Commonly Asked Questions in Diabetes Management Why??

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1 Commonly Asked Questions in Diabetes Management Why?? Marion J. Franz, MS, RD, CDE Nutrition Concepts by Franz, Inc. Minneapolis, MN

2 Objectives State guidelines for the treatment of hypoglycemia List guidelines for sick days Discuss adjusting carbohydrate (or insulin) for exercise Discuss the need for dietetic foods State the effects of alcohol in diabetes

3 Why was my blood glucose high after exercising? Should I buy dietetic foods? Why? Can I drink alcohol? Why did I drive off the road after I treated a low blood glucose? Why is my blood glucose high when I have the flu and didn t eat?

4 I Treated My Low Blood Glucose and 2 Hours Later I Drove Off the Road. Why? George: 36 y/o male; type 1 diabetes; A1c=6.8% Tested his BG at 3:00pm before driving: 60 mg/dl Treated with 3 glucose tabs Shortly after 5:00pm he drove off the road What advice do you have for George?

5 Treatment of Hypoglycemia Definition: BG <70 mg/dl Symptoms may or may not be present Sweaty, cold, unable to concentrate, dizzy Treatment Carbohydrate fruit, milk, juice, sweet, starch, glucose tablets On average, 15 g of glucose can increase BG from 60 to ~110 mg/dl (50mg/dL) over ~40 minutes BG starts to fall at 60 minutes and reaches previous treatment level at 2 hours Cryer et al. Diabetes Care 26:1902, 2003

6 Treatment of Hypoglycemia Cont. 15 g of carbohydrate recommended, preferably a glucose tablet instead of recommending 15 g of a quick, fast-acting or simple sugar Foods containing fat may blunt peak effect *Instruct patients on insulin therapy (or on insulin secretagogue) to carry source of carbohydrate that is convenient, readily available, easily and quickly consumed, and doesn t spoil

7 Carbohydrate Choices BG 1 fruit or 1 milk or 1 starch = Blood Glucose Increase =(15 g) (12 g) (15 g) ~50 mg/dl or Fun-size =1 oz (15 g)

8 Treatment of Hypoglycemia Cont. Hypoglycemia increases gastric emptying from ~50 minutes to ~25 minutes; emptying rates of solid foods and liquids are the same Adding protein to carbohydrate does not help in the treatment and does not prevent subsequent hypoglycemia Schvarcz et al. Diabetic Med 10:660, 1993; Gray et al. J Clin Endocrinol Metab 81:1508,1996

9 Treatment and Prevention of Subsequent Hypoglycemia: Carbohydrate vs Carbohydrate Plus Protein 8 Glucose mmoi/l Insulin Bread Bread + Meat pmoi/l Glucagon pg/ml Time (minutes) Gray et al. J Clin Endocrinol Metab 81:1508, 1996

10 Treatment of Hypoglycemia: Bottom Line Treat blood glucose <70 mg/dl, with or without symptoms If blood glucose between 70 and 50 mg/dl, treat with 15 g of carbohydrate; wait 15 minutes and test again, if still <70 mg/dl treat again with 15 g carbohydrate If blood glucose <50 mg/dl treat with 30 g carbohydrate; wait 15 min and test again to determine need for additional carbohydrate Test again in 40 to 60 minutes to see if additional carbohydrate is needed

11 Glucagon Emergency Kit Hormone that releases stored glycogen Use if unable to safely ingest oral carbohydrate Administered by another person May be given intramuscular or subcutaneous Standard dose 1.0 mg for adults; 0.5 mg for children Prescription is required Precautions May cause nausea/vomiting/headache Call 911

12 I Have the Flu and Can t Eat So I Didn t Take My Insulin, Now My BG is 380 mg/dl. Why? Kari: 24 y/o female; type 1 diabetes (on Lantus and for meals, NovoLog) Woke up with symptoms of flu; BG 265 mg/dl; ketones trace; took usual insulin dose and ate some breakfast Felt more nauseated as day went on; at 4:00pm began throwing up. Didn t eat and didn t take insulin At 10:00pm checked BG again; 380 mg/dl with large ketones She calls and asks what she should do?

13 Sick Day Guidelines Take usual insulin dose or oral glucose lowering pills, even if too sick to eat Usually need additional insulin (10% 20% increase or use correction factor for rapid-acting insulin of 1800/total insulin dose) Test BG every 2-4 hours Test for ketones any time BG >250 mg/dl *Call healthcare provider if BG=250 mg/dl or higher for 24 hours; call immediately with moderate to large ketones With acute abdominal pain and difficulty breathing go to a hospital emergency room immediately

14 Determine Correction Factor 1800 Rule: 1800 Total Daily Dose = BG decrease from 1 unit of insulin Example: units = 30 points mg/dl mg/dl mg/dl mg/dl +4

15 Sick Day Food Plan Drink 6-8 ounces of liquids every hour (such as water, broth, Gatorade or tea) Replace 15 g carbohydrate every hour (or about 50 g every 3-4 hours), especially if BG <200 mg/dl One carbohydrate serving: 1/2 cup regular soft drinks 1 popsicle (60-80 calories) 6 saltine crackers 1 cup soup 1/2 regular gelatin (sweetened) 1/2 cup ice cream or 1/4 cup sherbet Sugar-free medicines are NOT needed

16 I Exercised for an Hour and My BG was Higher After Than Before. Why? Bob: Sedentary 42 y/o male; type 2 diabetes; A1c=7.9% Started an exercise class at the health club BG=140 mg/dl before and 175 mg/dl immediately after class How do you explain this to Bob? What advice do you give to Bob?

17 Effect of Exercise on Blood Glucose Hyperglycemia After exercise of a high intensity, especially if untrained With insulin deficiency Hypoglycemia Most common after exercise Usually does not occur during the first minutes of activity Type 2 diabetes Regular physical activity improves insulin sensitivity Type 1diabetes May make glucose harder to control American Diabetes Association. Diabetes Care 27(suppl 1):S58, 2004

18 Post-Exercise Hypoglycemia Hypoglycemia most frequent 3-15 hours after completion of exercise Rarely during or immediately afterwards Not related to metabolic control Usually after strenuous activity or play or exercise after period of relative inactivity During transition from untrained to trained MacDonald. Diabetes Care 10:584, 1987

19 Hypoglycemia During Exercise If BG is dropping before exercise, adding exercise can contribute to hypoglycemia BG test before exercise reflects blood glucose at that time Unknown if BG at the time of exercise is stable or dropping Wasserman, Zinman. Diabetes Care 17:924, 1994

20 Hyperglycemia After Exercise High intensity exercise Can result in increased hepatic glucose production that exceeds instead of matching the need for glucose Mediated by stress hormones Insulin deficiency Can cause a decrease in cellular uptake of glucose And an increase in hepatic glucose production Purdon et al. J Clin Endocrinol Metab 76:566, 1993; Mitchell et al. Diabetes Care 11:311, 1988; Berger et al. Diabetologia 13:355, 1977

21 American Diabetes Association s Recommendations for Physical Activity/Exercise Vigorous physical activity should be avoided in the presence of ketosis For persons with type 2 diabetes, if the individual feels well and ketones are negative, it is not necessary to postpone exercise based simply on hyperglycemia For individuals on insulin and/or an insulin secretagogue, ingest added carbohydrate if pre-activity levels are <100 mg/dl American Diabetes Association. Diabetes Care 27(suppl 1):S61, 2004

22 Insulin Adjustment Hypoglycemia Prevention For planned exercise decrease insulin acting during activity Decrease premeal rapid-acting insulin by 50% for 30 minutes of exercise and 75% for 60 minutes Decrease basal and bolus for exercise >4 hours After exercise, insulin may also need to be decreased Rabasa-Lhoret et al. Diabetes Care 24:625, 2001

23 Carbohydrate Adjustment Hypoglycemia Prevention (Primarily for Insulin Users) For unplanned exercise increase carbohydrate by 15 g carbohydrate/hour low intensity exercise 30 g carbohydrate/hour vigorous exercise May need more or less depending on duration and intensity of activity Adding after exercise may prevent post-exercise hypoglycemia 3-4 glucose tabs=1 carbohydrate choice Sport drinks (1 cup)=1 carbohydrate choice Granola bar=1-2 carbohydrate choices ½ cup juice=1 carbohydrate choices

24 Exercise and Increased Glucose Utilization Moderate intensity exercise increases glucose uptake by 2-3 mg/kg/min above usual requirements 70 kg (154 lb) person= g/hr of exercise High intensity exercise increases glucose uptake by 5-6 mg/kg/min; exercise of this intensity cannot be sustained for long periods Wasserman, Zinman. Diabetes Care 17:924, 1994

25 I see sugar-free cough syrup at the drug store. What about all the dietetic foods advertised in magazines for people with diabetes and at the supermarket? Should I buy them? Mary, 42 y/o female; type 2 diabetes on nutrition therapy alone Regularly reads several magazines for people with diabetes Friends often give her sugar-free foods What advice do you have for Mary?

26 Sugar-Free Cough Syrup Sugar- and alcohol cough syrup was compared to sugar- and alcohol-free preparations Each given for 3-day in standard doses No differences in fasting and postprandial BG and lipids Amount of sugar in medications is small 1 tsp of sugar = 4 g carbohydrate LeMar, Georgitis. Diabetes Care 16:426, 1993

27 Eskimo Pie Regular Serving Size: 1 bar Calories: 160 Total Carbohydrate: 15 g No Sugar Added Serving Size: 1 bar Calories: 120 Total Carbohydrate: 13 g Sugar Alcohols: 2 g

28 Cookies Regular (Pepperidge Farm Milano) Serving Size: 3 cookies Calories: 180 Total Carbohydrate: 21 g Total Fat: 10 g Sugar Free (Pepperidge Farm Mint Milano) Serving Size: 3 cookies Calories: 170 Total Carbohydrate: 21 g Sugar Alcohols: 6 g Total Fat: 9 g

29 Beer Calories Carb Grams Alcohol % by Volume Miller High Life Miller High Life Light Miller Lite

30 Shredded Wheat Serving Size: 1 cup Total Carbohydrate: 40 g Dietary Fiber: 6 g Sugars: 0 g

31 I Heard it was OK to Have a Drink Before Dinner and I Shouldn t Change My Insulin or Food Plan. Why? Susie: 56 y/o female; type 2 diabetes on insulin and metformin Previous to diabetes usually had a glass of wine with dinner and would like to continue doing this What advice would you give to Susie? What do most patients think alcohol does to blood glucose levels?

32 Effect of Alcohol on Glucose and Insulin Levels in Persons with Diabetes Moderate amounts of alcohol with food have no acute effect on blood glucose and insulin levels Chronic ingestion (~45 g/day) can cause deterioration in glucose control; effects from excess alcohol are reversed after abstinence for 3 days The type of alcoholic beverage does not make a difference Koivisto VA et al. Diabetes Care 16:1612, 1993; Ben G et al. Am J Med 90:70, 1991; Rimm EB et al. BMJ 312:731, 1996

33 1 drink=12 oz beer (150 kcal) 1.5 oz 80 proof distilled spirits (100 kcal) 5 oz wine (100 kcal)=~15 g alcohol (ethanol)

34 Benefits from Moderate Intake of Alcoholic Beverages Studies suggest U- or J-shaped association, suggesting benefit from moderate consumption of alcohol (~15-30 g/day) Light to moderate amounts of alcohol increases insulin sensitivity and raises HDL cholesterol Wei et al. Diabetes Care 23:18, 2000; Reynolds et al. JAMA 289:289:579, 2003; Wannamethee et al. Arch Intern Med 163:1329, 2003; Bell et al. Diabetes Care 23:1630, 2000; Davis et al. JAMA 287:2559, 2002; Lazarus et al. Am J Epidemiol 145:909, 1997

35 Alcohol Guidelines If individuals choose to drink alcohol, daily intake should be limited to 1 drink for adult women and 2 drinks for adult men In persons with diabetes, moderate amount has no acute effect on glycemic control, blood pressure and triglycerides Data does not support recommending alcohol use to persons with or without diabetes who do not currently drink Alcoholic beverage should be considered an addition to the regular food/meal plan. No food should be omitted

36 Medical nutrition therapy is an essential component of successful diabetes management, care, and self-management training.

Managing your Diabetes when you are Sick. Type 1 Diabetes

Managing your Diabetes when you are Sick Type 1 Diabetes Disclaimer This is general information developed by The Ottawa Hospital. It is not intended to replace the advice of a qualified health-care provider.