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
2
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)
Foods containing carbohydrate (2)
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
Foods containing carbohydrate (3)
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)
Foods containing carbohydrate (4)
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
21Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)
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
22Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)
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
26Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)
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
7.5 units rapid acting
22.5 units intermediate acting
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
• 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)
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
7.5 units rapid acting
22.5 units intermediate acting
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
• 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)
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
7.5 units rapid acting
22.5 units intermediate acting
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
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
40
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
Blood glucose targets4–7 mmol/L pre-meals1
• 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
Blood glucose targets4–7 mmol/L pre-meals1
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