D-solve part four : using insulin

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How can you use insulin most effectively?

This case study concerns a juvenile onset type one diabetes boy. The case is also applicable to type twos who are using insulin.

Steven is a 14-year-old boy who has had type 1 diabetes for two years. His honeymoon period is coming to an end and he has recently changed from a twice daily mixed insulin regime to a multiple daily injection regime. His mother is very concerned to reduce the complications of diabetes and wants to know how he can keep his blood sugars as normal as possible. At the same time, she has read about “dead in bed” syndrome and wants to avoid night-time hypoglycaemia. How should his insulin regime managed to steer this fine line regarding optimal blood sugar control?

  1. “Steven should be dealing with his own diabetes management and his mum should be leaving him to it”. Is Steven old enough to deal with his diabetes by himself?

With the rise in provision for teenage diabetics to be seen on their own at special diabetic clinics there is sometimes the expectation that most young people have the motivation and ability to self-care for their diabetes. Parental involvement is sometimes perceived as a factor that will reduce the independence of the young person who has the diabetes. There is a fine line to tread here.

A study done by a nurse in the UK found that teenage girls with type 1 diabetes at the age of sixteen had markedly worse blood sugar control than boys of the same age with type 1 diabetes. The HbA1c difference amounted to an average of 2%. After extensive interviews with the teenagers and parents she discovered that the girls resented their mother’s interference and did indeed self care. The boys, however, were happy to have involvement from their mothers, and as a result had considerably better control.

Another study of teenagers with type 2 diabetes found a 4% gap in the average HbA1cs. Teenagers who involved their parents had an average HbA1c of 7%, but those who completely self cared had an average of 11%. Teenagers are not as self sufficient as perhaps they would like to be so, getting help from mum and the rest of the family can pay off.

The correct answer is NO. Involving others in the care of your diabetes can give you better control and is safer for insulin users.

Some academic papers concerning the importance of good family support in supervising and caring for teenagers are listed below:

J Pediatr. 1997 Feb;130(2):257-65.

Parental involvement in diabetes management tasks: relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus.

Anderson B, Ho J, Brackett J, Finkelstein D, Laffel L.

Source

Mental Health Unit, Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA.

Abstract

http://www.ncbi.nlm.nih.gov/pubmed/9042129

J Adolesc Health. 2012 May;50(5):491-6. doi: 10.1016/j.jadohealth.2011.09.007. Epub 2011 Dec 3.

Longitudinal trajectories of metabolic control across adolescence: associations with parental involvement, adolescents’ psychosocial maturity, and health care utilization.

King PS, Berg CA, Butner J, Drew LM, Foster C, Donaldson D, Murray M, Swinyard M, Wiebe DJ.

Source

University of Utah, Salt Lake City, UT, USA. pam.king@psych.utah.edu

http://www.ncbi.nlm.nih.gov/pubmed/22525113

Ketonuria

  1. Steven’s mum asks “Will he get ketones in his urine on a low carbohydrate diet?”

He may indeed get ketones. These are usually associated with a daily carbohydrate intake of 50g or less. These ketones are usually light in amount and are the by-product of fat metabolism. As long as the blood sugar is normal and he is well they are of no concern.

The ketones associated with ketoacidosis are due to a relative insulin deficiency and are often greatly exacerbated by infections and dehydrating illnesses. The ketonuria is high in amount and associated with high blood sugars – 13mmol/l or higher, generally feeling unwell, nausea and vomiting. Ketoacidosis is a diabetic emergency.

“Doctors are scared of ketosis. They are always worried about diabetic ketoacidosis. But ketosis is a normal physiological state. It’s the normal state of man. It’s not normal to have a McDonalds and a delicatessen round every corner. It’s normal to starve. Simply put, ketosis is evolution’s answer to the thrifty gene. We may have evolved to efficiently store fat in times of famine but we also evolved ketosis to efficiently live off that fat when necessary. Ketones make the body work more efficiently and provide a back up source of fuel for the heart and brain. The heart and brain run 25% more efficiently on ketones than blood sugar.” (Taubes quoting research of Richard Veetch)

Low carbohydrate intake is on a continuum from 30g (Bernstein) to 130g (Jovanovich) a day. The individual can decide from their food preferences, level of regular physical activity and health goals how far they wish to limit carbohydrate in their meals.

On the conventional high carbohydrate/ low fat diet in the UK, four in five children under five-year-olds and six in seven 11- to 16-year-olds are not achieving the recommended blood sugar targets (Diabetes UK, 2004) The target at this time was a HbA1c of 7.4% or less.

Similarly, in the USA, post-prandial blood sugar targets of 10mmol/l or less were only achieved by one in ten children or teenagers (Children with Diabetes, Gary Scheiner Strike that Spike 2006)

Despite many advances in blood sugar monitoring and insulin delivery methods there has been no change in children’s average HbA1cs in the last 25 years.

Diabet Med. 2013 Aug 19. doi: 10.1111/dme.12305. [Epub ahead of print]

Medical and psychological outcomes for young adults with Type 1 diabetes: no improvement despite recent advances in diabetes care.

Johnson B, Elliott J, Scott A, Heller S, Eiser C.

Source

Department of Psychology, University of Sheffield, Sheffield, UK; NIHR CLAHRC for South Yorkshire, Sheffield, UK.

http://www.ncbi.nlm.nih.gov/pubmed/23952498

Dr James Hays said in a 1999 San Diego conference about his low carbohydrate, high fat diet for diabetics: “In juvenile diabetics they may not be overweight and they might have more or less normal lipid levels but when they take this kind of diet it is possible to treat them with lower doses of insulin and make their lives a little safer.”

Short and long term studies on the use of a low carb diet in type one diabetes:

A Low Carbohydrate Diet in Type 1 Diabetes

JV Nielsen, E Jönsson… – Upsala journal of medical …, 2005 – informahealthcare.com

http://prdupl02.ynet.co.il/ForumFiles_2/28984756.pdf

Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: A clinical audit

JV Nielsen, C Gando, E Joensson… – Diabetology & Metabolic …, 2012 – dmsjournal.com

http://www.dmsjournal.com/content/4/1/23

The correct answer is YES. There may be ketonuria. This is not by itself a concern however.

  1. Steven should inject the rapid-acting insulin at least 15 minutes before eating for best effect.

 Although rapid-acting insulins can be given right before the meal, and for certain situations may be given afterwards, for example in toddlers who are unpredictable in their food consumption, or if the blood sugar was low before the meal, they generally work better to reduce post-prandial blood sugar spikes if given 15–30 minutes before the meal (Rassam et al, 1999).

The correct answer is YES. In usual circumstances this is the best timing.

7

  1. The most insulin that should be injected in a single shot is seven units.

The NICE guideline for type 1 diabetes states: “Aim for hypoglycaemia avoidance, while maintaining blood glucose control as close to optimum levels as is feasible. Avoid inappropriately pursuing tight blood glucose control if quality of life is compromised despite otherwise optimal care, or the risk of hypoglycaemia is significant to the individual.”

Seven units of insulin in one shot does not seem like a lot for many diabetics. By trial and error and completely separately Dr Bantle and Dr Bernstein discovered that this was the highest amount of an injected bolus of insulin that could be relied upon to work as expected.

Pump manufacturers go further than this and instruct users to spread out any bolus of more than 5 units over a length of time. This prevents the ball of fluid sitting around in the tissues beyond the expected action time and giving an unpredictable effect on blood sugars later on. The positive effects of this regime are predictable insulin absorption. This can vary by as much as 29-39% for higher amounts of insulin.  Galloway from Lilly found that a 70-unit bolus of regular insulin remained active for a week.

The number of injections to cover a high carbohydrate meal may indeed prevent patients from considering this advanced insulin technique. On the other hand they may welcome the freedom from unexpected hypos or soaring blood sugars. Parents may worry less about the consequences of low blood sugars at night. Dead in bed syndrome has not been completely explained, but is thought to occur when hypoglycaemia or autonomic neuropathy causes a fatal cardiac arrhythmia in an otherwise fit young diabetic.

Low carbohydrate diets result in far fewer episodes of hypoglycaemia. On a 70-90g of carbohydrate diet, rates fell from an average of 2.9 a week to 0.2 (Nielsen et al, 2005). When a low carbohydrate eating regime is undertaken, the amount of insulin used falls dramatically and far fewer of these 7 unit or less shots are required for meal coverage. Smaller doses also reduce lipoatrophy and lipohypertrophy.

The correct answer is YES. The 7 unit rule is a major tool to get your insulin working predictably.

  1. A single injection of rapid acting insulin can be successfully used to cover all meals.

NICE guidelines state: “Provide the types of insulin and the insulin injection device (usually injection pens) that allow optimal well being.”

Correction doses and coverage of high glycaemic carbohydrate such as sugar, bread, potatoes and rice are indeed best covered with a rapid acting insulin.

High-fat meals, low-glycaemic carbohydrates, such as non-starchy vegetables, pasta-containing meals, and meals containing more than about 3oz of lean meat or three eggs are best covered with two or more spaced injections of a rapid-acting insulin or by using a regular insulin such as actrapid, humulin S or pork hypurin soluble.

Actrapid is no longer available in pen form but  Humulin S from Lilly is still available in pen cartridges. Wokhardt produce soluble pork and beef cartridges for use in the Owen Mumford Autopen Classic. This is only available in one-unit increments as opposed to half-unit pens which are available for novorapid and more recently humalog.

Other people may prefer to use an insulin pump. The use of pumps is currently limited in the UK, but many units will allow their use if the costs are borne by the individual or are supplied by a charity. They are more widely available for children and women who wish to embark on a pregnancy.

The correct answer is NO. You need different insulins and timing techniques for different kinds of meals.

  1. Steven should check his blood sugar at least four times a day.

The NICE guidelines: “Advise a frequency of self monitoring depending on characteristics on an individual’s glucose control, insulin treatment regime and personal preference in using results to achieve the desired lifestyle.”

For most patients with type 1 diabetes this will be at least on rising, before lunch and dinner and before bed. In addition, the effect of exercise and acute illness will require much more intensive monitoring. Providing at least five strips a day is an essential minimum.

Seasonal changes occur in insulin sensitivity that can affect the requirements for basal insulin. Blood sugars taken around 3am are often best for monitoring this.

Insulin sensitivity varies throughout the day and night. Most people are most sensitive to insulin in the afternoon. Relative morning reduction in insulin sensitivity called the dawn phenomenon may also occur to some extent in the evening. This is called the dusk phenomenon.

Checking the average of blood sugars at various points through the day at 3- to 14-day intervals can help improve insulin sensitivity calculations when it comes to planning meal coverage.

When Steven starts driving lessons an even tighter monitoring system will be required. Drivers are best to test immediately before driving and at about hourly intervals during longer trips.

The correct answer is YES. Insulin dependent diabetics need to test at frequent intervals even when they feel fine.

  1. Accurate carbohydrate counting is necessary for prandial glucose control.

NICE guidelines regarding dietary management state: “Give advice that takes account of associated features of diabetes, eg excess weight and obesity, underweight, eating disorders, raised blood pressure and renal failure. Offer educational programmes that enable people to make optimal choices about the foods they wish to consume and insulin dose changes when taking different quantities of those foods. Discuss hyperglycaemic effects of different foods in the context of the insulin preparations chosen to match the person’s food choices. Discuss healthy eating to reduce arterial risk such as low glycaemic index foods, fruits and vegetables, types and amounts of fat. If appropriate discuss the effects of alcohol containing drinks on blood sugar excursions and calorie intake and the use of foods with a high glycaemic index.”

In order to achieve a close match between ingested food and insulin to achieve normal blood sugars, considerable educational resources need to be provided.

Carbohydrate type is relevant. Salad vegetables and broccoli have a lot of cellulose and low amounts of glucose. These types of carbohydrate may best be covered with regular insulin in the amount of approximately one unit of regular insulin to 8g of carbohydrate.

Bread, potatoes, rice and sugary foods are very rapidly turned to glucose and are best covered with a rapid-acting insulin in the amount of approximately one unit of rapid-acting insulin to 12g of carbohydrate.

As the amount of carbohydrate in a meal increases the more glucose increases and liver and peripheral tissues become more insulin-resistant. This increased need for insulin is not linear, it is exponential. Most people will find that they need proportionately more insulin for meals containing more than 30g of carbohydrate.

Fat does not need insulin cover at all. High fat meals, however, do retard the absorption of any carbohydrate that is present. Covering these meals with a proportion of regular insulin instead of a rapid-acting analogue single injection can help to prevent hypoglycaemia during these meals and to reduce post-prandial hyperglycaemia.

Protein does release glucose, but the process is a lot less efficient and slower than for meals containing sugars and starches. Regular insulin in the approximate amount of 2 units for each 3oz (or deck-of-cards size) of lean protein can be useful to remember.

Alcohol has a strong tendency to decrease background hepatic glucose production and can result in hypoglycaemia. It is not wise for patients with type 1 diabetes to consume more than one or two units of alcohol at one sitting. It is best to eat and drink together. Small quantities of alcohol taken at bedtime can successfully used to counteract the dawn phenomenon in some people.

A highly detailed educational programme is available from our site as well as a quicker slide show summary “How to achieve normal blood sugars with diet and insulin.”

There is a good internet carb counting course which is free of charge at this e-learning site. This has useful tables and photographs and also gets you started on calculating your insulin sensitivity at different times of the day.

It has a few limitations: The carb counting method is based on the old exchange  system of CP units or carbohydrate portions of 10g. This makes the measurements of your insulin requirements more complicated than they need be. It is best to stick to the simple calculation method which is the amount of carb that you can cover with one unit of insulin.

While no particular dietary strategy is advocated by the authors, the very large amounts of carbohydrate consumed by the case study participants could give you the idea that this is what you are expected to eat. Please bear in mind that these large amounts are to give you lots of practice in carb counting and have nothing to do with doing what is good for diabetes control.

The insulin to meal matching method described on the course is very basic and does not cover the highly advanced methods that are necessary if you wish to have normal blood sugars after eating a variety of meals and avoid hypoglycaemia.

The correct answer is YES. Accurate carb counting is very important for close meal to insulin matching. Taking the time to learn this is a good start. You can build on this with other more advanced techniques for normal blood sugars.

Other resources to help you obtain normal blood sugars are listed below:

This paper discusses why post prandial blood sugar is so important in the prevention of diabetic complications:

Point: Postprandial Glucose Levels Are a Clinically Important Treatment Target – Antonio Ceriello, MD

This book is very helpful if you want to learn to eyeball carbohydrate portions: Carbs & Cals & Protein & Fat: A Visual Guide to Carbohydrate, Protein, Fat & Calorie Counting for Diet & Weight Loss by Cheyette and Balolia.

The ACCUCHECK EXPERT SYSTEM is very helpful for estimating insulin doses at different meal times. You need to be proficient at carb counting and have worked out your insulin sensitivity at different times of the day. Your GP or UK diabetes clinic should be able to obtain one for you by speaking to the company representative. You will require a one hour training session prior to using it.

  1. Mum and Steven would benefit from advice on different sorts of support groups.

NICE guidelines state: “Make people with diabetes aware of support groups and their functions.”

Dr Bernstein’s site has a forum which is a helpful use of information and support. D-solve at http://www.dsolve.com has additional educational tools including a downloadable insulin calculator. The Insulin Dependent Diabetes Trust has helpful information for parents and children and a link to a site for teenagers with diabetes. They run an annual conference in Birmingham in October. The Children with Diabetes site has useful presentations that can help children, teens, parents and teachers. Diabetes UK run meetings and weekends for children under 12 years-old and their families.

Other internet support groups which support low carbing diabetics of all ages and of all types are:

  1. http://www.diabetes.co.uk/diabetes-forum/index.php
  2. DIABETES SUPPORT FORUM UK
  3. IDDT
  4. DR BERNSTEIN’S DIABETES FORUM

The correct answer is YES. The whole family can benefit from support groups which can be in person or online.

  1. Steven is doing very well if he can achieve the Diabetes UK target of a HbA1c of 7.4% or less.

HbA1c of 5.0% or more is associated with increased cardiovascular risk. Hba1c accurately predicts risk, whereas LDL and cholesterol do not.

The American Diabetes Association and others recommended from 2006 that diabetics are given both their HbA1c and corresponding average blood sugar levels to help them understand the necessity for good blood sugar control in the prevention of complications.

Average HbA1c levels compared to average blood glucose are:

A1c = blood sugar in mmol/l

5 = 5

6 = 6.6

7 = 8.3

8 = 10

9 = 11.6

10 = 13.3

11 = 15

12 = 16.6

13 = 18.3

14 = 20

  • A HbA1c <5 is optimal
  • 5-6 is considered “normal”
  • 6-7 is considered “good”
  • 7-8 is considered “fair”
  • 9 and over is considered “poor”.
  • At HbA1cs of <6.5 complication risk is considered “low”.
  • Arterial risk is raised at 6.5-7.4 and above. Microvascular risk rises at 7.5 and above.
  • Venous plasma glucose is considered low risk at fasting levels of 6.6 to 6.9. There is additional arterial risk at 7 or over.
  • For self-monitoring of whole blood there is a low risk at fasting levels <5.5. The arterial risk rises at 5.5-6 and there is additional microvascular risk >6.
  • Post-prandial blood sugar peaks give low risk up to 7.5, increased arterial risk 7.5-9 and additional microvascular risk >9.

(Diabetes for Dummies by Rubin and Jarvis.)

The conclusion is that the more a diabetic can sustain normal blood sugars without excessive hypoglycaemic risk the better.

The correct answer is NO.  For a teenager in the UK a HbA1c in the mid sevens is about 2% better than the average. This is despite free treatment and more frequent hospital visits and multidisciplinary input from staff that is provided by the NHS for this age group. Some adults who have attended the structural educational programme DAFNE can get HbA1c  at this level too. Complications are certainly reduced at the 7.5% compared to the more usual 9.5 % but will still arise if this level of HbA1c is maintained long term.

This chart shows the hbaic conversion to the new IFFA numbers:

http://baspath.co.uk/Hba1c_table.pdf

Delta_A330

  1. The family are going to Turkey in July for their holiday. Steven’s mother asks, “Do I need to take any particular precautions for the holiday?”  Does she?

Frio is a wallet that has a crystal padding. This swells when placed in water. Insulin can be kept cool even in hot temperatures and in cars when stored by this method. Hot temperatures can otherwise render insulin less effective than usual. This is particularly true for Lantus which seems to be more sensitive to both temperature and light than other insulins.

Take double of everything that you think you may need regarding the diabetes kit and split it between two passengers so that you will not be left short in the event of theft.

Metoclopramide injection along with the appropriate needles and syringes may be a useful item to carry. Administration is often necessary if glucagon needs to be given as this often provokes vomiting. It is not a substitute for medical attention should a vomiting illness occur but can prevent dehydration and the necessity for hospital admission if given.

Glucagon should be carried and accompanying travellers taught how to administer this.

A Medic alert bracelet can be helpful to alert strangers to the diagnosis should a diabetic become ill. Hospital personnel worldwide can access the medical history by phoning the number. Bracelets tend to be more obvious than neck chains as these can be hidden by clothing.

Sun screen is necessary of course and all the usual things you would take to reduce sunburn and heat stroke such as tee shirts for the pool and hats.

Mobile phones can be carried and must be kept charged. Telephones can help to keep family members in touch with each other.

No insulin should be put in luggage for the hold. It is likely to freeze and will be reduced in effectiveness.

A letter from your doctor or clinic explaining your need to carry insulin, syringes and other medication can be a great help if you are questioned by security staff.

Glucose gel can be carried on board in small quantities. Lucozade tablets can also be carried, but you may need to buy a small bottle of lucozade when you are past security if you want to use this to reduce the chance of hypoglycaemia.

Diastix used to be used to test the urine of patients with diabetes. It is much more useful these days to use the stixs to tell whether your draught drink is the diet version or not. In many locations both at home and abroad you do not always get what you ask for, and unless you test your sugars will be inexplicably high. You do not need to test if the diet drinks are in sealed cans or bottles. If you are really stuck, wasps are much better at distinguishing sugary drinks from the diet version, but this only works at certain times of the year – late summer.

Emergency cards can be constructed in the language of the country to which you are travelling. Sample cards regarding diabetic emergencies and hospital admissions can be seen at http://www.dsolve.com under the “How to construct emergency information” module. You can translate the medical history or other information using babelfish or other language tools available on the net.

Once you reach the resort find out where the nearest A&E department is and whether or not hotel reception staff can contact them on your behalf. It is worth carrying local emergency phone numbers with you if you intend to be in the wilds somewhere. Medical facilities in resorts can be variable. Find out where you can access help if needed before you ever need to do so for real.

Many insulin users need to reduce insulin doses in hot weather. This seems to be a predictable response for these people. Be sure to bring two meters and plenty of testing strips so that you can test and adjust more frequently than usual.

Bon voyage!

Conclusion

Helping people with diabetes and their families achieve normal blood sugars is a highly satisfying and worthwhile process. A person’s motivation to improve their destiny with diabetes is crucial. Dietary change can be quite simple but additional monitoring and insulin adjustments can be complex. By following this module you will have new information to help you. The educational site D-solve and the support site at Dr Bernstein’s Diabetes Solution can help expand your knowledge and self management skills further.

 

References

Further links

  1. Insulin Dependent Diabetes Trust (NOW RENAMED INDEPENDENT DIABETES TRUST)
  2. Children with Diabetes
  3. Dr Bernstein’s Diabetes Solution :
  4. The complete guide to achieving normal blood sugars
  5. D-solve: Low carb & low insulin diabetes management contains downloads on research.
  6. Also by Dr Katharine Morrison at this site: comprehensive module course for patients, carers and health professionals on the effective treatment of overweight, metabolic syndrome, type two and type one diabetes. Quick powerpoint presentation “How to achieve normal blood sugars with diet and insulin”. Diabetes calculator in downloads section that can be transferred to your pc. All of these resources are completely free of charge.
  7. Insulin for Life Australia

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