbohydrate consumed

is not just important for people on basal–bolus insulin regimens

42

43

Documents

Balancing carbohydrate intake and insulin treatment January 2014 Job code: UKDBT01551 Prescribing information is available at the end of this presentation