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Insulin Education Often Falls to Dietitians

Elizabeth Thompson Beckley

General practitioners, family doctors, even internists sometimes don't knowa lot about insulin, and the task of helping a diabetic patient manage insulintherapy may very well fall to the dietitian, says Alison B. Evert, RD, CDE, ofthe Joslin Diabetes Center, an education affiliate of Swedish Medical Centerin Seattle.

At the American Dietetic Association's Food and Nutrition Conference andExpo, held October 22–25 in St. Louis, Mo., Evert offered attendees anoverview of the latest in basal and bolus insulin therapy management.

"THINK LIKE A PANCREAS. IF YOU CAN DETERMINE THE AMOUNT OFCARBOHYDRATES IN A MEAL, YOU CAN DETERMINE THE AMOUNT OF INSULINNEEDED."

Basal, or "baseline," insulin, which most healthy adultssecrete at about 0.5–1 unit/hour, accounts for about 50% of the body'sinsulin production, she explains, and helps control blood glucose levelsovernight and between meals. Bolus insulin accounts for the other 50% and issecreted in two phases when blood glucose levels rise above 100 mg/dl. In thefirst phase, the body releases insulin about 15 minutes after a meal isconsumed. The second phase involves a continued release of insulin over1.5–3 hours, depending on how much fat is in the meal.

Evert described many of the most commonly prescribed insulin products thatattempt to mimic normally functioning beta-cells' prandial secretion for bolusinsulin and the 24-hour effect of basal insulin. She detailed methods ofcalculating the insulin-to-carbohydrate ratio used to determine anindividual's insulin sensitivity and guidelines for blood glucose correctionbased on blood glucose targets established by a patient's health careprovider.

Evert also explained the importance of carbohydrate counting to match orcover the anticipated postprandial blood glucose excursion with rapid-actinginsulin analogs. Counting carbohydrates allows for better glucose control andgives patients more flexibility with food choices, Evert says.

"It allows patients to fit insulin to their lifestyle" ratherthan change their lives to fit their insulin regime, she says.

But the dietetic professional cannot assume that all patients know what acarbohydrate is. Evert suggests dietitians focus on grams rather thancarbohydrate choices when educating patients because most new bolus insulincalculators are based on grams.

"Patients typically only need to know the carb content of commonfoods," she says, recommending that they learn about the foods they mostfrequently eat. For many people, there is not much variety beyond 3 differentbreakfasts, 5 lunches, and 7–10 dinners. Total carbohydrate content perserving includes fiber, starches, and sugars, but fiber can be subtractedbecause it is the starches and sugars that result in the postprandial rise inblood glucose, Evert notes.

BSIP/Phototake

Evert reminded attendees to ask their patients if they know how insulinworks, because many may know about onset action but not about peak action.

"Think like a pancreas," she says. "If you can determinethe amount of carbohydrates in a meal, you can determine the amount of insulinneeded."

However, this doesn't give patients a free pass to eat whatever they want,Evert warns. "They still need to eat healthful foods" and watchportion sizes.

Footnotes

FYI

The American Diabetes Association (ADA) Web site offers a brieftutorial on carbohydrate counting atwww.diabetes.org/for-parents-and-kids/diabetes-care/carb-count.jsp.The site includes links to FlashCarbs, a tool for learning the carbcounts of common and popular foods with flashcards, and Carb Counting MadeEasy, a book to help patients predict how the carbs in food will affecttheir blood glucose. Both are available at ADA's online bookstore:http://store.diabetes.org.

Another source for carbohydrate counting, The CalorieKing PocketCalorie, Fat and Carbohydrate Counter, is available online atwww.calorieking.com.

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