Diabetes Skills. Tips to help you keep your Blood Glucose in range. Food. Hypos. Data and Targets. Exercise

Transcription

1 Diabetes Skills Tips to help you keep your Blood Glucose in range Food Hypos Exercise Data and Targets

2 Targets: HbA1c NICE (2015) recommendation 48mmol/mol ( 6.5%) As close to this target as is possible taking into account individual daily activities and risk of hypoglycaemia To achieve this need to: Maximise time blood glucose is within target range Balance diet, insulin and activity to minimise variability Remember to maintain quality of life

3 FOOD

4 What is a healthy diet with Diabetes? Is it any different to a healthy diet without diabetes? Regular meals and snacks Balanced diet

5

6 Matching food with insulin Keeps BGs in range better after eating Basics: Inject before Carbohydrate Counting Allow 2-3hrs between meals for insulin to do its job Doesn t always work

7 The GI classifies carbohydrate foods according to how quickly they affect the blood glucose level. Standard Glucose 100 Glycaemic Index Low <55, Medium 55 70, High >70 What affects the GI of a food? Structure of food: more complex slower the digestion lower the GI Fibre soluble fibre (oats, pulses, fruit, veg) lowers GI Raw v cooked cooking increases GI Processing tends to increase GI Ripeness - more ripe, higher GI

8 GUESS THE GI

9 Managing GI with Insulin Low GI Use extended or multiwave boluses Consider split or delayed injection High GI (Breakfast) Bolus minutes before meal No need to increase insulin dose just calculate on carbs

10 TOTAL Energy Comes from a combination of: Mixed meals Carbohydrate Fat & Protein BOTH components affect BGs after we eat them

11 Mixed meals When meals are out of the regular balance High in Fat & Protein Carb Heavy BGs after we eat them become unpredictable.. My Carb Ratio doesn t work!

12 have an additional effect on blood glucose levels to carbs alone For most mixed meals (containing a mixture of carbs, protein and fat) ICR will cover the rise in BG caused by the fat and protein However Fat and Protein If a meal has a high fat and/or protein content, the fat-protein effect may show The blood glucose level may be higher for longer after the meal Giving additional insulin for the fat and protein can prevent these high BG levels happening

13 PHYSICAL ACTIVITY

14 Exercise is important for all youngsters but we are not getting enough. Young people with T1DM report even more barriers to doing exercise including fear of hypos or unpredictable BGs Why is it a challenge to keep BGs in range when we exercise?

15 Sprinting, swimming sprints Weightlifting, Climbing Gymnastics, Fencing Athletics Field events Football, Rugby, Hockey, Lacrosse Tennis, Squash, Rounders Running (middle distance) Playground games Skiing, Ice skating Jogging/cross country Brisk walking, long walks Cycling, Marathon running Triathlon Skateboarding

16 Effect on BG of different sports Graphic courtesy Professor Mike Riddell

17 Blood Glucose AFTER after exercise - The Whip, Double Dip BGs may be high immediately after Exercise hormones remain elevated Insulin Resistance Anaerobic, sprinting or intermittent exercise Pump off BGs may drop 1-4 hrs after BGs may drop again 7-11hrs after As muscle stores of glycogen replenish The hormonal response to a falling glucose is not as strong Sensitivity to insulin remains increased

18 So what can we do about it?? Management strategies for exercise with T1

19 Check Check Check!! Master your own diabetes Before, During, After There is no other way

20 Blood glucose targets BG level 5-8 when starting exercise and throughout exercise We also want to: Prevent hypoglycaemia after exercise Prevent high BGs during exercise and afterwards Muscles work better, reactions are faster, you can train for longer and recover quicker when BG levels are 5-8mmol/l

21 Before Exercise Plan if you can If Exercise will drop BGs Reduce bolus insulin for meals taken up to 2hrs before by 25%-50% Reduce basal insulin by 50% 90mins before Aim for BG 5-8 immediately before BG 4-5 have 10-15g snack BG 5-10 no extra snack for <30mins g for >60mins BG >14 check ketones. No exercise if ketones >1. Consider small correction if ketones <1 and start aerobic. Drink plenty

22 Exercise Nutrition - Snacks Fast acting 30g Jelly beans (25g carbs) Sports energy gels Glucose tablets Medium acting Cereal bar (20-30g carb) 30g raisins (20g carbs) Banana (25g carbs)

23 During Exercise Insulin Avoid bolus insulin Keep Reduced basal insulin by 50% - 75% Carbs For exercise >1hr extra carbs are likely to be needed. May be sooner if strenuous or no insulin adjustments made 0.5 g/kg/hr for every hour over the first hour FAST acting

24 Hydration Water Fine for shorter events No side-effects Sports Drinks Fast carbohydrate for longer events (30g carbs in 500ml) Isotonic improves hydration GI side-effects Easy to over-do it BGs too high

25 Using exercise to help you If glucose is high before activity you can use a low intensity warm-up to help bring this down If on the low side can you use a 10s sprint to help you? If going to the gym can you adjust the order in which you do things?

26 After Exercise Delayed hypoglycaemia can be a problem The Golden Hour restock your stores of carbs and protein within 1hr Snack 10-15g carbs AND Protein - no insulin Meal containing 1g/kg carbs and 0.5g/kg protein with half usual insulin Insulin Reduce bolus insulin by 25-50% for meals 2-4hrs after Immediately return to usual basal rate If evening exercise, reduce basal by 20% for 4hrs at bedtime

27 Golden Hour Snack ideas Milk shakes ( ml) Cereal (or cereal bar) and 200ml milk Nutty cereal bar Fruit and Nut mix Yoghurt and fruit Cheese and crackers Peanut butter sandwich Beans on toast Meat/fish sandwich

28 HYPO S

29 HYPOS Too much insulin Not enough carbohydrate Physical activity Anxiety or Excitement Timing of insulin injection/bolus Insulin action profile When last ate What else to consider When last active and the type of activity How frequently have blood glucose levels been low recently today this week overnight

30 HYPOS How to treat Survey in clinic in questionnaires: 43 out of 49 (89%) children vary the amount of glucose they use to treat hypo According to: Blood glucose level How they are feeling Sport % of children Amount of glucose taken Amount of glucose per Kg body weight Minimum Maximum Minimum Maximum 52% 9g (3 15g) 14g (5-20g) 0.18g/kg 0.29g/kg 33% 13g (4 40g) 20g (8 60g) 0.24g/kg 0.37g/kg 15% 10.5 (4-16g) 15g (12-16g) 0.32g/kg 0.42g/kg

31 HYPOS How to treat RECOMMENDATIONS ISPAD: (International Society for Paediatric and Adolescent Diabetes) 0.3g glucose per Kg body weight Body weight Approx Age Amount Up to 20Kg Up to 5 years 6g 30Kg 9 years 9g 40Kg 12 years 12g 50Kg 14 years 15g 60Kg + 16 years 18g Under 5 s 5g 5 to 11 years 10g Over 11 years 15g

32 HYPOS Treatment AIM: To raise the blood glucose level back into target range ISPAD: 0.3g glucose per Kg body weight will increase blood glucose by; 1 1.3mmol/l in 10 mins 2 2.1mmol/l in 15 mins If blood glucose is between 3.0 and 3.9mmol/l 0.3g glucose per Kg Sufficient to treat and avoid over treating If blood glucose less than 3.0mmol/l more glucose may be needed.

33 HYPOS What to treat with? 6g glucose per 100ml 15g glucose per bottle 15g sucrose per can 4g glucose per tablet 20 25g sugars, mainly fructose per carton.

34 DATA AND TARGETS What are we aiming for?

35 What information do you have to help achieve targets? Average glucose level from download % of glucose checks that are within, above, below target range Blood glucose checks Aim for; Pre meal target of 4.0 to 7.0mmol/l Post meal target of mmol/l Before bed mmol/l

36 90 day Average glucose checks HbA1c 47mmol/mol HbA1c 57 mmol/mol

37 My data Reports Target Data from Expert Meter Can look at data over 7 days, 14 days, 30 days, 60 days or 90 days Aim for more than 50% of readings to be Within target Aim to reduce the number of readings Above target Aim for a max of 10% of readings to be Below target Focus on the Green zone! Week on week try to get the Green zone to increase!

38 Targets: Pre meal mmol/l Post meal mmol/l Pre bed mmol/l 5 2 or 3 3 4

39 HbA1c 42mmol/mol HbA1c 62mmol/mol