Func%onal insulin therapy: rela%onship to carbohydrate intake
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1 Func%onal insulin therapy: rela%onship to carbohydrate intake Prof. Andrej Janež MD, PhD University Medical Centre Ljubljana, Slovenia
2 Conflict of interests Merck Sharp&Dohme, Novo Nordisk, NovarEs, Boehringer Ingelheim, Sanofi, Takeda,Lilly, Astra Zeneca, Lifescan, Medtronic
3 Basal/Bolus insulin treatment with rapid- aceng and long- aceng analogs or pumps Plasma insulin Breakfast Lunch Dinner Aspart Lispro Glulisin Glargine Detemir 4:00 8:00 12:00 16:00 20:00 24:00 4:00 Time 8:00
4 DCCT Research Group. New Engl J Med 1993;328:977. DCCT study
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6 Goals of FuncEonal insulin therapy (FIT) normoglycemia (HbA1c < 6,5%) normoglycemia (HbA1c < 6,5%) no hypos no hypos flexible ea%ng (dietary freedom) flexible eaeng (dietary freedom)
7 FIT knowledge 1. FuncEonal insulin replacement All about insulins Comprehension: basal bolus, prandial, correceon bolus Insulin dose adjustment 2. Tests of basal insulin, Carb factor, correceon factor 3. FuncEonal insulin replacement under special condieons (exercise, illness )
8 Carbohydrate CounEng and Diabetes
9 Why Carb Count? Need some methodology on which to base rapid- aceng insulin dosing with meals/snacks Can allow for more flexibility with eaeng for people with type 1 diabetes TheoreEcally, should be_er match insulin bolus to carb intake and result in reduced post- prandial hyper- and hypoglycemia
10 Benefits of Adjus%ng Insulin for Carbohydrates Allows More Flexibility No need to stay within carb ranges for meals For paeents on pump therapy or MDI eaeng schedule can be much more flexible More Advanced Form of Diabetes Management PotenEal for more accurate dosing Pump therapy requires carb input
11 Es%ma%ng CHO Weighing food Measuring using cups & spoons Food labels Recipes that list CHO content CHO CounEng tables/books
12 How many Carbs? Tbsp. Salad dressing Wine* - 5 oz Wine 0 grams Meat balls 0 grams Pasta w/ tomato sauce Dinner roll Salad greens 30 grams 15 grams 0 grams Salad dressing + 0 grams 3 meat balls 0 1 small dinner roll 1 cup pasta 0 1 cup tossed salad greens 30 TOTAL = 45 grams or 3 choices * According to the ADA, If adults with diabetes choose to use alcohol, daily intake should be one drink per day or less for adult women and two drinks per day or less for adult men.
13 Food Labels Locate Serving Size Locate total grams of carbohydrate Rules for fiber and sugar alcohols
14 Fiber and Sugar Alcohols For example: Total Carbohydrate 30 grams Dietary Fiber 10 grams 30 grams (Total Carbohydrate) - 5 grams (half of dietary fiber) 25 grams of Carb to count The same rule applies for sugar alcohol
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16 Calcula%ng a Dose 3 Step Process 1 st Step: Insulin to Carb Ra%o Determine how much insulin is needed for carbs eaten at meal or snack: Ø Count up total carb grams Ø Divide total grams by raeo
17 Calcula%ng a Dose 2 nd Step: Blood Glucose Correc%on Determine How Much Insulin is Needed to correct blood sugar (bg) to target Ø Check bg Ø Calculate insulin amount needed to bring bg into target range (i.e. 1 unit per 50 over 150- Individualized) 3 rd Step: Total Dose = Insulin needed for carbs plus insulin needed for bg
18 Es%ma%on of prandidal insulin Rule of 500: Carb factor 500 : TDD = g Carbs covered by 1Units short acting analogue insulin Example: CDO = 25 U 500 : 25 = 20 1 E covered 20 g Carbs
19 How to calculate insulin dose by coun%ng Grams of Carbs Insulin prescribed by MD: 1 unit of insulin for every 15 grams of Carb 1 burger pa_y + 1 hamburger bun + ½ cup peas + 1 small apple How many grams of Carb is in this meal? How many units of insulin are needed? grams of Carb 15 = 4 units of insulin
20 FIT TESTS
21 The evidence DAFNE study: course teaching flexible intensive insulin treatment combining with dietary freedom and insulin adjustment Improved A1c at 6 months (9.4% v. 8.4%, p<0.0001) Improved quality of life at one year DCCT study: using CHO/insulin raeos in intensively treated group improved glycemic control
22 DAFNE Dose Adjustment For Normal EaEng The aim of the programme is for parecipants to eat freely, and adjust their insulin to match carbohydrate load, physical acevity and insulin sensievity.
23 DAFNE Dose Adjustment For Normal EaEng A course adapted from the Michael Berger s Diabetes Training and Treatment Programme for people with Type 1 diabetes and started in the UK from Intensive group educaeon taking place over 5 consecueve days with a skills based focus. Led by Diabetes Specialist Nurse and DieEEan. Normally 6 to 8 parecipants per group.
24 Introduction DAFNE timetable Monday Tuesday Wednesday Thursday Friday What is diabetes? Discussion: Individual blood glucose levels ` Group discussion: Glucose levels Group discussion: Glucose levels Group discussion: Glucose levels Coffee Coffee Coffee Coffee Coffee Nutrition 1 Identify carbohydrates DAFNE insulin adjustment Hypoglycaemia Nutrition 4 Alcohol Eating out Healthy eating/ weight control Sick day rules Social aspects (Contraception and pregnancy optional) Lunch Lunch Lunch Lunch Lunch All about insulin Nutrition 2 Putting carbohydrate estimation into practice Nutrition 3 Food packaging Recipes Annual review and screening Coffee Coffee Coffee Coffee Close New insulin regime and individual targets Self monitoring Discussion: Individual blood glucose levels Managing physical activity Group dose adjustment session Questions for the Doctor Group dose adjustment session Quiz Evaluation and follow up arrangements
25 UK DAFNE Study n=144 pts in 3 UK centres DAFNE study group. BMJ 2002
26 Results: DTSQ DAFNE study group. BMJ 2002
27 How does it work in our center?
28 DIABETES FACTS Population: Type 1 DM: Prevalence: 6.9% Population: 2,054,199 Area: 20,273 km 2
29 Started in type 1 diabeec pts. Age EducaEon taking place over 3 consecueve days. Normally 3-4 parecipants per group. Offered to anyone who needs/wants to improve self- management skills. Offered to all newly- diagnosed paeents. Led by diabetes specialist nurse and diabetologist.
30 N= 180 pts mean age 38±10y duraeon diabetes 17±10y Hba1c 8.23 ± 0.8% ( 3 values 1 year before FIT) 3 values of HbA1c 1 year aver FIT Janez A et al. Diabetes 2007; 56; Suppl 1.
31 Effect of FIT on HbA1c 10 HbA1c (%) p< HbA1c PRED before FIT HbA1c PO aver FIT Janez A et al. Diabetes 2007; 56; Suppl 1.
32 Effect of FIT on severe hypoglycemia Number ŠTEVILO of severe HUDIH hypoglycemia HIPOGLIKEMIJ before PRED FIT p< aver PO FIT FIT Janez A et al. Diabetes 2007; 56; Suppl 1.
33 Effect of FIT on total daily insulin dose 60 CDO (IE) Total daily insulin dose (Units) p< before PRED FIT aver PO FIT POVPREČNA VREDNOST CDO Janez A et al. Diabetes 2007; 56; Suppl 1.
34 Janez A. J Int Med Res. 2012;40(4):
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49 Conclusions All people with Type 1 diabetes (also type 2 with basal- bolus therapy) should be offered a structured FIT educaeon course. Carbohydrate couneng is an important skill for all involved. FIT outcomes: lower HbA1c, no increase or even reduced sever hypos, be_er QoL.
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51 Thank you!
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