Transitions: MNT for Basic Diabetes Medications to Complex Insulin Regimens. Sara Weigel RDN, LD, CDE MAND Annual Meeting May 1 st 2015

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1 Transitions: MNT for Basic Diabetes Medications to Complex Insulin Regimens Sara Weigel RDN, LD, CDE MAND Annual Meeting May 1 st 2015

2 Objectives 1) Describe and discuss some of the most common diabetes oral medications and insulins. 2) Apply medical nutrition therapy recommendations as patients transition from basic diabetes medications to complex insulin regimens. 3) Discuss a case that illustrates MNT recommendations as a patient transitions from basic diabetes medications to a complex insulin regimen.

3 Diabetes Medications/Insulins Presented in alphabetical order For information related to recommendations, please refer to AACE or ADA algorithms Will not be discussing Combination oral drugs Very new oral medications or non-insulin injectables Cost

4 Alpha-Glucosidase Inhibitors Acarbose (Precose), Miglitol (Glyset) How it works Oral medication Slows absorption of glucose into the blood stream Advantages Weight neutral No hypoglycemia when used alone Disadvantages Bloating, gas, diarrhea Less effective than other medications Dose 3x daily

5 Biguanides Metformin (Glucophage), Glucophage XR, etc How it works Oral medication Decreases the amount of glucose released by the liver Improves insulin sensitivity Advantages May promote weight loss Unlikely to cause low blood sugars May help to reduce cholesterol levels Disadvantages GI side effects Lactic acidosis (very rare)

6 DPP-4 Inhibitors Sitagliptin (Januvia), Saxagliptin (Onglyza), etc How it works Oral medication Stimulates pancreas to release insulin Decreases amount of glucose released by liver between meals Advantages Take only 1 time daily Unlikely to cause low blood sugars Weight neutral Disadvantages Possibly cause upper respiratory tract infection, sore throat or diarrhea May increase risk of acute pancreatitis

7 Meglitinides Repaglinide(Prandin), Nateglinide(Starlix) How it works Oral medication Simulates the pancreas to release more insulin when blood sugar rises after a meal Advantages Works quickly when taken with foods May cause weight gain (but less than sulfonylureas) Disadvantages Effect wears off quickly; take 3x daily May cause stomach upset May cause low blood sugar

8 Sulfonylureas Glipizide(Glucotrol), Glyburide, Glimepiride (Amaryl), etc How it works Oral medication Stimulates the pancreas to release more insulin Advantages Combines well with other oral diabetes medications Disadvantages May cause low blood sugars May cause weight gain

9 TZDs (Thiazolidinediones) Rosiglitazone(Avandia), Pioglitazone(Actos) How it works Oral medication Makes tissues more sensitive to insulin Decreases the amount of glucose made in the liver Advantages Take with or without food Low chance of hypoglycemia Disadvantages May cause swelling and weight gain that could lead to or worsen heart failure Takes a few weeks or more to notice the effect

10 Amylin Mimetics Pramlintide(Symlin Pen 60, 120) How it works Taken by injection Slows stomach emptying Decreases amount of glucose released by the liver Advantages May promote weight loss Increased feeling of fullness Disadvantages May cause nausea/vomiting Increased risk of hypoglycemia Even though an injection, it cannot be mixed with other insulins

11 Incretin Mimetics (GLP-1) Exenatide(Byetta), Liraglutide (Victoza), Exenatide ER (Bydureon), etc How it works Taken by injection Slows stomach emptying Stimulates pancreas to release insulin Decreases amount of glucose released by the liver Advantages May promote weight loss through decreased appetite Some are once weekly injections (Bydureon, Tanzeum) Disadvantages May cause nausea, vomiting, diarrhea and headache May increase risk of pancreatitis May increase thyroid tumors Even though an injection, it cannot be mixed with other insulins

12 Insulin (meal time, bolus) Rapid-Acting (Humalog, NovoLog, Apidra) Short-Acting (Humulin R, Novolin R) Onset Within 15 min Onset 30 min to 1 hour Peak 1-2 hours Peak 2-3 hours Duration 3-5 hours Duration 5-8 hours When to take Immediately before (about 5-15 min) recommended meal When to take 30 min before recommended meal

13 Insulin (intermediate/long, basal) Intermediate (NPH) (Humulin N, Novolin N) Long (Lantus, Levemir*) Onset 1-2 hours Onset 1-3 hours Peak Duration When to take 4-12 hours hours 30 min before recommended meal Peak Duration When to take None ~24+ hours (*smaller doses ~12 hours, larger doses 18-24) At same time daily. May need to take up to 2x daily

14 Fixed Insulin Programs Combined rapid/short insulin and intermediate insulin May be pre-mixed or combination of insulins Pre-mixed Humalog 75/25, Humalog 50/50, NovoLog 70/30 Humulin 70/30, Novolin 70/30 Typically injected before breakfast and before evening meals

15 Flexible Insulin Program (basal/bolus, MDI) Goal is to mimic a working pancreas Separate injections of basal and bolus insulins

16 Insulin Pumps Mimics a working pancreas Uses only rapid or short acting insulin Boluses need to be taken at every meal

17 U-500 Insulin 5x concentration of regular insulin Can be taken up to 4x daily The larger the dose, the longer the tail

18 How many patients have Dietitian appointments? Many people with diabetes do not receive any structured diabetes education or nutrition therapy Of 18,400 people with diabetes, only 9.1% saw a Dietitian within a 9-year period! MNT visits have shown a decrease in A1c by % Evidence Analysis Library, 2014; Evert, A., Diabetes Care, 2013

19 One size does NOT fit all The Bad news: Diabetes and its treatment have a negative impact on quality of life, particularly in terms of dietary restrictions imposed by traditional treatment options DAFNE Study group The Good news: It is the position of the American Diabetes Association (ADA) that there is not a one-size-fitsall eating pattern for individuals with diabetes. Evert, A., Diabetes Care. 2013

20 Address Individual Needs Provide practical tools Personal and cultural needs Barriers to change Health literacy and numeracy Promote healthy eating patterns Willingness to change Access to healthy foods Maintain pleasure of eating Evert, A., Diabetes Care, 2013

21 Mix of Macronutrients No ideal percentage recommendations Carbohydrate 45% Fat 36-40% Protein 16-18% Typical macronutrient distribution among most people with diabetes Evert, A., Diabetes Care, 2013

22 Priority Focus: Glycemic Control Amount of carbohydrate and available insulin Carbohydrate monitoring estimation carb counting meal plan Evert, A., Diabetes Care, 2013

23 Balancing Food and Medication

24 MNT Recommendations Consistent eating patterns (plate method, carb counting, meals plans, etc) MNT and physical activity Oral medications Fixed insulin doses Evidence Analysis Library, 2014

25 Oral Medications: specifics Sulfonylureas Meglitinides Alpha-glucosidase Inhibitors

26 MNT and Sulfonylureas Main goal: Reduce risk of hypoglycemia Do not skip meals Eat about the same times daily Consistent carbohydrate Review Rule of 15 Carry a carb containing source when physically active Evert, A., Diabetes Care, 2013; Warshaw, H., & Bolderman, K., 2008

27 MNT and Meglitinides Consistent Carbohydrate Skip a meal = skip the dose Add a meal = add a dose Warshaw, H., & Bolderman, K., 2008

28 MNT and Alpha-Glucosidase Inhibitors Prevents digestion of polysaccharides If hypoglycemia occurs, choose a monosaccharide Glucose tabs Honey Evert, A., Diabetes Care, 2013; Warshaw, H., & Bolderman, K., 2008

29 MNT and Non-Insulin Injectables Consider discussing ways to decrease nausea: Eat smaller meals Avoid overeating Cut down on fatty foods Recommended avoidance of alcohol Amylin Mimetic: (SymlinPen) Take before meals containing at least 30g carbohydrate or 250 calories Kreen, S., Nutrition Today, 2014

30 MNT and Fixed Insulin Plans Consistency is Key! Eat at about the same times daily Do not skip meals Eat about the same amounts of carbohydrate/food daily Consistent carb to match the insulin Match Your Insulin to Your Carbs, 2014; Evert, A., Diabetes Care, 2013; Mayo Clinic Patient Education, 2013

31 MNT and Flexible Insulin Plans MDI (basal/bolus): Match insulin and carbohydrates Can vary meal times Consistent carb with set rapid insulin doses Insulin to carbohydrate ratios offer more flexibility Improved glycemic control and quality of life Evidence Analysis Library, 2014; Evert, A., Diabetes Care, 2013

32 Match food and rapid insulin

33 MNT and insulin pumps Accurate carbohydrate counting is essential Technology allows greater flexibility Extended boluses (dual, square wave) Warshaw, H., & Bolderman, K., 2008

34 MNT and U-500 Limited recommendations Consistency in calories and carbohydrates Cochran, E., Diabetes Spectrum, 2009

35 Is it really the food? Is the medication/insulin regimen appropriate?

36 Case study (HB) 63 year old male, accountant New type 2 diabetes diagnosis (A1c 7.3%), BMI 35 Starting lifestyle modification ( diet and exercise ) Skips breakfast, out to lunch many days, travels frequently Overwhelmed by new diagnosis

37 Case study (HB) RDN Intervention: Plate method Why? No medications or insulins Overwhelmed Eats out often Travels Realistic

38 Case study (HB) Two years later A1c is now 8.7% PCP started him on Metformin, then later added a Sulfonylurea RDN Intervention: Review plate method Encourage regular meal times, not to skip meals Explain which foods have carbohydrates and importance of carbohydrate consistency Rule of 15

39 Case study (HB) HB is now retired and eating most meals at home Wife cooks majority of the meals and is concerned which foods and portions are best RDN Intervention: Review carb consistency Show food models Use labels on packaged items Online resources (www.calorieking.com, etc)

40 Emphasize healthy eating with carbohydrate counting Which breakfast is your patient choosing? Breakfast #1 Breakfast #2 2 Pop Tarts 1.5 cups cheerios 1 cup skim milk banana

41 More than consistent carb Breakfast #1 Breakfast #2 2 fried eggs, 2 sausage patties ½ cup hash browns 2 pieces white toast 1 tbsp. butter 1 tbsp. jelly 1 cup coffee Total carb. ~60 grams Total fat - 65 grams Total calories cup cheerios 1/2 cup skim milk 1 cup blueberries 1 slice whole wheat toast 1 tbsp. peanut butter 1 cup coffee Total carb. ~60 grams Total fat - 8 grams Total calories - 360

42 Case study (HB) Initially he was able to decrease his A1c to 6.8% Unfortunately A1c continues to increase PCP chooses to start him on basal insulin RDN Intervention: Review and broaden nutrition education No major changes for RD to recommend

43 Case study (HB) Another year later HB transitions to a basal/bolus program Rapid insulin ( at meals) Varied blood sugars for the next 2 months Despite previous education, he had been told that he can now have more flexibility in his eating habits and has been eating: Veggies and lean proteins at meals Fruits for snacks

44 Snacking and Flexible Insulin Want or need a snack? Habit? Consider individualized coverage with I:C ratio Discuss snack options that will have less effect Sugar-free gum, jello and popsicles Non starchy veggies Light string cheese Small amount of nuts Warshaw, H., & Bolderman, K., 2008

45 Case study (HB) Worked with RDN and nurse educator to establish an insulin to carb ratio through consistent carbohydrate (1:5g) 1 unit per 5g total carbohydrate Appreciates the flexibility of foods and portions

46 DAFNE (Dose Adjustment for Normal Eating) Study Primary Outcomes A1c Immediate group improved from 9.4% to 8.4% at 6 mos Delayed group 9.3% to 9.4% at 6 mos Hypoglycemia No differences between the groups ADDQol (Audit of Diabetes-Dependent Quality of Life) Immediate group found significant improvements, especially freedom to eat as I wish score, as well as quality of life Continued to improve even after 1 year DAFNE Study Group, British Medical Journal, 2002

47 Take home messages Understanding the diabetes treatment regimen is vital Continual nutrition education is important for glycemic control Individualize

48 References Academy Of Nutrition and Dietetics Evidence Analysis Library. Diabetes Type 1 and 2: DM: Executive summary and recommendations. Retrieved November 13th, 2014 from American Diabetes Association (2014). Match your insulin to your carbs. DAFNE Study Group (Amiel, S., Beveridge, S., Bradley, C., Gianfrancesco, C., Heller, S., James, P. & Newton, D.) (2002). Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: Dose adjustment for normal eating (DAFNE) randomized controlled trial. British Medical Journal, 325, 1-6. Cochran, E. (2009). U-500 Insulin: When more with less yields success. Diabetes Spectrum, 22(2), Evert, A., Boucher, J., Cypress, M., Dunbar, S., Franz, M., Mayer-davis, E. & Nwankwo, R. (2013). Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 36, Keen, S., Craven K., Kolasa, K., (2014). Nutrition Strategies for Patients on New Incretin Therapies for Type 2 Diabetes. Nutrition Today. 49 (5), Mayo Clinic: Patient Education (2013). Diabetes Self-Management: Medications: Insulin. Rochester, MN. Mayo Clinic: Patient Education (2013). Using Insulin-to-Carbohydrate Ratios. Rochester, MN. Symlin Pen (2008). Medication Guide. Retrieved July 8, 2014, from Victoza website: Frequently Asked Questions. Retrieved July 9, 2014 from Warshaw, H., & Bolderman, K. (2008). Practical carbohydrate counting: A how-to-teach guide for health professionals (2nd ed.). Alexandria, VA: American Diabetes Association.

49 Questions?

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