blood glucose levels

How to Calculate Bolus Insulin Dosing for Protein

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People with diabetes who use insulin with meals are probably well-aware of the importance of accurately counting carbohydrates in order to calculate their bolus insulin dose. Fewer may be aware that protein can also have a significant impact on their blood glucose level.

In a process called gluconeogenesis, our bodies can actually make glucose from non-carbohydrate sources. Unlike carbohydrates, which are quickly broken down to glucose, protein conversion to glucose takes place over several hours, and thus can have a less pronounced, but a considerable effect, on blood glucose levels.

metabolism summary

For a long time, it was believed that the rate of gluconeogenesis is quite stable. In fact, recent studies have pointed out that shifts in the rate of gluconeogenesis occur based on the individual’s diet.

When it comes to administering insulin for protein, the need for this may be particularly apparent in those who follow a low carbohydrate diet. This is because, while some protein is always converted to glucose, the rate of this process is higher when fewer carbohydrates are taken in.

So how does one determine whether they need to inject insulin for protein? Figuring this out will take some careful observation of blood glucose trends for several hours after a meal as well as some trial and error.

Many people who follow a low carbohydrate diet will always take some bolus insulin to cover protein intake. Websites or apps such as Calorie King can be very useful in learning to calculate the protein content of a meal. Most individuals will start with a trial insulin dose that covers anywhere from 20% – 50% of the protein consumed.

What this means is that the protein content will be estimated and anywhere from 20% – 50% of the protein will be counted as if it were carbohydrate. For example, if one consumes 4 oz (~113 g) of chicken, and chicken is approximately 25% protein by weight, one would estimate that they are likely consuming approximately 30 g of protein. Thus, one may take insulin to account for 6 g (20%) to 15 g (50%).

bolusing for protein

Those individuals who consume more carbohydrates will likely experience a lower rate of gluconeogenesis and the need to administer bolus insulin for protein may be less apparent, or only apparent when a very high-protein meal is consumed. Many people who eat a high-carbohydrate diet chose to only bolus for protein in these circumstances.

Whether using an insulin pump or multiple daily injections, most administer the protein bolus one to two hours after their meal, or when they start to see an upward trend on their CGM. Others have found that regular (R) insulin better matches the protein peak and administer it at the start of their meal. It may be a good idea to try different approaches to see what works best for you, starting conservatively, and increasing the protein bolus if the blood glucose level still increases several hours after the meal.

THIS WEARABLE PATCH USES SWEAT TO MONITOR BLOOD GLUCOSE LEVELS

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diabetes patch

Hui Won Yun, Seoul National University

A dual-function patch for diabetes

Researchers have created a patch that both monitors blood glucose and delivers medication when needed.

People with diabetes prick their fingers multiple times a day to check their blood glucose levels, and dose themselves daily with injections of insulin. This monitoring is crucial, as rises in sugar levels in the blood can, over time, increase a diabetic patient’s risks of developing long-term complications from the disease. But this pricking and injecting can also be painful and tedious, making it harder for people to follow their doctor’s orders.

Over the past few years, researchers have been working on more convenient and less intrusive ways for people to monitor their diabetes. Now, a group of international researchers led by Dae-Hyeong Kim from the Institute for Basic Science in Seoul, South Korea have created a dual patch that can both monitor blood glucose levels and deliver medication that reduces high sugar levels when they occur. Their work was published today in Nature Nanotechnology.

How Does It Work?

The technology uses graphene, an extremely strong and flexible material made of carbon atoms and often used in wearable devices. In the past, scientists have used graphene to create similar patches, but certain properties of graphene have made it difficult to detect changes in sugar levels. To improve its abilities, the researchers in this study added gold particles and a surrounding gold mesh to the graphene.

When a diabetic person puts the patch on, the device captures sweat from the person’s skin. Sensors within the patch pick up on the sweat’s pH and temperature changes that signal a high glucose level. Once a high level is detected, heaters in the patch start to dissolve a layer of coating, exposing microneedles that then release a drug called metformin that can regulate and reduce high blood sugar levels. (If you’re curious, a microneedle injection would feel like either nothing at all or just a slight tingle.) Blood sugar readings are also wirelessly transmitted to a mobile device for the person to read and monitor.

The researchers researchers hope this combination of monitoring and drug delivery will help diabetics be able to better regulate the fluctuations of blood glucose throughout the day.

diabetes patch 2

Hui Won Yun, Seoul National University

The patch uses graphene, a strong and flexible material often used in wearable devices.

Next Steps

The researchers tested the patch on diabetic mice as well as two adult men with diabetes. In the future, before they can test the patch on more people, the researchers will have to scale up the drug delivery part of the device to inject human-sized doses.

In a news and views article that accompanied the paper, Richard Guy, a professor of pharmaceutical sciences at the University of Bath said that this patch has moved the field closer to the “coveted prize” of a non-invasive feedback system that combines monitoring and responsive drug delivery. However, he also acknowledged that more research needs to be done to answer key questions, including whether the device can stand up to increased sweat induced by vigorous exercise, whether the device can do this type of monitoring for a full 24 hours, and, most importantly, whether the drug delivery component can be scaled up and be able to deliver metformin “without an unfeasibly large number of microneedles and/or an unacceptably large patch.”

If the researchers can answer these key questions, this could mean a significant improvement in the health of diabetic patients.

 

Diabetes in Midlife Linked to Faster Cognitive Decline

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Diabetes in midlife is associated with an increased rate of cognitive decline over a 20-year follow-up, a new study shows.

And while patients with diabetes at midlife had a steeper cognitive decline than patients without diabetes, greater loss of cognitive function was also seen for patients who had prediabetes with only modestly raised blood glucose levels.

“These data suggest that primary prevention of diabetes or glucose control in midlife may protect against later-life cognitive decline,” the authors conclude.

The effect was greater for patients with a longer duration of diabetes, highlighting the importance of intervention as early as possible.
“The implication is that we have seen over a 20-year period what happens before the development of dementia,” coauthor A. Richey Sharrett, MD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, commented to Medscape Medical News. “This gives patients and care providers a window of opportunity to do something about it.”

Diabetes can be prevented in some cases or at least delayed by lifestyle improvements, and when diabetes has already occurred, it can be controlled, he added. “Our results give additional reasons to do this. People dread dementia more than anything else. The idea that dementia can be delayed or reduced is a strong motivator. This is a pretty good reason to keep blood sugar in control.”

The findings are published online December 2 in Annals of Internal Medicine.

A “Window of Opportunity”

The study, lead by Andreea M. Rawlings, MS, also at Johns Hopkins, analyzed data from the Atherosclerosis Risk in Communities (ARIC) study, which prospectively followed 15,792 middle-aged adults from 1987 to 2013.
The current analysis is based on 13,351 participants (mean age at baseline, 57 years); 56% were female, 24% were black, and 13.3% had diabetes.

Cognitive testing was performed at visit 2 (1990 to 1992), visit 4 (1996 to 1998), and visit 5 (2011 to 2013) and involved three tests: the Delayed Word Recall Test, the Digit Symbol Substitution Test of the Wechsler Adult Intelligence Scale-Revised, and the Word Fluency Test. From these, a global cognitive Z score was calculated.

Blood glucose levels were calculated as hemoglobin A1c (HbA1c) values from stored whole blood samples.

Of the initial cohort, 17% did not attend any follow-up visits, leaving 10,720 individuals who attended visit 4 and 5987 who attended visit 5. The median duration of follow-up was 19.3 years.

Results showed that individuals with diabetes had a 19% greater decline in global cognitive Z score: a decline of 0.92 vs 0.78 for persons without diabetes (a difference of 0.15).

The authors estimate that this difference in Z score is equivalent to an age difference of 4.9 years older or the difference in cognitive performance of a 60-year-old person vs a 55-year-old person if they are otherwise similar.

 Persons without diagnosed diabetes but with an HbA1c level of 5.7% to 6.4% at baseline also had significantly more cognitive decline over 20 years (adjusted difference in global cognitive Z score of –0.07) than persons with an HbA1c level less than 5.7%.

The greatest decline was found in patients with poorly controlled diabetes, defined as an HbA1c level of at least 7.0%, who had a larger decline than those with better controlled diabetes with an HbA1c level less than 7.0% (adjusted global Z score difference, –0.16; P = .071).

Diabetes duration seemed to be a factor, with a greater cognitive decline late in life for participants with longer-duration diabetes.

“Critical Aspect of Successful Aging”

“Maintaining cognitive function is a critical aspect of successful aging and ensuring a high quality of life,” the authors write. “Diabetes and glucose control are potentially modifiable and may offer an important opportunity for the prevention of cognitive decline, thus delaying progression to dementia. At the population level, delaying the onset of dementia by even a couple of years could reduce its prevalence by more than 20% over the next 30 years.”

Dr Sharrett explained to Medscape Medical News that other studies have linked diabetes to dementia but that this is the largest, with the longest follow-up.

“But what really sets it apart from other studies is that we measured change in cognition over time in diabetics and nondiabetics using the same tests in a standardized way,” he said. “This gives us assurance that our findings are real. In fact, I would say we are sure they are conservative.”

The study did not address possible mechanisms, although exclusion of persons who had a stroke after baseline attenuated the results slightly, suggesting that stroke partially mediates the association.

Dr Sharrett suggested that elevated blood glucose could affect cognition in different ways. While there is obviously a link between diabetes and vascular disease that could lead to vascular dementia, he believes that raised blood glucose levels may also affect the Alzheimer’s type of dementia.

“There is substantial controversy as to whether diabetes affects β-amyloid deposits or tangles that are the classical hallmarks of Alzheimer’s dementia,” he commented.

“It is difficult to ascertain what the cause of dementia is,” he added. “Postmortem studies have shown that both Alzheimer’s and vascular pathology can often be present. While it is often thought that most dementia is related to Alzheimer’s disease and there has been disappointment that we haven’t been able to delay or prevent this yet, there is a sizable portion of dementia that is related to the vasculature and we can do something about that.”

“Our observations that diabetes duration and even prediabetes [are] associated with faster cognitive decline emphasize the importance of adopting a healthy lifestyle as soon as possible,” he concluded.

Diabetes in Midlife Linked to Faster Cognitive Decline

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Diabetes in midlife is associated with an increased rate of cognitive decline over a 20-year follow-up, a new study shows.

And while patients with diabetes at midlife had a steeper cognitive decline than patients without diabetes, greater loss of cognitive function was also seen for patients who had prediabetes with only modestly raised blood glucose levels.

“These data suggest that primary prevention of diabetes or glucose control in midlife may protect against later-life cognitive decline,” the authors conclude.

The effect was greater for patients with a longer duration of diabetes, highlighting the importance of intervention as early as possible.
“The implication is that we have seen over a 20-year period what happens before the development of dementia,” coauthor A. Richey Sharrett, MD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, commented to Medscape Medical News. “This gives patients and care providers a window of opportunity to do something about it.”

Diabetes can be prevented in some cases or at least delayed by lifestyle improvements, and when diabetes has already occurred, it can be controlled, he added. “Our results give additional reasons to do this. People dread dementia more than anything else. The idea that dementia can be delayed or reduced is a strong motivator. This is a pretty good reason to keep blood sugar in control.”

The findings are published online December 2 in Annals of Internal Medicine.

A “Window of Opportunity”

The study, lead by Andreea M. Rawlings, MS, also at Johns Hopkins, analyzed data from the Atherosclerosis Risk in Communities (ARIC) study, which prospectively followed 15,792 middle-aged adults from 1987 to 2013.
The current analysis is based on 13,351 participants (mean age at baseline, 57 years); 56% were female, 24% were black, and 13.3% had diabetes.

Cognitive testing was performed at visit 2 (1990 to 1992), visit 4 (1996 to 1998), and visit 5 (2011 to 2013) and involved three tests: the Delayed Word Recall Test, the Digit Symbol Substitution Test of the Wechsler Adult Intelligence Scale-Revised, and the Word Fluency Test. From these, a global cognitive Z score was calculated.

Blood glucose levels were calculated as hemoglobin A1c (HbA1c) values from stored whole blood samples.

Of the initial cohort, 17% did not attend any follow-up visits, leaving 10,720 individuals who attended visit 4 and 5987 who attended visit 5. The median duration of follow-up was 19.3 years.

Results showed that individuals with diabetes had a 19% greater decline in global cognitive Z score: a decline of 0.92 vs 0.78 for persons without diabetes (a difference of 0.15).

The authors estimate that this difference in Z score is equivalent to an age difference of 4.9 years older or the difference in cognitive performance of a 60-year-old person vs a 55-year-old person if they are otherwise similar.

Persons without diagnosed diabetes but with an HbA1c level of 5.7% to 6.4% at baseline also had significantly more cognitive decline over 20 years (adjusted difference in global cognitive Z score of –0.07) than persons with an HbA1c level less than 5.7%.

The greatest decline was found in patients with poorly controlled diabetes, defined as an HbA1c level of at least 7.0%, who had a larger decline than those with better controlled diabetes with an HbA1c level less than 7.0% (adjusted global Z score difference, –0.16; P = .071).

Diabetes duration seemed to be a factor, with a greater cognitive decline late in life for participants with longer-duration diabetes.

“Critical Aspect of Successful Aging”

“Maintaining cognitive function is a critical aspect of successful aging and ensuring a high quality of life,” the authors write. “Diabetes and glucose control are potentially modifiable and may offer an important opportunity for the prevention of cognitive decline, thus delaying progression to dementia. At the population level, delaying the onset of dementia by even a couple of years could reduce its prevalence by more than 20% over the next 30 years.”

Dr Sharrett explained to Medscape Medical News that other studies have linked diabetes to dementia but that this is the largest, with the longest follow-up.

“But what really sets it apart from other studies is that we measured change in cognition over time in diabetics and nondiabetics using the same tests in a standardized way,” he said. “This gives us assurance that our findings are real. In fact, I would say we are sure they are conservative.”

The study did not address possible mechanisms, although exclusion of persons who had a stroke after baseline attenuated the results slightly, suggesting that stroke partially mediates the association.

Dr Sharrett suggested that elevated blood glucose could affect cognition in different ways. While there is obviously a link between diabetes and vascular disease that could lead to vascular dementia, he believes that raised blood glucose levels may also affect the Alzheimer’s type of dementia.

“There is substantial controversy as to whether diabetes affects β-amyloid deposits or tangles that are the classical hallmarks of Alzheimer’s dementia,” he commented.

“It is difficult to ascertain what the cause of dementia is,” he added. “Postmortem studies have shown that both Alzheimer’s and vascular pathology can often be present. While it is often thought that most dementia is related to Alzheimer’s disease and there has been disappointment that we haven’t been able to delay or prevent this yet, there is a sizable portion of dementia that is related to the vasculature and we can do something about that.”

“Our observations that diabetes duration and even prediabetes [are] associated with faster cognitive decline emphasize the importance of adopting a healthy lifestyle as soon as possible,” he concluded.

Jardiance to treat type 2 diabetes available by prescription in US

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Empagliflozin tablets are now available by prescription in pharmacies across the United States, according to a statement from Boehringer Ingelheim Pharmaceuticals and Eli Lilly and Company.

Designed for treating adults with type 2 diabetes, Empagliflozin (Jardiance, Lilly) has swiftly made it onto shelves, following an FDA approval at the outset of August.

Walgreens, Rite Aid, Kroger and other leading chains and independent retailers are carrying the new therapy, according to the statement, which improves glycemic control when used as an adjunct to diet and exercise.

Taken once-daily in 10 mg or 25 mg doses, the sodium glucose co-transporter-2 (SGLT2) inhibitor blocks reabsorption of glucose in the kidney, thereby increasing glucose excretion and lowering blood glucose levels.

The therapy is not designed for patients with type 1 diabetes or diabetic ketoacidosis. Jardiance can cause dehydration that might lead to a drop in blood pressure and may cause patients to become dizzy or faint, the release stated.

FDA approval was granted following a large clinical program involving more than 10 multinational trials and more than 13,000 adults with type 2 diabetes, with results showing significant HbA1C reduction as a treatment along or combined with metformin, sulfonylureas, insulin and pioglitazone.

Urinary tract infections and vaginal yeast infections were the most common adverse reactions reported, according to the statement, and hypoglycemia was reported more commonly in patients also receiving sulfonylurea or insulin.