The Children with Diabetes Friends for Life conference is well underway in Orlando and I’m here with my family. I have time now only for some quick updates so here it goes.
1.When I first saw Jeff Hitchcock and Laura Billetdeaux, I felt like I was seeing celebrities. What they and their team pull off with this conference is amazing, and it’s really wonderful to see it all in action.
2. Seeing all of the green wristbands on the people with diabetes makes me want to cry – with happiness and with sadness.
3.The children’s programs are terrific. My kids are having a lot of fun and the other kids seem to be very happy as well.
4. The keynote breakfast this morning was in a room whose temperature reminded me of Michigan winters. (Note: If there’s no fridge in your room, store insulin in the ballroom.)
5. The names of the ballrooms – Crystal, Palms, Cypress – are making me think of the “Love Boat.” Aloha deck later tonight, anyone?
6. Jeff Hitchcock’s welcome speech this morning: “Why are we here? To make a difference in the life of someone we love.”
“We don’t do diabetes for a perfect A1c, but so our kids will grow up happy healthy and dancing on the beach.” Jeff then showed pictures of his newlywed daughter in her wedding dress and as he teared up said, “There’s just a little bit of onion in the room here.”
7. Jeff’s speech was followed by a talk from Tom Karlya, “Diabetes Dad.” Some highlights from Tom’s presentation:
“It’s what you do when the curveball is thrown!”
“It stinks to have this disease in your family and in yourself. But you have to do something about it.”
“There’s not one person who has made more mistakes at this than me.” (Followed by a story about the time he packed his fourth grade daughter’s lunch and instead of diet cola he gave her a can of Coor’s Light. He learned about his mistake when he received a call from the school.)
“Teach yourself to learn! Knowledge is power.”
“You need to keep learning because diabetes does not care.” “Just don’t do nothing. It’s not a matter of either/or…”
The welcome sign of CWD FFL 2000 said “Welcome children with diabetis”
Tom then showed an inspirational video from the Barcelona Olympics in 1992, when runner Derek Redmond tore his hamstring mid-race. Redmond’s father, motivated by strong love, left the stands and ran onto the field and helped his son finish the race despite the pain and tears.
“Are you in the stands or in the race?”
”Don’t carry your kids the whole time. Give them the tools to stand up on their own and let them finish the race.”
8. Jen Block on Carbs:
Here are my notes on this lecture. I think I hit all of the main points. If I forgot anything please add.
-FDA regulation 21 cfr101.9 specifies the variants for class 11 naturally occurring nutrients which includes the total carb content is allowed to be off by 20% (Author’s note: So, apparently carb counts on labels can be off by 20%, and our meters can be off by 20%. The cynic in me is now thinking: Each and every bolus is a total gamble. If you can’t figure out how to bolus, it’s not your fault!!!)
-There are food scales that are small enough to fit in purses. There’s a smart scale called Eat Smart Food Scale.
-Is it practical to weigh all the time? No, but it can be used as a means to gain familiarly with food.
-Different ways to estimate carbs:
CFM carb factor method
Portion Estimation (e.g. adult’s fist = 1 cup), Long sandwich 8 grams per inch, Pizza 30 grams per hand sized piece (fingers together)
(Odd slide displayed of fist with slice of cantaloupe, 20g. Another odd slide of pizza and a hand with fingers together next to pizza (1 1/3 hand =40 grams)
Carb counting tools:
Calorie King calorieking.com also in a smart phone app (at least half the room uses calorie king)
Lenny the Lion: games aimed at kids, teaches carb counting
USDA Food Composition: www.nal.usda.gov/fnic/foodcomp/search
Audience recommended and Sanofi’s gomeals.com
Do different carbs impact glucose differently?
All carbs (except fiber) convert to glucose eventually
Glycemic Index (GI) reflects magnitude of BG rise for first two hours following ingestion
GI number is percent or rise relative to pure glucose 100% glucose is in bloodstream within 2 hours
The GI is based on feeding measured portions of food with 10-50 grams of carb to 10 people without diabetes and monitoring BG response over 2 hours.
Most GI studies were done in Canada and Australia.
Note – consuming a mixed meal (carb,p rotein, fat) will blunt the post-prandial excursion.
Rates of conversion: moderate GI is 56-69, High is 70 or more
Very few in audience us GI when blousing. If they use it, they use Low, Moderate and High, not actual numbers
A banana has a GI of 70. But it changes by how ripe the banana is.
Bowl of chocolate ice cream: A low GI food because the fat slows it down. GI is 37
Corn: Gi 60 – moderate
What about fiber?
Fiber can slow down conversion of enzymes that work on starch slowing the conversion to glucose.
If a food contains more than 5 grams of fiber, subtract half the grams of fiber from the carbohydrate grams to get the total carbohydrate grams.
Small amounts of fiber may not make a difference. Need to get to 5 grams
Jen, “The bottom line: Fiber is good for you.”
Foods that are higher in fiber have a lower GI
What about fat and protein?:
They slow gastric emptying, which means they also slow the digestion of starch.
Jen: “For everyone, and especially children, carbs are very important energy source.”
What are possible causes of variable glucose response?:
Fat and protein content
Fasting, pre-meal BG
Degree of insulin resistance
Type and source of carb
Physical form (whole fruit vs.juice)
Type of starch (amylose is lower and amylopectin is faster)
Degree of processing (higly processed foods are digested faster)
Ripeness of food
Food preparation -cooking swells starch molecules and softens foods which speeds up rate of digestion
(Author’s Note: Everything is a possible cause of variable glucose response)
(Source:evert, 2012 and ADA nutrion recommendation and intervitons for diabetes, position statement diabetes care 31 (suppl 1) 2008)
Now you know the carb content… What Next?
Monitor BG with meter/CGM to assess the impact of the food on BG
Know Your Insulin
The key to achieving post meal BG levels in target range is knowing theimpact of the meal on your BG and how best to match the insulin to the food’s impact on BG
Insulin onset time for currentily available rapid-acting insulin is 5-15 minues (so if eating fast acting carbs there might be a mismatch)
If you doubt the impact of carbs on glycemic control… more than 1 missed meal bolus/week was associated with ½% increase in A1C
-Burdick, Chase, Pediatrics 113:e221, 2004
Insulin’s peak is between 30-90 minutes
Duration of insulin is 4-6 hours
Matching insulin to carbs, the real challenge
Study: Glucose three hours after meal was lower with pre-meal insulin given 15 mn prior or immediately before meal rather than after
If low before meal, treat low, then inject meal insulin
Timing of premeal insulin should be based on clinical experience and may not be advisable when:
Timing of meal is not certain or carb intake is not predictable (young children who might not eat food given)
Bolus caluclators on pumps can track insulin on board – really helps
Extended/square wave bolus -give insulin over time, works well for low carb meals high in fat/protein and for gastroparesis
Combination/dual wave bolus
What about eating pizza? It takes a lot of work!
Carbs are main factor in diet impacting glycemic control
Carbs are an efficient source of energy for the body (“we need them”)
GI:different carbs impact glucose differently
Fast and protein slow down gastric emptying and thus slow down digestion of starch
If you simply count carbs and not fat protein you may gain weight.
“What you’re doing every day is challenging and it’s challenging for a lot of reasons!”
9. I attended a session on Pregnancy and Motherhood with T1D led by Kelly Close (Diatribe), Kerri Sparling (sixuntime), and Melissa Balland (Sweetlyvoiced). I will report on that when I have time.
10. I love meeting all of you. Being here is an amazing experience.