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Clinical Nutrition 3 > Intensifying Diabetes > Flashcards

Intensifying Diabetes Flashcards

1
Q

What is intensive therapy?

A

-A system of matching insulin doses to food, activity and life events using individualized adjustment guidelines based on glucose results

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2
Q

What kind of insulin therapy is intensive therapu

A

-Basal-Bolus Insulin Therapy (BBIT)

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3
Q

How is BBIT be administered?

A
  • Multiple daily-injections (MDI)

- Continuous subcutaneous insulin infusion

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4
Q

Who can use intensive therapy?

A

-Type 1, Type 1.5, Type 2 and gestational

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5
Q

What is Type 1.5?

A

-LADE (Late-Autoimmune Diabetes of Adults) looks like Type II initially, but will require insulin earlier. They will also develop anti-bodies similar to type I

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6
Q

What is a key concept with diabetes and intensive insulin therapy?

A

Individualization of the diet is key

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7
Q

What are the medical benefits of IT?

A
  • 45% reduction in microvascular complications (DCCT)

- 42% risk reduction in cardiovascular events (EDIC)

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8
Q

Other benefits of IT?

A
  • Insulin therapy can be integrated into the individuals preferred lifestyle habits
  • Quality of life is improved
  • Overall better control
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9
Q

What are the disadvantages of intensive therapy?

A
  • More injections
  • Requires CHO counting
  • Frequent monitoring(4x/week) is necessary
  • Weight gain
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10
Q

3 reasons for weight gain in IT?

A
  • Tighter control = less glycosuria (retaining more sugar)
  • Extra insulin for extra food
  • Over treating of hypoG
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11
Q

Discuss overtreating hypoG

A

We know the standard CHO amount to treat HypoG is 15 g, however many people will feel unwell during a hypo and immediately eat as much sugar as they can. This is linked to weight gain and counterintuitive to their goals.

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12
Q

When is a lower A1C target of = 6.5% recommended? Why?

A
  • Adults w/ type II diabetes NOT on insulin secretagogues or insulin
  • Likely newly diagnosed
  • A1C at this level may increase risk of HypoG if on these drugs
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13
Q

A1C target for most adults with type I or II diabetes?

A

= 7.0%

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14
Q

A1C target for functionally dependant?

A

7.1-8.0%

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15
Q

A1C target for recurrent severe hypoglycemia and/or hypoglycemia unawareness, limited life expectancy or frail elderly w/ dementia?

A

7.1-8.5%

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16
Q

In palliative/comfort care how should A1C be addressed?

A
  • No specific target

- Avoid higher A1C to minimize symptomatic hyperglycemia and acute/chronic complications

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17
Q

To achieve a target A1C of = 7%, what are the targets for preprandial PG and 2-h postprandial PG?

A
  • 4.0-7.0 mmol/L

- 5.0-10.0 mmol/L

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18
Q

If A1C is not at target, what are the target preprandial PG and 2-h postprandial PG?

A
  • 4.0-5.5 mmol/L
  • 5.0-8.0 mmol/L
  • -> More strict blood glucose targets
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19
Q

When A1C is not optimal, there are more strict BG targets. What should be considered?

A

Balance benefit against the risk of hypoglycemia

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20
Q

(T/F) we can always realistically normalize blood glucose

A

F

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21
Q

Diabetes is a combination of genetics and environment. What else can impact a patients management of diabetes?

A
  • Work environment (i.e. busy shift and cannot do injection
  • Family dynamics (i.e. working parents, is there support?)
  • Education level(i.e for CHO counting)
  • Cultural beliefs
  • Finances, not all medication is covered
  • Mental illness
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22
Q

2 key factors which lead to failure to normalize blood glucose in Type II patients?

A
  • Myths regarding insulin therapy leading to the underutilization of insulin
  • Inadequate understanding of the consequences of poor control
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23
Q

What are myths regarding insulin utilization?

A
  • It is a death sentence
  • They have failed
  • They are extremely sick
  • -> The truth is that insulin is simply another medication, which is extremely effective in delaying the onset of other complications
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24
Q

What is the mean time to inulin titration?What is the consequence?

A
  • 9.2 yers
  • This is currently TOO late, and is not aggressive enough
  • We need earlier intervention
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25
Q

What are the two targets of therapy to achieve normal A1C? What is essential?

A

-Fasting PG
-2-hr PP PG
Monitoring is essential

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26
Q

Differentiate between monitoring BG values with a glucometer vs. continuous glucose monitoring

A
  • Glucometer is only getting instantaneous screenshots or “frames” of BG during the day
  • CGM will continously measure blood glucose, and we can have a “movie” of how BG changed throughout the day
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27
Q

(T/F) Flash glucose monitoring allows us to continually measure BG

A

F

Similar to glucometer, but easier to do

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28
Q

In people with type II diabetes, what is PPG and independant risk factor for? Has the same been demonstrated for type I diabetes?

A

Myocardial Infarction

-Not yet, but can be inferred as hyperglycemia ca acutely alter normal homeostasis.

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29
Q

What are 7 factors which can alter PPG?

A
  • Pre-meal blood glucose and timing of injection
  • GI of food
  • Large volume, high fat/pro/fibre
  • Time of day
  • Stress, illness, exercise and hormones
  • Gastroparesis
  • Adequate basal insulin
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30
Q

Discuss PPG and time of of day

A
  • Post-breakfast peaks are often the highest and “most difficult” to bring down - require more insulin.
  • Upon waking up our GH and cortisol levels are the highest, therefore we have insulin resistance in the early AM
  • We also tend to eat more refined CHOs for breakfast
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31
Q

Discuss PPG and gastroparesis

A
  • Can offset the onset of insulin and expected digestion of the meal
  • Can cause either hyper or hypoglycemia depending when insulin is taken
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32
Q

How can we asses if there is adequate basal insulin?

A

If they skip a meal, their basal insulin should keep BG steady.
-If BG creeps up, we may need to increase basal insulin.

33
Q

_____ is the largest glycemic excursion of the day

A

Breakfast

34
Q

Administration of rapid insulin analogs ____ mins before mealtime will result in lower post-prandial glucose excursions and more time spent in the ____ mmol/L range without increased risk of hypoglycemia.

A
  • 15

- 3.5-10.0

35
Q

The postprandial glucose has a mean peak time of _____

A

75 minutes

36
Q

When do rapid-acting insulin analogs display a maximum effect after subcutaneous injection?

A

~100 mins

37
Q

When will the height of the postprandial glucose excursion be minimized?

A

When the insulin peak action is synchronized with the glycemic excursions after a meal

38
Q

What is key about giving bolus insulin?

A

The timing

39
Q

Which type of insulin may be most effective for a synchronized peak with the glycemic excursion?

A
  • Faster-acting

- Can inject right at time 0 (beginning of meal)

40
Q

Why is it so hard for people to achieve their blood sugar targets?

A

The fear of hypoglycemia

41
Q

What is common behaviours observed in patients with hypo fears?-

A
  • Often very scared of night-time reactions and will keep BG high at bedtimes “just in case”
  • Over-treat hypoG
42
Q

“Morning-after” symptoms of hypoG?

A
  • Wicked morning headache
  • Foggy head
  • Waking up w/ messed up blankets
  • Nightmares or vivid dreams
43
Q

Explain why having one hypo reaction will increase the risk for another

A
  • During a hypo, there is a rapid utilization of counterregulatory hormones glucagon, cortisol and adrenaline
  • These hormones are rapidly depleted, and take time for store to replenish
  • Physiologically disadvantaged to increase BG after a hypo
44
Q

What are important questions to aks someone after having a hypo?

A
  • When did it happen?
  • Did they check their BG when symptomatic?
  • How are they treating?
  • Why did it happen?
45
Q

Explain how alcohol cause hypo

A

If we have low blood sugar, glucagon in the liver will function to increase BG. If there is alcohol, it will be detoxing in the liver, sparing the function of glucagon.

46
Q

Why is A1C not always representative of good glucose control?

A

Because A1C is the AVERAGE

-We don’t know if this i the average between crazy highs and crazy lows

47
Q

What is important to communicate about A1C to patients?

A
  • That average blood glucose and A1C are NOT the same things
  • A1C is an indicator of long-term glucose control over the pat 3 months
  • Average blood glucose is the actual measure and average of Bg
48
Q

What does Total Daily Dose (TDD) mean in Type I diabetes?

A
  • Includes both basal and bolus insulin needs

- Ideally 50% of total dose given as basal insulin and 50% as rapid (bolus)

49
Q

What is the typical Type I adult diabetic insulin dosage?

A

0.3-1.0 units/kg/day

50
Q

When is 0.3 units/kg used?

A

New onset of type I

51
Q

Why is such a low insulin dose used in new onsets of type I?

A
  • They likely have some residual pancreatic function and insulin production
  • “Honeymoon” period where in 1-2 year they will require more insulin
52
Q

Average insulin dosage in Type I diabetes?

A

0.5-0.7 units/kg/day

53
Q

Insulin dosage in young adults (age 18-21) Type I DM?

A
  • 0.7-1.0

- Higher due to “still growing” higher GH causing insulin resistance

54
Q

Recommended adult dosage of insulin if HBW?

A

0.5 units/kg

55
Q

Recommended adult dosage of insulin if overweight?

A

0.7 units/kg

56
Q

Recommended adult dosage of insulin if obese with A1C >9%?

A

1.0 units/kg

57
Q

What does the Insulin to Carb ratio tell us?

A

How many grams of CHO are “covered” by 1 unit of
insulin
-The ratios vary at meals, and the strongest ratio is usually at breakfast (“tighter” carb ratio)

58
Q

I:C when TDD > 40 units total?

A

500/TDD = 1 unit: ___ g CHO

59
Q

I:C when TDD < 40 units total?

A

450/TDD = 1 unit: ___ g CHO

60
Q

How should we compare I:C with?

A

With weight requirement formula

-Then use clinical judgement

61
Q

What is the weight formula for I:C ratio?

A

(5.7 x wt) / TDD = 1 unit: ___ g CHO

62
Q

What is the sensitivity/correction factor?

A

The drop in mmol/L that each unit of rapid insulin will provide

63
Q

What is the sensitivity/correction factor useful for?

A

Correcting glucose once a target is set. allows for better control

64
Q

How is ISF estimated?

A

100/TDD = ISF

65
Q

How can ISF be used so patients can calculate their own correction insulin dosages?

A

(Actual BG - target BG) / Rounded off ISF

66
Q

What are they 4 rules of good blood glucose control ?

A
  • Check A1C and ensure it is a true value
  • Consider hypo
  • See if basal is adequate
  • Bolus: look at mealtimes 2hr post to evaluate carb:ration
67
Q

When may A1C be invalid?

A
  • Anemia
  • Blood loss
  • High and lows providing an acceptable “average”
68
Q

What should always be treated first/prioritized when monitoring patient BG?

A

-Hypoglycemia

69
Q

When should their not be a difference of more than 2 mmol/L for BG?

A
  • At night-time
  • There is only basal insulin acting, therefore no other factors should affect blood glucose
  • Adjust basal insulin if not at target
70
Q

How can we ensure bolus insulin is titrated properly?

A

-Aim for no more of a 3 mmol/L elevation after meals

71
Q

What is self-management education (SME)?

A

A systematic intervention that involve active patient participation in self-monitoring of health parameters and/or decision making

72
Q

What does empowering patients through self-management education improve?

A
  • A1C and quality of life
  • Guides them towards making informed decisions
  • Enables and enhances problem-solving skills
73
Q

What are the basic knowledge skills that all patient should know?

A
  • SMBG
  • Medication adjustment
  • Problem solving and identifying
74
Q

What is lipohypertrophy?

A

A lump under the skin caused by the accumulation of extra fat at the site of many subcutaneous injections of insulin.

75
Q

What are the consequences of lipohypertrophy? What should we recommend?

A
  • Unsightly, mildly painful and may change the timing or completeness of insulin action
  • Rotate injection sites often
76
Q

What would be a concern about changing insulin injection sites due to lipohypertrophy?

A
  • With lipohypertrophy, the insulin release is slow and incomplete
  • Therefore, if we move to a new site, there will be more sensitivity
  • May risk hypoglycemia
  • May have to reduce insulin medication
77
Q

A patient has an average CHO intake of 56 g at breakfast with an average insulin administration of 4 units. What is the CHO ratio?

A

56 g CHO/4 Units insulin = 14 g CHO per unit of insulin

78
Q

When is it a good time to calculate CHO ratios?

A
  • When the patients blood glucose is well controlled

- When the blood sugar is in target before a meal an doesn’t rise more than 3 mmol/L at 2hours post meal

Clinical Nutrition 3 (30 decks)

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