Balancing carbohydrate
intake and insulin
treatment
February 2016
Job code: UKDBT01551(1)
Prescribing 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
3
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
4
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
1. Franz MJ (2000) Diabetes Spectrum 13: 132–41; 2. Gillespie SJ et al (1998) J Am Diet Assoc 98; 897–905
5
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
1. Rabasa-Lhoret R et al (1999) Diabetes Care 22: 667–73; 2. Franz MJ (2000) Diabetes Spectrum 13: 132–41; 3. Collier G et al
(1984) Diabetologia 26: 50–4
6
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
Diabetes UK (2012) Starchy carbohydrates. Available at: http://bit.ly/IUKt0e (accessed 18.12.2013)
7
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
Diabetes UK (2012) Fatty and Sugary Foods. Available at: http://bit.ly/1e08tbD (accessed 18.12.2013)
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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
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
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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
Diabetes UK (2012) Milk and dairy foods. Available at: http://bit.ly/18LOk6j (accessed 18.12.2013)
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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
Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)
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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?
12
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
13
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
Calories per day
(kcal)
Carbohydrates per day (g; based on 50% of
calories)
1500
190
2000
250
2500
315
3000
375
 Total amount of carbohydrate ingested is the primary determinant of
post-prandial blood glucose response2
Table 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
14
Half of our time is spent in the postprandial state
Postprandial state
Postabsorptive state
Fasting state
06:00
10:00
Breakfast
14:00
Lunch
Monnier L (2000) Eur J Clin Invest 30(Suppl 2): 3–11
18:00
22:00
02:00
06:00
Dinner
15
© International Diabetes Federation,
2011
ISBN 2-930229-81-0
www.idf.org
16
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
International Diabetes Federation (2011) 2011 Guideline for the management of post-meal glucose in diabetes. Available at:
http://bit.ly/1bS6aYB (accessed: 18.12.2013)
17
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
Inzucchi SE et al (2012) Diabetes Care 35 1364–79
19
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
Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)
21
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
Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)
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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
Diabetes UK (2012) Understanding labels. Available at: http://bit.ly/1gBJzUO (accessed 18.12.2013)
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Food label example
NHS Choices (2013) Food labels. Available at: http://bit.ly/1bKKSvY (accessed 18.12.2013)
25
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
Diabetes UK (2012) Carbs Count. Available at: http://bit.ly/19UAEWM (accessed 18.12.2013)
26
Carbohydrate content of snacks
Snack
Carbohydrate content (g)
Banana
19–28
Teacake
38
Crumpet
18
Digestive biscuit
9
Diabetes UK (2011) Carbohydrate Reference List. Available at: http://bit.ly/1cCgXnt (accessed 18.12.2013)
27
Example of a food diary
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
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Carbohydrate quiz
Match method to treatment
CARBOHYDRATE
BUDGET
CONSTANT
CARBOHYDRATES
CARBOHYDRATE
COUNTING
CARBOHYDRATE
BUDGET PER
MEAL
EXACT
CARBOHYDRATES
PER MEAL
ADJUST INSULIN
FOR
CARBOHYDRATES
EATEN
Source: Diabetes Management and Training Centers, Inc.
30
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
Source: Diabetes Management and Training Centers, Inc.
31
= 2.5 g
Total
Source: DAFNE Food Plate Models
= 50 g
32
=3g
Total
Source: DAFNE Food Plate Models
= 90 g
33
Teaching patients to eat “under the curve”
Blood glucose level
post-meal: 16.1 mmol/L
Consider options ?
Blood glucose level
pre-meal: 6.1 mmol/L
34
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
Source: Diabetes Management and Training Centers, Inc.
35
Activity profile of premixed insulin analogues
(25:75)
Insulin activity
50 UNITS
12.5 units rapid acting
37.5 units intermediate
acting
6
7
8
9
10
11
12
1
30 UNITS
7.5 units rapid acting
22.5 units intermediate
acting
2
3
4
5
6
7
8
9
10
11
Blood glucose targets
4–7 mmol/L pre-meals1
12
1
2
3
4
Time
•
•
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
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
36
Activity profile of premixed insulin analogues
(25:75)
Insulin activity
50 UNITS
12.5 units rapid acting
37.5 units intermediate
acting
6
7
8
9
10
11
12
1
30 UNITS
7.5 units rapid acting
22.5 units intermediate
acting
2
3
4
5
6
7
8
9
10
11
Blood glucose targets
4–7 mmol/L pre-meals1
12
1
2
3
4
Time
•
•
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
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
37
Activity profile of premixed insulin analogues
(25:75)
Insulin activity
50 UNITS
12.5 units rapid acting
37.5 units intermediate
acting
6
7
8
9
10
11
12
1
30 UNITS
7.5 units rapid acting
22.5 units intermediate
acting
2
3
4
5
6
7
8
9
10
11
Blood glucose targets
4–7 mmol/L pre-meals1
12
1
2
3
4
Time
•
•
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
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
38
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
1. Unger J (2013) In: Schwartz Z (ed). Diabetes Management in Primary Care (2nd Edition). Lippincott Williams & Wilkins, PA, USA:
62–112
39
Fixed doses of rapid-acting insulin in a
basal–bolus regimen
Insulin activity
Blood glucose targets
4–7 mmol/L pre-meals1
Rapid-acting insulin
Long-acting insulin
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
Time
•
•
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
• 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
40
Varying doses of rapid-acting insulin in a basal–
bolus regimen
Insulin activity
1 unit per 10 g of
carbohydrate
Blood glucose targets
4–7 mmol/L pre-meals1
Rapid-acting insulin
Long-acting insulin
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
Time
•
•
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
• 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. Inzucchi SE et al (2012) Diabetes Care 35 1364–79
41
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
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UKDBT01551(1) – February 2016