1. Elizabeth DeRobertis, MS, RD, CDN, CDE, CPT Director of The Nutrition Center, Scarsdale Medical Group www.nutritionistliz.com

2. Diabetes Complications 2 out of 3 people with diabetes die from heart disease or stroke Diabetes is the #1 cause of adult blindness Diabetes is the #1 cause of kidney failure Diabetes causes more than 60% of non- traumatic lower-limb amputations each year NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

3. Incidence of Diabetes Type 1 diabetes 5% to 10% of diagnosed cases of diabetes Type 2 diabetes 90% to 95% diagnosed cases of diabetes NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2011

4. Diabetes Control and Complications Trial (DCCT)  The DCCT is a clinical study conducted from 1983 to 1993 by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).  Compared effects of two diabetes treatment regimens – standard therapy and intensive control – on the complications of diabetes DCCT. New England Journal of Medicine, 329(14), September 30, 1993.

5. Tight glucose control is key to preventing or delaying complications of diabetes Any sustained lowering of blood glucose helps, even if the person has a history of poor control DCCT Findings DCCT. New England Journal of Medicine, 329(14), September 30, 1993.

6. DCCT Findings Lowering blood glucose reduced risk of:  Eye disease by 76%  Kidney disease by 50%  Nerve disease by 60% DCCT. New England Journal of Medicine, 329(14), September 30, 1993.

7.  Testing blood glucose levels at least 4 x day  Four daily insulin injections or use of an insulin pump  Adjustment of insulin doses according to food intake and exercise  A diet and exercise plan  Monthly visits to a health care team composed of a physician, nurse educator, dietitian, and behavioral therapist.

8.  Follow-up 12-year study looked at whether tight control can decrease the heart and blood vessel diseases (macrovascular disease) related to diabetes.  Tightly controlled blood sugar: ◦ Lowered the risk of heart disease events, like heart attacks, by 40%. ◦ Lowered the risk of death from heart disease by about 60%. ◦ Slowed the progress of eye disease and kidney disease by 35% to 90%.

9.  A1C 5.7-6.5% Pre-diabetes  6.5% or higher type 2 diabetes  Lower A1C in Type 1 may indicate more hypoglycemia  Fasting glucose goal 110 or less  2 hour post prandial goal 140 or less  During pregnancy, 1 h pp goal 120 or less

10.  A1C is elevated but blood glucose readings appear within range.  Be a detective and alter times of the day they are testing blood glucose.  Patients tend to test when they know numbers will be good! Need to search out potential spikes in blood glucose.

11.  Combination of long-acting and rapid- acting insulin.  Achieves most precise control of blood glucose while offering the most flexibility in food choice and timing of meals.  The types of long acting insulin include insulin glargine (brand name Lantus ®) and insulin detemir (brand name Levemir ®).  Long-acting insulin provides a continuous level of insulin, mimicking the slow, steady (basal) secretion of insulin provided by the normal pancreas.

12.  Fast-acting (also known as rapid-acting insulin), or bolus.  The rapid-acting types of insulin include: Insulin Glulisine (Apidra®), Insulin Lispro (Humalog®) and Insulin Aspart (Novolog®).  Begins working within about 15 minutes of bolus, peak 60 to 90 minutes later and have a duration of therapeutic activity of approximately 2-4 hours.  Most patients experience that these types of insulin work strongly in their body for the first 2 hours, and the remaining 2 hours are more of a tail effect.

13.  Dosage of long acting insulin is usually consistent from day to day.  Rapid-acting insulin should be continuously adjusted by the patient, on a meal by meal basis, and should be based on their current blood glucose, and also on the amount of carbohydrates that they plan to eat.  Many healthcare professionals use a sliding scale approach, which has significant limitations.

14.  Insulin works differently in each person’s body.  Help patients to calculate an individualized Insulin to Carbohydrate Ratio and to calculate their own Sensitivity or Correction Factor.  Once the patients know these ratios, there is less guesswork needed when correcting for a high blood glucose, or adjusting insulin for meals, and the process becomes a lot more precise.

15. Rule of 1800  Add up the total amount of insulin the patient takes during the day, taking into consideration both the long acting and rapid acting insulin (this is called the Total Daily Dosage or TDD).  Divide this number into 1800, and you will get the point drop per unit of rapid acting insulin.  For example, if someone’s total daily dose is 50 units of insulin, divide 1800 by 50 = 36 mg/dl drop per unit of insulin. So the Correction or Sensitivity factor is 1 unit of Insulin: 36 mg/dl.  This means that for each 36mg/dl that this person is above their target blood glucose, they need 1 unit of insulin for correction.

16.  Step #1 – Test sensitivity factor at a time when blood glucose is high ◦ At least 2 hours after a meal/last insulin dosage ◦ Not when blood glucose is above 300mg/dl  Step #2 - Take 1 unit of the rapid acting insulin, and DO NOT EAT. Wait 2 hours & test blood glucose again.  Step #3 – Take starting blood glucose, and from that number, subtract the resulting blood glucose 2 hours later.  Result - The difference is the amount that 1 unit of insulin decreases blood glucose.

17.  Starting Blood Glucose 200mg/dl, and 2 hours later blood glucose comes down to 130mg/dl, this means that 1 unit of insulin decreased blood glucose by 70 mg/dl.  Starting Blood Glucose 170mg/dl, and 2 hours later blood glucose comes down to 120mg/dl, this means that 1 unit of insulin decreased blood glucose by 50 mg/dl.  This test should be done at various times of the day.  Any time blood glucose is above target, this correction or sensitivity factor can be used to calculate how much insulin patient needs to return to target blood glucose.

18. Rule of 500 (450)  Add up the total amount of insulin the patient takes during the day, taking into consideration both the long acting and rapid acting insulin (this is called the Total Daily Dosage or TDD).  Divide this number into 500, and you will get an approximate for the grams of total carbohydrate that will be covered by 1 unit of insulin (5).  For example, if someone’s total daily dose is 50 units of insulin, divide 500 by 50 = 10 grams of total carbohydrate. So the Insulin to Carbohydrate ratio is 1 unit of Insulin:10 grams of Total Carbohydrate.  This means that for each 10 grams of total carbohydrates that this person eats, they need to take 1 unit of insulin.

19.  Step #1 – You can identify insulin: carbohydrate ratio at a meal that is starting with a good blood glucose. This means no insulin is needed towards correction.  Step #2 – Identify how many carbohydrates are in the meal. It is a good idea to eat something ‘pre-packaged’ with a nutrition label, such as a frozen dinner, so the carb count is accurate.

20.  Step #3 – Take the number of units deemed appropriate. This may have been recommended by doctor using a sliding-scale approach, or by using the Rule of 500 calculation.  Step #4 – Test blood glucose 2 hours after meal. It should be 140mg/dl or less. If blood glucose 2 hours after the meal is within range that means that the amount of insulin administered was accurate.  Step #5 – To calculate insulin: carbohydrate ratio, divide the Total Carbohydrates in the Meal by the # of Units of insulin administered.

21.  If the meal had 45 grams of carbohydrate, and patient took 3 units of insulin, that means 1 unit of insulin, for 15 grams of carbohydrate (or 1:15).  If the meal had 60 grams of total carbohydrate, and patient took 6 units of insulin, that means 1 unit of insulin for every 10 grams of carbohydrate (or 1:10).

22.  Final Step – If your blood glucose 2 hours after the meal was too high or too low, insulin: carbohydrate ratio can still be calculated as described above, but you know right away to alter the numbers that are being using, to make them lower or higher based on blood glucose response. For example, if you used 1:15, and blood glucose was too high after the meal, next time use 1:14.  Insulin to Carbohydrate Ratio may vary based on the time of the day.  Some people use a different Insulin to Carbohydrate Ratio at each meal.

23.  Once a patient has calculated their Insulin: Carb ratio, and Sensitivity or Correction Factor, they have the ability to eat what they would like, when they would like, and alter the insulin they take to accommodate their food choices.  Test blood glucose at start of meal to determine if they need any insulin towards correction. Use the Sensitivity Factor to calculate how much insulin they need for correction.  Count the carbohydrates in the meal, and using their Insulin: Carbohydrate ratio, figure out how much insulin they need to cover the Total Carbohydrates in the meal they are about to eat.  Finally, add the units of insulin needed for correction to the units of insulin needed to cover the total carbohydrates in the meal. That is the total amount of insulin needed for this particular scenario.

24.  Detailed log helps to identify patterns and evaluate carbohydrate counting and also calculate ratios.  Patient can start by logging what they are currently doing.  Log should include blood glucose before and 2- hours after meals, carbohydrate content of the meals, and the insulin doses.  This data enables the diabetes team to retrospectively calculate the current regimen, and then make recommendations for change.  1% decrease in A1c when blood glucose results are recorded (bode, 1996).

25. Time BG Prior to Meal Food Consumed Total Grams Carbs Insulin For Correction (1:___) Insulin for Food (1:___) Total Units BG 2 Hours Later BG 2 Hours Later

26. Food Labels are First Choice … and then.. USE TECHNOLOGY instead of Food Models! Websites: www.calorieking.com or www.myfitnesspal.comwww.calorieking.comwww.myfitnesspal.com Restaurant Websites are very helpful Apps: CalorieKing or Myfitnesspal, RapidCalc for insulin dosing Food Scales with Nutrient Database:

27.  Take a smaller bolus at meal prior to exercise  Eat a certain amount of carbohydrates based on blood glucose prior to exercise  Use temporary basal rate setting with insulin pump  Suspend pump for time period prior to exercise  Use temporary basal rate AFTER exercise to prevent hypoglycemia later in the day

28.  Rule of 15 ◦ Blood Glucose under 70mg/dl ◦ Eat 15 grams of carbohydrates  4 ounces juice, 8 ounces fat free milk, 4 glucose tabs, 4 ounces soda ◦ Wait 15 minutes and re-test blood glucose  Aim to prevent over-treating & rebound effect

29.  Multiple Basal Rates automatically kick in throughout the day, compared to single dosage of long-acting insulin.  Bolus Wizard – calculates precise amounts of insulin (no rounding) based on current blood glucose and total carbohydrate intake.  Multiple Insulin:Carb Ratios & Sensitivity Factors.  Tracks Active Insulin.  Temporary Basal Rates.

30.  Temporary Basal Rates for Exercise, Illness, Stress.  Ability to suspend insulin delivery  Ease of multiple boluses throughout the day to cover snacks and corrections  Dual & Square Wave bolus features  Less injections – change every 3 days

31.  Real Time System beams blood glucose to insulin pump every 5 minutes (288 readings/day)  Displays 3 hour and 24 hour trends, with arrows to help with treatment decisions  High and low blood glucose alarms  Insulin suspend feature!  Ability to steer blood glucose during the day using sensor and temp basal rates  Worn for about 7-9 days at a time  Download reports