10/18/2012
Jill L Quarry, MS, RD, LDN, CDE
Clinical Dietitian Specialist
Pediatric Diabetes Management
October 30, 2012
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Name the evidenced-based treatment for
hypoglycemia
Identify if there is a benefit of adding protein
at snacks to improve blood sugar control
List the basic recommendations for timing of
insulin injections with meals
Treatment for hypoglycemia
Protein myths
Exercise snacks
Fat doesn’t count
HbA1c
Timing of insulin
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10/18/2012
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Favorite treatments:
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Chocolate bar
The “cocktail” (orange juice with sugar)
Soda
Juice
“It’s a good time to have his favorite treats”
“Any kind of sugar works”
“Glucose tablets make my blood sugar too
high”
If not treated promptly, can be an emergency
Stages of hypoglycemia
◦ Mild: SWEAT
◦ Moderate
◦ Severe
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Benefits of proper treatment
DCCT (1993) (1)
American Diabetes Association (ADA) (2)
◦ < 70 mg/dl
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Barbara Davis Center for Childhood Diabetes
(BDC) (3)
◦ < 60 mg/dl
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10/18/2012
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Mild hypoglycemia can be treated with “15
grams of easily absorbed carbohydrate”
 ADA Position Statement on Care of Children and Adolescents with
Type 1 Diabetes (4)
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Ingestion of “15-20 g glucose is the preferred
treatment” for hypoglycemia
 ADA position Statement on Nutrition Recommendations and
Interventions (5)
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In a study that tested effective treatment
options for hypoglycemia in type 1 diabetes,
it was shown that glucose tablets were the
most effective at raising the BG level
◦ McTavish, et al. “Effective Treatment of Hypoglycemia in Children with
Type 1 Diabetes: A Randomized Controlled Clinical Trial” (6)
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10/18/2012
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Give sugar in some form as fast as possible
After the blood glucose is back to target, the
child can eat some other solid food
Use snacks to prevent insulin reactions
(especially if using NPH)
15 grams of CHO
Check BG 15 mins later
If the BG is still below 70 mg/dl, have another
15 grams of CHO
Medical alert
Carry fast acting carbohydrates at all times
How much do kids need? (Handout)
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10/18/2012
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“Protein will help to keep the BS up and
prevent hypoglycemia”
Add protein to snacks to “hold ‘em over…”
“a protein snack at bedtime prevents
nocturnal hypoglycemia”
Lantus or Levemir at bedtime and night time
NPH insulin is active during the sleeping
hours
More hypoglycemia occurs at night (severe)
Hypoglycemia unrecognized while sleeping
Misinformation regarding prevention of
hypoglycemia can give parents false sense of
security
Barbara Davis Center for Childhood Diabetes
(BDC)
American Diabetes Association (ADA)
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10/18/2012
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“a solid snack containing protein, fat and
carbs is best for bedtime”
 Chase P and Maahs D. “Understanding Diabetes: A Handbook for
People who are Living with Diabetes.” (3)
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“….protein should not be used to treat acute
or prevent nighttime hypoglycemia”
 ADA position Statement on Nutrition Recommendations and
Interventions (2)
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Protein has not been shown to have an effect
on glucose levels, even when consumed in
high amounts
“When 50 g of protein was ingested in test
subjects, plasma glucose concentration did
not change after the protein meal …”
◦ Collier, G, et.al. “The Effect of Coingestion of Fat on the Glucose,
Insulin, and Gastric Inhibitory Polypeptide Responses to Carbohydrate
and Protein.” (7)
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10/18/2012
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Food Science 101
Bedtime snack of a solid food with mixed
macronutrients is best
Blood glucose level goal for bedtime is > 130
mg/dl (3)
Protein is “free”, it “doesn’t matter”
“I can have a snack if my number is good”
Snacks are needed to prevent low blood
sugars
“Snack em” for all exercise
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10/18/2012
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Weight trends among children with type 1
diabetes
Extra snacks
Consistency of snacks
Forming habits
American Diabetes Association: Goals of
Medical Nutrition Therapy (5)
DCCT (1)
Individualize to balance the insulin activity (2)
Be consistent. When possible, eat meals and
snacks at the same time (3)
Exercise snacks
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10/18/2012
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“Snack foods should include carbohydrates,
protein and some fat” (3)
Use low saturated fat foods (5)
Exercise related hypoglycemia: more common
after, rather than during exercise
◦ Consume CHO as needed during activity to keep BG
in goal range
◦ May occur up to 72 hours after exercise due to
repletion of muscle and liver glycogen
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Be consistent
Snack foods should include carbohydrates,
protein and some fat.
Use low saturated fat snacks
Limit to <30g CHO
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Healthy snacks (Handout)
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◦ < 30 g CHO
Exercise snacks
◦ If BG <100, 10-15 g CHO snack for 30-60 min.
◦ If exercise is within 2 hours following a meal, can reduce
bolus insulin.
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10/18/2012
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My meter average BG is lower than the HbA1c
The HbA1c must be wrong
The HbA1c doesn’t matter for children
After-meal BG rises have significant impact
on HbA1c.
BG variability
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10/18/2012
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American Diabetes Association (ADA)
DCCT
“People diagnosed with type 1 diabetes in
childhood have a high risk of early … CVD.”
 Krantz JS, et.al " Early Onset of Subclinical Atherosclerosis in
Young Persons with Type 1 Diabetes.” (8)
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Research reported at the ADA scientific sessions
indicated that the average blood sugars during
the three hours after eating, not before,
correlates most closely to HbA1c levels.
Research on the effects of postprandial
hyperglycemia has also shown an increase in the
risk of death from heart disease in those with
Type-2 diabetes, earlier onset of kidney disease,
and accelerated progression of retinopathy in
those with Type-1.
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10/18/2012
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ADA (2)
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Toddlers and preschoolers
School age (6-12)
Adolescents and young adults (13-19)
> 19 years
7.5-8.5%
< 8.0%
< 7.5%
< 7.0%
“I don’t know how much he is going to eat”
“Maybe he’ll want seconds”
“He might refuse to eat”
“He doesn’t like a lot of foods”
“I forget to take it”
1 hour after a meal, about half of the glucose
has entered the blood steam
After an injection, 85% of the rapid action
remains at 1 hour
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10/18/2012
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Barbara Davis Center for Childhood Diabetes
(BDC) (3)
“Intensive diabetes management is most
easily accomplished using Lantus/Levemir
insulin (once daily) and a rapid acting insulin
20 minutes prior to food intake.” (3)
Pre-meal BS level and foods to be eaten
should be taken into consideration when
deciding when to take a mealtime insulin
dose
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10/18/2012
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Insulin Timing in Relation to BS
◦ BS within target range
 take insulin 5 -15 minutes early
◦ BS above target range
 take insulin 20 - 45 minutes early
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Have a great day!
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