IN THIS CHAPTER
Determining how much carb to eat at mealtimes
Gaining insight on insulin action
Coordinating your meals and insulin
Matching meds to meals
Chapter 5 provides assessment tools to help determine daily carbohydrate intake targets. But knowing how much carb to eat in a day is only part of the picture. It’s equally important to distribute the carb budget between meals, and possibly snacks, throughout the day. Blood glucose can be difficult to control if too much carb is consumed at one time. This chapter helps you establish a reasonable carb intake target for individual meals.
This chapter also explains the relationship between food and some of the medications used to treat diabetes. Whether you are controlling your diabetes with diet alone, pills, insulin, or a combination of medications, there is a lot to be said for timing. How much you eat is one factor, but when you eat is another. In order to optimize blood-glucose control, the timing of meals and meds is critical. If you use insulin, it’s especially important to grasp insulin action profiles for the specific types of insulin you use. Carb intake and insulin must be strategically balanced to assure safety and effectiveness. Discuss managing your meals and meds with your healthcare provider to get personalized advice.
Distributing Your Daily Carb Intake
Achieving blood-glucose control is easier if you eat reasonable portions and distribute your carbohydrate intake throughout the day instead of overeating at one time. This section explains the importance of carbohydrate distribution and meal timing.
Skipping meals is not advised. Missing breakfast or lunch often leads to overeating later in the day. Excessive carb intakes at dinner can drive blood-glucose levels way up. Hyperglycemia in the evening can be slower to resolve because many people are less active at that time of day.
Striving to eat three meals per day
A balanced meal that contains carbohydrate, protein, and fat typically takes about four hours to fully digest, with the highest blood-glucose level around one to two hours after eating. Some foods, such as yogurt and fruit, digest quicker than that, while other foods digest slower. Deep-fried and fatty meals can take longer to digest because fat delays digestion. In Chapter 4 I explain that as a meal digests, some of the glucose becomes available for immediate use but that glucose is also delivered to the liver and muscles to be stored as glycogen. Glycogen stored in the muscles can be used later, but only by the muscles. Glycogen stored in the liver can be released as needed and shared with the other cells and organs throughout the body.
Eating three meals and spacing them roughly four to six hours apart keeps a steady supply of glucose and nutrients available to the body. An example of well-spaced meals would be breakfast at 8 a.m., lunch at 1 p.m., and dinner at 6 p.m. There is certainly room for personal preference, and you don’t have to start your day at 8 a.m. The main idea is that once you have breakfast, whatever time that happens to be, aim to have lunch four to six hours later, and then dinner four to six hours after lunch. Meals are typically finished digesting in about four hours, so your liver will tide you over between meals by releasing glucose from glycogen storage as needed until the next carbs are consumed.
Chapter 5 provides guidelines for establishing daily carbohydrate intake targets. Once you have a sense of how many carbs your body needs in a day, you can then decide how to divvy up the carbs into separate meals. Table 6-1 is designed to help you establish a reasonable mealtime carb target. The recommended carb ranges are based on gender and variables such as age, caloric needs, and activity. Consider the criteria in the left column when picking your carb intake target.
TABLE 6-1 Establishing Mealtime Carb Targets
|
Women |
Grams of Carb Each Meal |
|
Calorie controlled; for middle- to older-age, less-active women |
30–60 grams |
|
Maintenance calories; for younger to middle-age, moderately active women |
45–75 grams |
|
Higher calorie; for young women and active exercisers |
60–90 grams (possibly more) |
|
Men |
Grams of Carb Each Meal |
|
Calorie controlled; for middle- to older- age, less-active men |
45–75 grams |
|
Maintenance calories; for younger to middle-age, moderately active men |
60–90 grams |
|
Higher calorie; for young men and active exercisers |
75–105 grams (possibly more) |
Carb targets are expressed in ranges. A range allows for flexibility and variation in appetite, activity, and blood-glucose trends. For example, if you choose a range that calls for 45 to 75 grams of carb per meal, the assumption is that you will have three meals per day and each meal will have between 45 and 75 grams of carb. For example, breakfast could have 45 grams of carb, lunch might contain 60 grams of carb, and you could have another 55 grams of carb at dinner. All three meals are within the carb-range budget.
Saving up the carbs from one meal to have a bigger amount at a different meal doesn’t really work. You shouldn’t skip lunch and have twice as much at dinner. The point is to distribute carbs in manageable amounts throughout the day. The range sets an upper and lower limit of how many carbs to eat at each meal. Having diabetes inherently makes it difficult to tolerate very large carb intakes in one sitting. You’re bound to benefit from spacing out your meals and controlling your portions, whether you take diabetes medications or not. Having a mealtime carb budget that you stick with most of the time helps stabilize blood-glucose levels. If the higher end of the range isn’t well-tolerated, aim for the lower end of the range.
Opting for smaller meals with controlled snacks
Some people find it easier to control post-meal blood-glucose spikes by eating four to five smaller meals per day rather than three main meals. You may choose to distribute your daily carb intake into three smaller meals and one or two between-meal snacks. Plan to wait at least two hours after a meal before adding a carb-containing snack. If you face a long period of time between lunch and dinner, having a snack midway between the meals may be beneficial. An afternoon snack may curb hunger and help with portion control at dinner. Going into dinner ravenously hungry can lead to overeating.
For example, if you’re aiming for 160–200 grams of carb per day, you can have three meals with 45 grams of carb each and two snacks with 20 grams of carb each. Such a pattern equals 175 grams of carb total. You have room for some flexibility while staying within the daily carb target range. (See Chapter 5 to choose your daily carb intake range.)
It’s fine to fit in a noncarb snack whenever you desire (as long as excess calories aren’t leading to unwanted weight gain). String cheese, for example, doesn’t raise blood glucose, so it can be an “anytime” snack.
By definition, snacks are supposed to be small. It can be easy to get carried away. A snack with up to 15–20 grams of carb is reasonable. You may tolerate a snack with 30 grams of carb, especially if you are fitting in a walk or some form of activity.
Be mindful of your snacking. It all adds up. Read labels. Don’t eat directly out of a multi-serve container or you may end up eating multiple servings. If you do consume too many carbs while snacking, your blood-glucose level at the next mealtime may be higher than desired. If your blood glucose is already elevated when you eat your meal, your glucose levels will likely climb even further. Plenty of snacks have few or no carbs. Raw veggies are low in carbs and calories. Dipping veggies in Ranch dressing or scooping up guacamole won’t increase the carb count much at all (just the calories). Cottage cheese, a hard-boiled egg, or a few nuts can curb hunger without driving up blood-glucose levels. For more carb-controlled snack ideas, see Chapter 22 .
Stabilizing Blood-Glucose Levels at Breakfast and Dinner
The following practical pointers regarding the first meal of the day and the last meal of the day may help you stabilize blood-glucose levels.
Breaking your fast: The importance of breakfast
Some people say breakfast is the most important meal of the day. There are lots of reasons to eat breakfast:
· Research has shown that people who eat breakfast have a mental edge with enhanced memory, attention, reasoning, creativity, and problem-solving skills.
· Children who eat breakfast consistently perform better at mental tasks.
· Many studies show that eating breakfast is actually correlated with a reduced incidence of obesity.
There is usually a long period of time without food in the hours between dinner and breakfast. The last meal of the previous day is done digesting in a few short hours. When the final meal has digested, you survive on the glucose that was previously stored as glycogen in your liver. Once glycogen reserves are gone, your body resorts to the starvation mode of metabolism, which means you turn your muscles and body fat into fuel. Going 8 to 10 hours without food isn’t unusual, but skipping breakfast can easily increase the period of fasting to 12 or more hours, which is too long. Breakfast breaks that cycle. (See Chapter 4 to find out more about how the liver is able to create glucose out of muscle and ketones out of fat.)
The hormones that direct the liver to release glucose from glycogen stores are called counter-regulatory hormones. These hormones surge at or before dawn and cause transient insulin resistance, which may contribute to elevations in fasting blood-glucose levels. Your healthcare provider can assess the need for medication adjustments to resolve this problem. If you find your blood-glucose levels are more difficult to control at the morning meal, then choose breakfast foods that contain complex carbohydrates, such as oatmeal or whole-grain toast, and pair them with protein such as eggs or peanut butter. Breakfast foods and fluids that digest rapidly can lead to steeper rises in blood glucose. (See Chapter 10 for more about the variables affecting digestion rates and glucose control.)
Considering the merits of an earlier dinner
Type 2 diabetes is characteristic of insulin resistance. Insulin sensitivity is enhanced with physical activity. A moving and contracting muscle is a muscle that is burning glucose. If you go to bed shortly after eating, your muscles will be relaxed and therefore less able to help your insulin transport glucose. Any activity after a meal helps muscles use glucose. Exercise, an after-dinner walk, or even light housekeeping improves the way insulin works.
A meal takes about four hours to fully digest, with blood-glucose levels peaking about one to two hours after eating. If your blood-glucose peaks are above target when you go to bed, you may find that blood glucose stays higher all night and potentially contributes to elevated fasting-glucose levels the next day. If that is an issue for you, try to eat dinner about three to four hours before going to sleep. For example, if you go to bed at 10 p.m., eat dinner by 6 or 7 p.m.
Understanding Insulin Action
When the pancreas is working properly, it produces just the right amount of insulin to keep blood glucose controlled within a fairly narrow range. People who do not have diabetes have blood-glucose levels between 70 and 140 milligrams per deciliter (mg/dl) all the time, regardless of what they eat. “Normal” fasting blood glucose is 70–99 mg/dl. Post-meal blood-glucose levels remain below 140 mg/dl if you don’t have diabetes.
The American Diabetes Association (ADA) recommends fasting and pre-meal blood-glucose levels of 80–130 mg/dl. The ADA suggests peak post-meal blood-glucose levels below 180 mg/dl. Notice the ADA is not suggesting that everyone with diabetes should achieve normal nondiabetic blood-glucose levels. Blood-glucose targets are lower during pregnancy and may be less stringent in other situations. Discuss your personal blood-glucose targets with your healthcare providers.
As you find out in Chapter 4 , carbohydrate-containing foods digest and turn into glucose, which then enters the bloodstream. A functioning pancreas produces a surge of insulin to match the amount of carbohydrate in the meal. Some glucose is stored in the liver and the muscles as glycogen. During extended periods of time without food, such as while you sleep, the liver releases glucose from glycogen storage because the body needs a steady supply of glucose. A working pancreas releases just enough insulin to match the glucose that is being slowly released from the liver.
Insulin replacement therapy for someone with type 1 diabetes should mimic physiologic insulin as closely as possible. Rapid-acting or short-acting insulins are used to cover the carbs at mealtime. Intermediate-acting or long-acting insulins are used to cover the glucose that is released from the liver between meals. Insulin types and action times are covered in this section.
Comparing insulin options
Everyone with type 1 diabetes and many people with type 2 diabetes use insulin. Insulin is typically administered with insulin syringes, insulin pens, or an insulin pump. Type 1 diabetes treatment requires the use of two types of insulin unless an insulin pump is used (I discuss pumping insulin later in this chapter). There must always be baseline insulin, typically one of the long-acting insulin options. In addition, insulin is needed to handle the carbohydrate in meals. Rapid-acting insulin options are the best match for the digestion timing of meals.
See Table 6-2 for a list of the insulins currently on the market. To better grasp the way insulin works, use Table 6-2 to locate the type of insulin you use in the left column and then note the action times to the right. The key differences have to do with the onset, peak, and duration times. To clarify further:
· Onset: The time before the insulin reaches the bloodstream to begin working
· Peak: The time that the insulin is working at maximum strength
· Duration: How long the insulin continues to lower blood glucose
TABLE 6-2 Insulin Action Profiles
|
Insulin |
Onset |
Peak |
Duration |
|
Rapid-Acting: Lispro (Humalog); Aspart (NovoLog); Glulisine (Apidra) |
15 minutes |
1 hour |
Under 5 hours |
|
Regular or Short-Acting: Humulin R; Novolin R |
30 minutes |
2–3 hours |
5–8 hours |
|
Intermediate-Acting (NPH): Humulin N; Novolin N |
2–4 hours |
4–10 hours |
10–16 hours |
|
Long-Acting: Detemir (Levemir); Glargine (Lantus, Basaglar, Toujeo) |
2 or more hours |
Minimal |
Up to 24 hours |
|
Degludec (Tresiba) |
1 hour |
Minimal |
At least 42 hours |
Checking out concentrated insulins
The standard concentration for insulin in the United States is U100, which means 100 units of insulin per milliliter. The following insulin products offer more-concentrated versions so you use a smaller volume of insulin to get the same number of units:
· Humulin Regular offers U500, which is a version that is five times the concentration of Regular insulin. There are 500 units per milliliter.
· Lispro (Humalog) offers a U200 version with 200 units of insulin per milliliter.
· Toujeo U300 is a more concentrated form of glargine. It has 300 units of insulin per milliliter.
· Degludec (Tresiba) offers two concentrations: U100 with 100 units per milliliter and U200 with 200 units per milliliter.
Looking at blended insulin preparations
In addition to the concentrated insulins in the preceding section, there are also combination insulins. Rapid- or short-acting insulin is blended with intermediate- or long-acting insulin in one solution. The mixture is a set percentage. For example, 70/30 is 70 percent intermediate-acting insulin mixed with 30 percent rapid- or short-acting insulin. In this instance, 10 units of 70/30 would provide 7 units of intermediate-acting insulin, and 3 units of rapid- or short-acting insulin. When you increase or decrease the dose, you change the amounts of both types of insulin in the blend. If you want, or need, to independently adjust the components, you need separate bottles of the two types of insulin.
The blended insulin options include
· 70/30 with NPH and Regular
· 50/50 with NPH and Regular
· 70/30 with insulin aspart protamine and Aspart
· 75/25 or 50/50 with insulin lispro protamine and Lispro
· 70/30 with Degludec and Aspart
Combination insulins are typically administered twice daily: one injection before breakfast and one before dinner.
· The morning injection provides insulin coverage for breakfast (the rapid- or short-acting part kicks in first), and the intermediate-acting insulin provides the second peak effect, which covers the carbs in lunch. The pros: One shot covers two meals and you don’t have to draw up and mix two types of insulin in the same syringe. The cons: You are locked into a specific lunch meal in both timing and amount of carb. The insulin that is injected in the morning is set to peak at lunch, and there is no stopping it.
· The pre-dinner injection covers the carbs in the dinner and the glucose that is released from the liver overnight.
I provide more info on managing meals with blended insulin later in this chapter.
You cannot fine-tune doses, because increasing or decreasing the dose affects both types of insulin in the blend. For that reason, blended insulin preparations are not ideal for managing type 1 diabetes; however, they may be appropriate for certain people with type 2 diabetes. Your medical professionals can help personalize an insulin plan that is best for you.
Pumping and inhaling insulin
An insulin pump, which is worn externally, is a programmable device that delivers insulin continually via an infusion set (small catheter), which is inserted under the skin into fatty tissue. The infusion set is typically replaced every two to three days. Some pumps are waterproof and submersible, while others have a quick-release to remove the pump for bathing. Numerous pumps are on the market, and their features vary.
An insulin pump holds only one type of insulin (rapid-acting), but it has two main modes of insulin delivery:
· The basal rate is a programmable rate of insulin that is delivered continuously. It replaces the need for intermediate- and long-acting insulins. Insulin delivery patterns can be customized to an individual’s needs considering things such as exercise and hormonal fluctuations.
· The bolus mode of delivery refers to the amount of insulin that is needed for a meal as determined by carbohydrate counting, or for correcting blood-glucose elevations. The pump user presses a button to deliver the desired amount of bolus insulin.
Individualized carbohydrate ratios and correction ratios are programmed into the pump. You just need to let the pump know what your blood-glucose level is and how many carbs you plan to eat, and the pump does the math. The pump has a memory that tracks total daily insulin administration, and data is downloadable for computer printout. Pump initiation requires a prescription and a team of experts to train and monitor the pump user.
Afrezza is an inhaled version of rapid-acting insulin. It is used in combination with long-acting insulin. It begins working within 5 minutes (onset), reaches maximum strength in 12 to 15 minutes (peak), and is done working in about three hours (duration).
THE APPROVAL OF THE FIRST HYBRID CLOSED-LOOP SYSTEM
September of 2016 marked a historic advancement in the management of type 1 diabetes. The FDA approved the MiniMed 670G — the first hybrid closed-loop system in the world. The device combines two current technologies: an insulin pump and a continuous glucose monitor. What has changed is that the two technologies are now being allowed to “talk to each other.”
· The pump can adjust basal insulin delivery according to the blood-glucose fluctuations detected by the sensor. Insulin delivery will automatically suspend if blood-glucose levels fall too low. Automated insulin adjustments minimize high- and low-glucose levels. The user still needs to count carbs and enter the amount of carbs into the pump. The pump then calculates the correct insulin dose for the food and displays the recommended dose. The user just needs to “accept” the dose.
· Finger-stick blood-glucose monitoring is still indicated for calibrating the sensor and making insulin bolusing decisions.
The system is approved for nonpregnant adults and youth 14 years and older who have type 1 diabetes. The approval of the device, which is slated to be available in the spring of 2017, marks a significant milestone.
Coordinating Insulin Action with Meals
Rapid-acting and short-acting insulins are used to cover the blood-glucose rise after a meal. Insulin doses and action times need to match the amount of carb and the timing of digestion. This section explains two common approaches to determining how much insulin to take at mealtimes: insulin-to-carb ratios (ICR) and sliding-scale insulin (SSI). Blended insulins, such as 70/30 insulin, impose the need to be regimented with mealtimes and carbohydrate intake amounts, as I explain in detail.
This section provides examples of insulin dosing. Actual insulin requirements vary greatly from one person to the next. Do not change your insulin regimen based on the theoretical discussion in this book. Speak to your diabetes specialist about your insulin plan.
Enjoying the flexibility of insulin-to-carb ratios
Insulin-to-carb ratios allow for flexibility in carb intake. The general concept is that 1 unit of rapid- or short-acting insulin will “cover” a set amount of carb. For example, a ratio of 1:10 means 1 unit covers 10 grams of carb, and a ratio of 1:15 means 1 unit covers 15 grams of carb. The mealtime or snack dose is determined by the amount of carbohydrate planned as well as the ratio. For example, consider a meal with 60 grams of carb. The recommended dose could vary for three different people. A person with a ratio of 1:10 would take 6 units for 60 grams of carb. Someone else might be on a 1:12 ratio and need 5 units, and yet another person might be on a 1:15 ratio and need 4 units.
Ratios can also change within the day for the same person. Morning hormonal surges can cause insulin resistance at that time of day, so a stronger ratio may be required at breakfast than is needed for lunch or dinner. For example, a person might need a ratio of 1:10 at breakfast but 1:15 at lunch and dinner. Ratios can also vary on active versus sedentary days.
The insulin-to-carb ratio only covers the carbs in the meal. It doesn’t address the current blood-glucose level. If blood glucose is above target range at mealtime, a correction ratio is also needed. This ratio can vary from one person to the next. For the sake of providing an example, say someone needs 1 unit of rapid-acting insulin for every 50 mg/dl their blood glucose is elevated above a target pre-meal number. If the blood-glucose target is set at 120 mg/dl but the pre-meal blood glucose is 220 mg/dl, then a person with a correction ratio of 1 to 50 would take 2 units for the correction (here’s the math: 220 minus 120 is 100; 100 divided by 50 is 2).
When using insulin-to-carb ratios, the mealtime insulin dose is the sum of the two separate calculations: the amount of insulin needed for the food (insulin-to-carb ratio) plus the amount of insulin needed to bring blood-glucose levels back into target range (known as the correction ratio or the insulin sensitivity factor).
The benefit of using ratios is that you can adjust your own dose according to how much you want to eat. You aren’t locked into eating the exact same amount of carb at every meal of every day. Ratios also allow you to make corrections to blood-glucose levels. Use a calculator if needed; most phones have one. It’s a new skill, and it takes some practice.
Get your doctor’s advice on how to initiate ratios. After you start using ratios, you’ll want to assess how well the ratios are working. Figuring out what your ratios should be takes a little trial and error. Gather data. Record the pre-meal blood glucose, the carb count, and the dose of insulin. Be sure to count carbs as accurately as possible. Check blood-glucose levels again about four hours after the meal to see whether your level is near target. Gather and review at least one to two weeks’ worth of data in order to fine-tune the ratios. Keep in mind other variables can affect blood-glucose results. Blood-glucose levels may be lower after exercise and higher if you’re sick or stressed. There will always be some variability in blood-glucose results simply because injected insulin isn’t quite the same as a pancreas that does it all for you automatically.
Keeping carbs consistent when using sliding-scale insulin dosing
Sliding-scale insulin dosing isn’t as precise as using ratios (see the preceding section), but it may be simpler. Sliding-scale insulin is when your insulin dose is based solely on your current blood-glucose level. Your medical provider designs a dosing scale, and the number of units of insulin recommended increases incrementally as blood-glucose levels rise.
Table 6-3 shows a glimpse of what the layout of a sliding-scale insulin regimen may look like. This sort of insulin dosing plan relies on having the same amount of carb at each meal. The need for a pre-set and consistent carb budget is often overlooked. The dose of insulin injected can’t possibly cover the carbs in every meal consumed if carb intakes are variable. For example, a dose of 6 units may be too much insulin for a low-carb meal but may not be enough insulin for a high-carb meal.
TABLE 6-3 Example of Sliding-Scale Insulin
|
Blood Glucose |
Units of Insulin |
|
70–100 |
The doctor would fill in for your needs. |
|
101–150 |
… |
|
151–200 |
… |
|
And so on … |
… |
While sliding-scale dosing is simpler, it doesn’t erase the need to understand how to quantify carbohydrate portions. See Chapter 7 to brush up on label reading and Chapter 8 to find out how to count carbs.
Basing injection timing on pre-meal blood-glucose levels
Rapid-acting insulin is designed to be injected five to ten minutes before eating a meal. If pre-meal blood-glucose levels are running higher than desired, injecting a few minutes earlier may help by giving the insulin a head start at lowering glucose levels. If you check your blood glucose 20–30 minutes before the meal, you’ll have the opportunity to inject early if desired. The insulin then has a chance to lower the blood glucose somewhat before the pending meal digests and adds even more glucose to an already elevated level. On the flip side, if pre-meal blood-glucose levels are lower than desired, you may opt to eat half of the meal before injecting the rapid-acting insulin to give the food a head start. (For pre-meal hypoglycemia, treat the low blood glucose as described in Chapter 15 .) Regular insulin is slow to get started and is always supposed to be injected 30 minutes before the meal. However, if blood-glucose levels are elevated, it can be injected 45 minutes before the meal. Most people aren’t in the habit of stopping to check blood glucose a full 45–60 minutes prior to eating, which makes using regular insulin less convenient than rapid-acting insulin.
Being regimented if you use 70/30 insulin
I discuss blended insulin options in the earlier section “Looking at blended insulin preparations .” There are several different blends, but all contain a mixture of two different insulins: a longer-acting type and a shorter-acting type.
Figure 6-1 illustrates the action profile of 70/30 insulin. The horizontal axis is a 24-hour timeline that shows the onset, peak, and duration times of the insulin. This figure illustrates the insulin action timing of two injections of 70/30 insulin — specifically, the blend with rapid-acting and intermediate-acting insulins.
© John Wiley & Sons, Inc.
FIGURE 6-1: Action profile of 70/30 blended insulin.
The first injection is at 7 a.m. The blended insulin has two phases of action:
· The rapid-acting portion covers the breakfast meal and wears off by 11 a.m.
· The intermediate-acting portion doesn’t even begin to work for almost two hours. It then works over a sweeping length of time. You can see by the darker shading that it ramps up and works before, during, and after lunch.
One critical thing to remember is that it’s necessary to eat lunch about four to six hours after the morning injection because the intermediate-acting insulin is set to peak. You need to provide carbs to go with it. The second point to keep in mind is that the dose of insulin doesn’t vary, so the amount of carb needs to be consistent every day. You can’t eat a low-carb salad one day and a carb-heavy pasta meal with garlic toast the next day.
The second injection of the day in this example is at 6 p.m. The rapid-acting part (indicated by the light shading) covers dinner and the intermediate-acting portion of the blend (indicated by the darker shading) works while you’re sleeping. As described in Chapter 4 , the liver releases glucose all night long. The glucose coming out of the liver is covered by the intermediate-acting portion of the blended insulin. If the dose is appropriately set, you shouldn’t get hypoglycemic overnight.
Some people with type 2 diabetes do fine with this regimen because the blended insulin adds a layer of help to the insulin already being made in the body. Twice-daily injections of blended insulin are less than ideal for someone with type 1 diabetes, however, because the insulin can’t be fine-tuned adequately. Notice also that the insulin wears off fairly early in the morning (by 7–8 a.m. in this example), which means someone with type 1 diabetes would “run out” of insulin and start making ketones if she didn’t get up and take another injection — so no sleeping in.
Another issue is that most people release a surge of hormones in the pre-dawn hours, and those hormones can cause blood-glucose levels to rise. It’s known as the dawn phenomenon. Hormones cause blood glucose to rise in two ways: Hormones can stimulate the liver to release extra glucose, and hormones can increase insulin resistance, so insulin doesn’t work as well. The net result can lead to elevated fasting blood-glucose levels. Instead of using blended insulin, some people inject the rapid-acting and intermediate- or long-acting insulins separately, enabling doses to be independently adjusted. Given the option, it is usually more effective to inject NPH insulin at bedtime rather than at dinnertime. That way the NPH peaks later and lasts longer into the morning hours, which can improve fasting blood-glucose levels.
There are pros and cons when using blended insulins. Insulin dosing plans need to be carefully crafted with the help of a medical provider well-versed in managing diabetes.
Managing Carbs on Oral Diabetes Meds
Some people with type 2 diabetes are treated with a combination of insulin and oral agents (pills), while others take only insulin, only pills, or nothing at all. Numerous oral medications are currently available for treating diabetes, with more yet to come. There are injectable medications other than insulin. This section reviews the importance of dietary diligence when using diabetes pills.
Review your medications with your healthcare provider. Ask when you should take your doses and what to do if you miss a dose. Some pills should be taken before the meal, while others are best tolerated withthe meal. Find out whether the meds you take have the potential to cause hypoglycemia.
Keeping the carbs appropriate
If blood-glucose levels aren’t being controlled by lifestyle modifications, medications may be needed to manage type 2 diabetes. Many medications are available, which may be used alone or in combination. Long-standing type 2 diabetes often requires several medications to successfully reach blood-glucose targets. Eat a healthy, balanced diet with adequate carbs. Don’t overdo carb intake because excessive carb loads make the pancreas have to work too hard. But don’t undereat carbs either. Use Chapter 5 to find the right amount of carbs for you.
Blood-glucose levels that are persistently elevated (when eating an appropriate amount of carb) indicate the need for initiating or adjusting medications. Some of the medications used for diabetes management require attention to carb intake, as discussed next.
Any medication that stimulates the pancreas to produce extra insulin may cause hypoglycemia if not enough carbs are consumed:
· A class of medications known as sulfonylureas stimulates sustained insulin release over a period of many hours. The typical dosing schedule is once or twice daily. If you take one of these medications, it is important to stick with your meal plan and eat an appropriate amount of carbohydrate. Don’t skip meals or skimp on carbs, or you could end up hypoglycemic. Aim for three meals spaced four to six hours apart. See Chapters 19 , 20, and 21 for menu plans with consistent carb amounts.
· Meglitinides are medications that also stimulate insulin release; however, the effect is shorter lived. The dose taken before a meal stimulates insulin release for just that meal, not all day. Due to the short duration of action, there is less risk of hypoglycemia, but you should still be cognizant of eating carbs.
Biguanides (Metformin) decrease the amount of glucose that is released from the liver. Hypoglycemia is unlikely because insulin secretion isn’t affected. It is best to take this medication with food to reduce the risk of upset stomach.
Knowing your limits
Medications can help you achieve control of your diabetes, but dietary management will always be at the foundation of treatment. There is no medication that erases the need to pay attention to what you eat. Simply put, you can out-eat any medication. Part 2 of this book gets to the nitty-gritty of carb counting. Use the information in this book to establish a reasonable carbohydrate plan with healthy diet principles. Monitor blood glucose and share the results with your doctor. Work with your healthcare providers to determine and monitor your medication needs.