Expert Tips for Prescribing Exercise Q&A
with Gary Scheiner, MS, CDE

1. Question related to slide 33 (snacking to prevent hypo): Does this depend on their blood sugar before the workout--do you recommend that they check their blood sugar prior to exercise and have a snack if it is at a certain level?

Very good observation! The amounts on the chart assume that the blood glucose (BG) is within the patient's target range pre-workout. If higher, less carb is needed. If lower, more is needed.

2. What are the hormones that are part of causing hyperglycemia during activity?

Predominantly adrenal hormones (epinephrine/norepinephrine) along with cortisol.

3. Do you find most people whose blood glucose rises during exercise have type 1 vs. type 2 diabetes?

Depends on the "insulin dependency" of the person with diabetes. Those who can still produce a fair amount of their own insulin can produce enough to compensate for the adrenaline rush.

4. What would be the best option for activity for someone on multiple daily injections to avoid both hypo and hyperglycemia?

I don't think there is a single activity that works best for everyone. Intensive activities have the propensity to cause more dramatic BG changes, so moderate intensities are probably best for achieving stable BG.

5. What education is recommended for patients that might be trying to follow ketone type diet that want to exercise, risk for ketosis and safety?

Lots and lots of hydration is going to be essential. Performance may be hindered somewhat with very-low-carb diets, but it can still be done if adequate insulin is taken and hydration is maintained.

6. For a person that experiences hyperglycemia post-exercise in the morning hours before eating breakfast - what would you recommend to prevent those glucose spikes?

They may need to take insulin proactively prior to the workout. A conservative dose of rapid insulin is usually best.

7. How do you use continuous glucose monitoring (CGM) technology around exercise?

CGM is a great tool for seeing the direction BG is headed going into the workout, as well as to ward off lows during exercise and evaluating post-workout patterns.

8. What about someone with diabetes taking steroids for asthma and exercising and taking insulin? Due to different peak times with steroids and insulin, how do you incorporate exercise with these 2 conditions when steroids are prescribed long-term on daily basis?

I'd start out assuming that the inhaler has no effect… apply the usual insulin adjustments and see what happens. If BG rises, adjust the insulin accordingly.

Advanced Carbohydrate Counting Q&A                                                             

Paula Clinton, RD, CDE

1. On the food label example, total carbohydrate is 13g but sugar plus dietary fiber = 6g. Where are the remaining 7g from?

The fiber and the sugars are shown separately on the food label but are already included in the total carbohydrate amount.  The sugar includes natural sugars like fructose, lactose plus added sugars. Carbohydrate fillers make up the rest of the total carbohydrate amount.

2.  Are whole fat dairy products considered unhealthy? They all seem to contain trans fat.

Whole fat dairy products get a bad rap because of the saturated fat they contain. This type of fat can increase blood cholesterol levels and increase risk of heart disease if consumed in excess quantities. No more than 7% of your total daily calories should come from saturated fats, according to the American Heart Association. If you consume approximately 2,000 calories per day that means your saturated fat limit is 16 grams or 140 calories from saturated fat. If you eat less or more than 2,000 calories, your saturated fat limit is respectively lower or higher than these values.

3. Do you look at glycemic load?

The glycemic load (GL) of food is a number that estimates how much the food will raise a person's blood glucose level after eating it. One unit of glycemic load approximates the effect of consuming one gram of glucose.  Glycemic load is based on the glycemic index (GI).  The GL is one thing to consider when managing blood glucose levels.

4. Where would you find details on sugar alcohols? 

If there are sugar alcohols in a product they will be listed on the label under carbohydrates.  There will be a separate line indicating the amount. Remember, these have already been counted in the total carbohydrate amount and may need to be subtracted from the total carb amount before the insulin dose is calculated. See food label below.

5. Can you talk about adjusting pre-meal insulin as a technique to manage the spike?

The rapid acting insulin we have today is still not as fast as we need it because carbohydrates begin to digest during the first bite, before the insulin starts to work. That is one reason we are back to the concept of the “pre-meal bolus.” Here is what we use in my office/clinic.

>100 mg/dL (5.6 mmol/L) – give insulin 10 min before eating
>150 mg/dL (8.3 mmol/L) – give insulin 15 min before eating
>200 mg/dL (11.1 mmol/L) – give insulin 20 min before eating
>250 mg/dL (13.9 mmol/L) – give insulin 25 min before eating
>300 mg/dL (16.7 mmol/L) – give insulin 30 min before eating

You don’t have to give the entire meal bolus; just give something to give the insulin a running head start. If you know a person always gives 8 units at breakfast, when that person wakes up, check BG and if >100 mg/dL (5.6 mmol/L) give the necessary correction dose and consider giving up to half of the breakfast dose. Obviously, this is not for everyone, use caution and common sense.

6. When subtracting fiber, do you have to make sure the fiber is listed from a whole grain source and is the FIRST ingredient on the food label?

As a rule of thumb, I have patients subtract all the fiber, regardless.

7. Comment: consider having patients compare plain yogurt and fruited yogurt to see the effect of added sugar.

This is a great idea! Helping patients to explore the vast differences between foods and the food labels is always an eye opening experience. They may still choose to have the yogurt with the fruit added but they will know the difference.

8. To cover one Fat Protein Unit (FPU) with insulin, you said that 1FPU = grams of carb that the particular individual covers with 1 unit insulin, correct? I.e. for a 1:10 ratio, if someone ate 40 grams CHO + 2FPUs, they would need 6 units of insulin, correct? And they dose that all at once, or at two separate times?

40g carb plus 2FPU’s; 1u for every 10g carb; 6 units of insulin total is the correct amount.  However, the delivery of this insulin is spread out. Based on the Warsaw formula I discussed in the presentation, the 4u for carb coverage would be given immediately as a normal bolus through the pump. The remaining 2FPU’s would be an extended delivery over 4 hours using the pump.

9. What is the best artificial sweetener to recommend (especially for T2 patients)? I've been hearing about the new "natural" sweeteners. Is there a benefit?

“The best,” I have to admit I don’t know. What I do know is they are all safe to use whether a person has diabetes or not. They should be used in moderation and are a better alternative than consuming the calories and carbohydrates from added table sugar.  

10. You mentioned there is an increase in insulin resistance in the morning. Do you know what causes this, and is it true for both type 1 and type 2?

Insulin resistance or being more resistant to insulin in the morning can be due to a variety of things. 

Release of growth hormone overnight, especially during puberty, can cause an increase in insulin resistance in the morning. This can cause a need for increased insulin overnight and a more aggressive insulin-to-carb ratio and correction factor at breakfast.

The apparent increased insulin requirement for breakfast compared with lunch or dinner can also be related to lack of residual insulin effect from a preceding meal than to any morning insulin resistance. 

The dawn phenomenon is the body's response to hormones released in the early morning hours. This occurs for everyone. When we sleep, hormones are released to help maintain and restore cells within our bodies. These counterregulatory hormones (growth hormone, cortisol and catecholamines) cause the glucose level to rise, thus increasing the need for additional insulin.

11. Do you use/recommend carb scales?

Yes! Not necessarily forever and ever, but it really helps to get a handle on portion and carbohydrate amounts. Scales are great to weigh pizza (very hard to carb count), bakery items, etc.

12. Is advanced carb counting for everyone?

NO!  As with everything in diabetes, you need to know your patient and individualize the treatment.  Some people would love to count carbs AND FPU (i.e. Engineer!).  And for others this method will not be appropriate or necessary. It’s your job to figure out who would benefit from advanced carb counting and tell them about it. 

13. What does “extended” mean in the example: 2FPU extended over 4 hours?

The only way to “extend” insulin delivery is to use an insulin pump. In the example above the 2FPU will be programmed via the pump to deliver the 2 units over the course of 4 hours (verses being given immediately in a bolus).

14. How do you separate the effect of basal insulin on post-prandial rise in BG?

Basal insulin patterns should be determined first by completing a basal rate check. During any 4 hour period of fasting (no carbs/no bolus insulin given), the BG should not go up or down more than 30 mg/dL (1.7 mmol/L) in either direction. Usually the day is broken down into 4 hour segments to complete over the course of a week or so. Once the basal rate is optimally set, it should maintain BG even if the person does not eat. After that, the insulin-to-carb ratio is calculated and tested to ensure the 2 hour post-prandial BG is less than 180 mg/dL (10 mmol/L) and the 3-4 hour post-prandial BG returns to the pre-meal target.

15. Any new, faster acting insulin in the pipeline?

Yes, but not in the US yet. An ultra-fast rapid-acting insulin aspart (Fiasp) has been approved by the European Commission, covering all 28 European Union member states. Fiasp has been approved in Canada and filed with FDA in the US.  Fiasp is a new-generation mealtime insulin that works faster and more like the natural physiological insulin response to meals. It has a similar safety profile to Novolog insulin in the US and NovoRapid in the UK and is approved for the treatment of diabetes in adults with type 1 or 2 diabetes as well as for use in insulin pumps.

16. There is a feeling that patients can eat 15-60g of carb at a meal. Is that too broad?

Again, everything in diabetes has to be individualized. Also, it depends on the type and amount of diabetes medications a person takes. That being said, I think it’s reasonable for people with diabetes to consume 15-60g of carbohydrates at one sitting. The best way to find out if it worked is to have the person check their BG before the meal and 2 hours after the first bite of the meal to see if they fall within their post-prandial target. The 2 hour post-prandial BG should be 180mg/dl or less.

17. Is there a specific amount of protein and fat a person should eat?

The American Dietetic Association has established dietary guidelines (2010), which sets energy, macronutrient, and micronutrient needs based on age. Recommended macronutrient proportions for adults (19 years and older) is: carb 45–65%, protein 10–35%, and fat 20–35%.

18. Have you ever considered using a straight bolus for the carbs and then using a temp basal rate over the next 3-6 hours? 

No, I have never done that simply because it seems like more work. I’m a firm believer in letting the pump do the work for you. The outcome of doing that is similar to a “combo bolus,” but without the extra step. I’m also a firm believer in…if it ain’t broke, don’t fix it. If that works for someone, great!

19. Am I understanding correctly that the FPU’s are either 1, 2, 3, or 4 units of insulin given over the time frame on slide 25, and the units don’t change by weight?

Yes, you understand correctly.  However, once again, everything is meant as a starting point and you need to help patients make adjustments from there. There absolutely is a difference in a 5 year old boy who weighs 30lbs and an 18 year old boy who weighs 150lbs. The FPU scale is meant for adults and needs to be tested by having patients check their BG at various times post meal. Remember to think of each patient as their own individual science project.

20. Can FPU apply without using an insulin pump?

The concept applies but would be very difficult to execute without an insulin pump.  This is truly meant for someone who is using a pump.

Answers to Questions:

Q: With so many people not being diagnosed with diabetes, why don't physicians add the A1c testing, so that we can prevent prediabetes from becoming T2D?

A: Good question! As we know an early diagnosis of type 2 diabetes as well as an early diagnosis of prediabetes is critically important to slowing the progression of the disease which really is a continuum. Prediabetes and type 2 diabetes, according to the American Diabetes Association’s diagnostic criteria (http://care.diabetesjournals.org/content/39/Supplement_1/S13.full.pdf+html), can be diagnosed with either an A1c measure or blood glucose measures. While the awareness of prediabetes is rising, it is still very low. All healthcare providers need to do whatever we can to raise awareness and provide the important message that early action can help reverse or, more likely, slow the progression of prediabetes to type 2 diabetes. Let’s not just depend on busy primary care providers. In addition, it’s the provision of appropriate and adequate education and support, such as that provided by a variety of programs recognized by the National Diabetes Prevention Program recognition process (http://www.cdc.gov/diabetes/prevention/recognition/) and discussed in this webinar, that are and will make the impact. Unfortunately, screening or detection alone does not accomplish this.

Q: Was mindfulness compared or mentioned in the Obesity Guideline paper? What does the research say about this approach vs "lower calorie?"

A: To the best of my knowledge mindfulness as a “dietary approach” was not mentioned in this report (Jensen MD, et al. Guideline for the Management of Overweight and Obesity in Adults: A Report of the ACC, AHA, TOS Task Force on Practice Guidelines. Circulation. https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739....). However, the mindfulness approach and teaching concepts can be integrated into any dietary approach or be used alone to raise awareness and help a person change their relationship with food.

Q: High restraint and low disinhibition sound like contrary terms. How can both be factors?

A: I’ve gone back to the paper I referenced which recapped 10 years of follow up from the National Weight Control Registry (Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23). I realize the terms seem contrary but perhaps these definitions will help. Dietary restraint is defined as a tendency to consciously restrict or control food intake so high restraint is the ability to restrain from intake when around food. Dietary disinhibition is defined as a tendency to overeat in the presence of palatable foods or other disinhibiting stimuli, such as emotional stress. Therefore low disinhibition is the ability to not overeat in these situations.

Q: Are there any apps that you like or recommend to your clients to track food intake?

A: There are many good apps available to help clients track their food intake such as myfitnesspal, fatsecret, livestrong, calorieking, and many others. However, what is most important is that the tracking tool a clinician suggests speaks to the individual and they can easily (and will) continue to use it. For some people just tracking intake with pencil and paper or in an excel document suffices. They don’t need or want a fancy, complicated app, while others want the latest tool.

Q: Can you suggest some menu planning websites (other than ADA) to assist patients in their weekly efforts to lower calories?

A: As with apps there are a multitude of menu planning and shopping websites and apps (some related). What’s most important is that clinicians offer a few of their picks to clients and then encourage them to try them out and see what they like best and feel they will use over time.

Q: How do you address inaccurate ideas that a client may cling too that are preventing them from being successful (e.g. I don’t over eat, I’m just sedentary).

A: I think its best that you try to dance with clients rather than doing battle. There’s usually plenty to focus on in the area of healthy lifestyle and behavior change. You may want to use the technique of asking if they are willing to try an experiment for a week or two to try something out that focuses on a concept they are clinging to. Therefore they will likely prove it incorrect. However, if a client is taking some actions that according to your knowledge are hazardous to their health, then you should let them know this or address it with their provider.

Q: Can you quantify "good glucose control?"

A: There are two sources of goals for glucose management for diabetes which includes both fasting and post-meal goals and A1c. First are the glycemic goals from the American Diabetes Association’s Clinical Practice Recommendations (http://care.diabetesjournals.org/content/39/Supplement_1/S13.full.pdf+html). The other set, which differ slightly, are the goals from American Association of Clinical Endocrinologists (AACE) at this link: https://www.aace.com/files/dm-guidelines-ccp.pdf. With either set of goals, it’s important to differentiate between diagnostic numbers and management goals.

Q: Is it ok to use a 2-3 carb per meal in females and 3-4 carb per meal for males for weight loss?

A: I don’t necessarily provide people with prediabetes or type 2 diabetes with a meal plan unless this is something that they ask for or I ascertain that it will be helpful. I’m much more inclined to help a person assess their current eating habits and food choices, particularly amounts of food they eat. With this information I would review their findings. I would encourage them to choose a few simple to achieve goals to tackle first, perhaps it’s what they are drinking (non-alcoholic and alcoholic beverages) or their portions or lack of fruits and vegetables. I recommend that you let a person’s food habits guide recommendations rather than overlaying a plan that might not work for them.

Q: I've seen research indicating limiting food intake to an 8-10 hour period per day boosts metabolism and decreases insulin resistance. Any comments?

A: I’m not familiar with this research. What we know decreases insulin resistance and increases insulin sensitivity is weight loss and sufficient physical activity. They’re both powerfully effective if implemented.

Q: What about timing of eating? PM? Nighttime?

A: As noted in the response to the last question, there are very few conclusions and consensus guidance on recommendations regarding the timing of eating or frequency of eating. I would emphasize that people you work with are likely to be more successful with weight loss and diabetes control with fewer behaviors they are asked to try to change. Let their current habits and food choices drive the process.

This study was mentioned by Kim Kelly, Pharm D, who was moderating our webinar: Jakubowicz D.: Fasting Until Noon Triggers Increased Postprandial Hyperglycemia and Impaired Insulin Response After Lunch and Dinner in Individuals With Type 2 Diabetes: A Randomized Clinical Trial. Diabetes Care. 2015;38:1820–1826.

Q: One of the recommendations for successful weight loss was not to count carbs. Often, patients must count carbs to determine their insulin doses. Any comments/suggestions on how to handle this?

A: This statement does not accurately reflect my statement during the webinar. The point I was making was about the research-based factors for long term successful weight loss and weight maintenance. Typically speaking these are individuals who are overweight and have been diagnosed with prediabetes or type 2 diabetes. The research shows that eating a relatively lower fat intake (<30%) is helpful. It’s important to note that the weight loss plan in both the Diabetes Prevention Program and in the Look AHEAD study focused on lower fat and total calories. They didn’t focus on a specific amount of carbohydrate or carbohydrate counting. I was not referring in my comments to people with type 2 diabetes who take meal-time bolus insulin and making dosing decisions based on the amount of carbohydrate they consume.

Webinar attendees provided the following responses to this discussion question: What are a couple of successful strategies you’ve used in your clinical practice to assist clients with their weight control efforts, either weight loss or long term control?

- Identifying eating triggers and reducing them is key

- Having the person develop 1-2 specific action plans/SMART goals, keeping food/activity journal, regular follow-up, team-based care

- Logging all they eat using an app

- I've seen the most success by tailoring the meal plan to the patients eating style with consideration to the amount of carbohydrate and glucose control

- Strategies - portion control, using a smaller plate, journaling