Tailoring Diabetes and Nutrition Management. Tailoring Diabetes and Nutrition Management. Diabetes Mellitus: Diabetes Mellitus: Clinical Presentation

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1 Tailoring Diabetes and Nutrition Management Tailoring Diabetes and Nutrition Management Target your population Set priorities as to what to change first Julie Kuenzi, RN, MSN, CDE Ruth Koehler, RN, BSN, CDE Patricia Puestow, RD, CD, CDE Specify strategies with measurable outcomes Diabetes Mellitus: Clinical Presentation Diabetes mellitus type Usually insidious in onset Usually occurs in those over years old, but can occur at almost any age Usually have the metabolic syndrome (DM, dyslipidemia, hypertension, truncal obesity) A progressive disease Diabetes Mellitus: Treatment In DM type 1 insulin therapy Multiple daily injections Pump therapy Ruth Koehler, RN, BSN, CDE In DM type Diet and exercise Oral agent Combination Insulin 1

2 SCREENING Lab Test Normal Pre- Diabetes Diabetes Fasting Blood Sugar (on two separate occasions) Random Blood Sugar (on two separate occasions) A1C (Glycosylated hemoglobin) Less than 1 Less than 1 Less than 6% 1-1 Greater than or equal to Greater than Before meals/fasting (mg/dl) Blood Sugar Goals Non-Diabetes Diabetes Goals Additional Action Suggested < <7 >18 QUESTION: WHAT METER IS BEST? 1 3 hours after meals (mg/dl) Bedtime (mg/dl) A1C (%) <1 <18 >18 <1 <6 <7 FREESTYLE ULTRA CONTOUR AVIVA ANSWER: THE ONE THE PATIENT WILL USE The one covered by insurance American Diabetes Association (8). Clinical Practice Recommendations 8. Diabetes Care. 31(Suppl 1): S1-S11 Treatment for Type Diabetes May Change Over a Lifetime Diabetes Medications

3 Beneficial effects of insulin Glucose control Non-glucose related metabolic effect lipid metabolism Anti-inflammatory inflammatory Builds lean muscle mass Improves glycogen stores INSULIN DELIVERY DEVICES Insulin pens Insulin pumps Vial and syringe Continuous Glucose Monitors What does it look like? DexCom FreeStyle Navigator Medtronic Retrieved from Google Images Pro Help find trends Fine-tune control Life saving for hypo unaware patients See effects of dietary intake See effects of exercise Pros and Cons Con Expense-- --most insurance does not cover Still need to perform finger sticks Lag time between finger sticks and interstitial fluid Need to calibrate Elements of Physiological Insulin Replacement Basal the level of insulin present in the fasting and post meal state Bolus dose the amount of insulin needed to cover the carbohydrates of a meal Correction factor (CF) or Sensitivity Factor how much a blood glucose level will decrease with one unit of rapid or short acting insulin. 3

4 Action Profiles of Insulins Twice Daily Split-Mixed Insulin Plasma insulin levels Aspart, glulisine, lispro Regular NPH Detemir Insulin Effect Rapid-acting acting Insulin NPH insulin Glargine B L D HS Meals B Hours Burge MR, Schade DS. Endocrinol Metab Clin North Am. 1997;6:7-98; Barlocco D. Curr Opin Invest Drugs. 3;:1-1; Danne T et al. Diabetes Care. 3;6: Premeal Rapid-acting acting Insulin and Night-time time Basal Insulin Twice Daily Split-Mixed Insulin with NPH at HS Insulin Effect Rapid-acting acting Insulin Basal insulin Insulin Effect Rapid-acting acting Insulin NPH insulin B L D HS Meals B B L D HS Meals B Insulin Action Times (SQ Administration) Type Regular (Humulin( Humulin R or Novolin R) Rapid acting insulin: Lispro (Humalog ) Aspart (Novolog ) Glulisine (Apidra ) NPH = isophane (Humulin N or Novolin N) Onset ~3 min 1 min hours Peak - hours 3-9 min 1 hours Duration 8 hours 3 hours 1 hours Glargine (Lantus ) 3 hours No peak Up to hours Detemir (Levemir ) Insulin 7/3 (Humulin 7/3 or Novolin 7/3) (Premixed 7 % NPH & 3 % Regular) Novolog Mix 7/3 (Premixed 7% insulin aspart protamine & 3% insulin aspart ) Humalog Mix 7/ (Premixed 7% insulin lispro protamine & % lispro) Humulin / (Premixed % NPH & % Regular) Ultralente and Lente are no longer manufactured 3 hours 3 min -1 min 1 min 3 min 6 8 hours 1 st peak hours nd peak 1 hours hours (no nd peak) hours (no nd peak) 1 st peak hours nd peak 1 hours Up to hours 1 hours 1 hours 1 hours 1 hours

5 Starting MDI Starting insulin dose by weight. X wgt.. in lbs or. X wgt.. in kg Bolus dose (aspart/lispro/glulisine( aspart/lispro/glulisine) ) = % of starting dose at each meal Basal dose (glargine/detemir/nph( glargine/detemir/nph) ) = % of starting dose at bedtime Example-Starting MDI in lb person Starting dose =. X wt in lbs. X = unit Bolus dose = % of starting dose at each meal x. = 8 units before each meal Basal dose = % of starting dose at bedtime X. = 16 Estimating Insulin to Carbohydrate Ratios Carbohydrate/Insulin ratio (CIR) CIR in grams + 6 X Body Weight (kg) / TDD Carbohydrate/Insulin ratio (CIR)( / TDD EXAMPLE Carbohydrate / Insulin Ratio 6 X 7 kg = / = 1. Carbohydrate / Insulin Ratio / =1 1 Rule A formula used to predict how much one unit of Regular insulin will lower blood glucose. 1 is divided by the total daily dose. Example: If total daily dose is units: 1/ = 3 mg/dl 1. unit of insulin drops blood glucose by 3 mg/dl 17 Rule A formula used to predict how much one unit of rapid acting insulin will lower blood glucose. 17 is divided by the total daily dose Example: If total daily dose is units: 17/ = 3 mg/dl 1. unit of insulin drops blood glucose by 3 mg/dl

6 Differences in Insulin Treatment Between Type 1 and Type More glucose variability in type 1 More hypoglycemia in type 1 High dose of insulin in type Insulin profiles are more spread out and prolonged in type The result is the need for less sophisticated regimen in Type Insulin Replacement in DM Requires larger amounts to overcome insulin resistance Requires a basal, base, and correction dose, but because of the nature of the insulin resistance, basal requirements are much higher Because of the larger amounts of insulin required the characteristic insulin activity curves are more blunted and prolonged Blood Glucose (mg/dl) < (base dose) /3 Sliding Scale Breakfast Insulin 7/3 Treat the low blood sugar. Recheck blood glucose in 1 mins.. If sugar is more than 7, then take the number of units of insulin in the 7-9 row, if before breakfast or supper only Supper Insulin 7/ Custom Sliding Scale <7 = Treat Hypoglycemia Per Protocol 7-9 = 3 units SQ Regular Insulin Short form: (base dose) = units = 7 units 11- = 9 units 1- = 11 units 1-3 = 13 units = 1 units 31- = 17 units 1- = 19 units > = 1 units > 3 3 NPH insulin 3 units subcutaneous at breakfast NPH insulin 1 units subcutaneous nightly Regular Insulin units subcutaneous as directed in the below algorithm. Blood Glucose (mg/dl dl) < > NPH + Regular Insulin Breakfast (Units Regular Insulin) Treat the hypoglycemic episode per hypoglycemia protocol Lunch (Units Regular Insulin) 1 3 Supper (Units Regular Insulin) Nighttime (Units Regular Insulin) 1 3 Custom Insulin Scale (Lantus & Lispro) Blood Glucose (mg/dl) < (base dose) > Breakfast Lispro Lunch Lispro Treat the low blood sugar. Recheck blood glucose in 1 mins.. If sugar is more than 7, then take the number of units of insulin in the 7-9 row, if before a meal Take 1 units of Lantus at bedtime Supper Lispro Bedtime Lispro 1 3 6

7 Commonly Used Insulin Average Price Aventis Lantus vial $91. Lantus Pens $17.1 NovoNordisk Novolog vial $96.1 Novolin R vial $.8 Novolin N vial $.8 Novolin 7/3 vial $.8 Innolet Pens 7/3 $89.9 Flexpens $181.1 Alternate Brand Insulin Relion (Manufactured( by NovoNordisk) Regular vial $1.96 NPH vial $1.96 7/3 vial $1.96 Froedtert West OP Pharmacy, /9/8 WalMart Pharmacy, /3/8 Commonly Used Insulin Average Price Lilly Humalog vial $96.1 Humalog pens $181.1 Humulin R $.8 Humulin N $.8 Humulin 7/3 $.8 Tailoring Diabetes and Nutrition Management Choose realistic goals to reach and maintain Choose goals with the patient that are safe Froedtert West,OP Pharmacy, /9/8 SUMMARY PAT PUESTOW RD, CD, CDE 1. Many insulins & devices are available in our toolboxes.. Need to customize insulin regimen to meet patient s s needs goals goals financial ability 3. Encourage starting insulin earlier rather than later in the diabetes treatment regimen 7

8 NUTRITION Knowledge and Proficiency with carb counting = Increased accuracy of rapid- acting insulin doses!! Inaccurate carb counting = decreased accuracy of rapid-acting acting insulin doses!! WHY? Understands rationale for carb counting-relationship of carb on blood sugar excursion Hope Warshaw,MMSC RD CDE BC-ADM Alexandria, Virginia WHAT? Knows what foods contain carb and those that do not contain carb Knows common serving sizes HOW MUCH? Knows amounts of carb to consume daily with meals/snacks Uses Uses measuring tools for determining carbs WHERE? What Affects Blood Sugar Proteins Fats Carbohydrates Uses Uses carb counting resources 8

9 Effect on Blood Sugar Approximately 9% of carbohydrates turn into blood sugar within 1minutes to hours After eating CARBOHYDRATES It may take up to 1 hours after eating before a blood sugar effect is seen PROTEIN Fats take a long time to digest. large amounts can make you insulin resistant Since carbohydrates raise blood glucose the most that s s what needs to be counted. FAT CARBOHYDRATES Carbohydrate is the main nutrient affecting post-prandial prandial blood sugars Monitoring carb intake by carb counting as one meal planning approach, is a key strategy to achieve glycemic control What is Carbohydrate Counting? A meal planning method that allows the management of how much carbohydrate is eaten at meals and snacks. 9

10 Total Carbs Matter It is the TOTAL amount of carbohydrate consumed -- NOT the source, that is most responsible for raising blood sugar. Carbohydrate Counting can be used by anyone with diabetes! Effectiveness Flexibility BENEFITS: Ease of Implementation Food Groups that Contain Carbohydrate Starches bread, pasta, rice, cereal, legumes, potatoes, starchy vegetables Fruit apples, oranges, bananas, juices Milk yogurt, fluid milk, hot chocolate Vegetables carrots, broccoli, beets, greens Other casseroles, pizza, soup, snack foods, desserts, beer Which foods contain Carbohydrate? Skim milk Diet Cola Baked chicken Turkey sandwich Watermelon Spaghetti Mayonnaise Cookies Ice Cream Scrambled eggs Peas Fat-free yogurt Peanuts Banana Baked Potatoes Corn Tuna Pizza Starches Fruit Common Food Servings Milk/Yogurt Vegetable ½ cup mashed potatoes/peas/corn 1/3 cup pasta/rice 3 cups popped popcorn 1 small apple ( oz.) 17 grapes (3 oz.) 1 ¼ cup strawberries 1 cup milk (8oz.) 1 cup yogurt (8oz.) ½ cup carrots 1 cup raw carrots Pork chops Jelly beans 1

11 Carb Counting Tools Methods of Carb Counting Nutrition Labels Measuring Tools You can count carbs by grams or by choices 1 Choice = 1 grams Sample Carb Counting What About Alcohol? How Big is Your Glass? carb choices + 1 carb choice + 1 carb choice = carb choices 3 g of carb + 1 g of carb + 1 g if carb = 7 g of carb Carbohydrate Content of Popular Alcoholic Beverages 1 oz. Beer 13 grams 8 oz. Wine grams 1 oz. Vodka, Gin, Brandy grams 1 oz. Smirnoff Ice 36 grams 8 oz. Bloody Mary Mix 9 grams 1 oz. Bailey s Irish Cream grams 11 oz. Mike s Hard Lemonade 38 grams 1 oz. Liqueur (Grand Marnier) 9 grams 6 oz. Mudslide mixer 31 grams 11

12 Websites for Carb Counting a food database you can download a nutrition web site that will tally your carb intake daily Portion Distortion quizzes Work on a Personal Database List -1 foods regularly consumed Look at the refrigerator, pantry and freezer Think of foods eaten in commonly prepared meals Note quantity of the food usually consumed Weigh and measure foods Determine the carb content in amounts usually eaten Over time, review and revise data Take your Calorie King on the road Recipe Calculation List ingredients and amount in the recipe Determine amount of carb in each ingredient Total the amount of carb from the ingredients Divide the total amount of carb by the total amount of servings in the recipe Tips for Restaurant Carb Counting: Learn to be an excellent portion size estimator. Use similar carb data in Calorie King to estimate carb data Carbohydrate for Insulin Therapy Basal Insulin Lantus Levemir NPH Bolus (Rapid-Acting) Humalog Novolog Apidra Pre-mixed Insulin 7/3 7/ / NPH: Consistent meal timing & consistent carbs Consistent Carb or insulin:carb ratio Consistent Meal timing & Consistent carb Consistent Carb Defined: Minimum of 3 meals daily Consistent grams of carb or carb choices with meals Example: grams of carb or 3 carb choices 1

13 Formulas for Insulin Therapy Carb:Insulin Ratio Indicates how many grams of carb 1 unit of rapid-acting acting insulin will cover Take /Total Daily Dose = Amount of carb 1 unit of insulin will cover Example: / 3 = 13 Carb:Insulin Ratio = 13 :1 Lean type 1 Carb:Insulin Ratio = 1:1 Obese type Carb:Insulin Ratio = :1 Formulas for Insulin Therapy Correction Factor (Insulin Sensitivity) Indicates how much 1 unit of rapid-acting acting insulin will decrease blood sugar 17 Rule 17/Total daily Dose = Correction Factor (CF) Example: 17 / =3 mg/dl Correction Factor (CF) Lean type 1 CF can be - mg/dl Type CF can be 1- mg/dl Carb & Insulin Guidelines for Exercise Guidelines to Maintain a Desirable Blood Sugar with Exercise Monitor blood sugar before and after to establish the baseline response. Log blood sugar, food, exercise, diabetes medications, to achieve a better understanding of how exercise affects blood sugar May need to use reduce rapid-acting acting insulin 3-% prior to moderate activity For vigorous activity, may need to reduce rapid- acting -8% Exercise Guidelines (cont d) It is safest to exercise when glucose- lowering medications are not peaking. THANK YOU!!! Exercise performed 1-1 hours after meals generally lowers risk for hypoglycemia and may blunt the post-meal blood sugar rise. Adjust carb intake before, during and after exercise as necessary to maintain adequate blood sugar control and to optimize exercise performance. 13

14 Questions? 1