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Introduction to Carbohydrates and the FreeStyle Libre Nicola Taylor Diabetes Specialist Dietitian University Hospitals of Derby and Burton Supported by a restricted educational grant from Abbott Nicola Taylor Diabetes Specialist

  1. Introduction to Carbohydrates and the FreeStyle Libre Nicola Taylor Diabetes Specialist Dietitian University Hospitals of Derby and Burton Supported by a restricted educational grant from Abbott

  2. Nicola Taylor • Diabetes Specialist Dietitian, University Hospitals of Derby and Burton NHS FT • DAFNE educator • Derby FreeStyle Libre lead • Derby Dietetics lead for Insulin pumps & CGM Disclosures: Educational grant from Abbott Diabetes Care

  3. Learning objectives • Identify sources of carbohydrate in the diet • Explain the effect of carbohydrates on glucose levels • Recognise how Glycaemic Index (GI) affects glucose levels • Understand how carbohydrate counting can help you to manage glucose levels • Understand how you can use the Freestyle Libre to assess carbohydrate counting skills

  4. Sources of Carbohydrate Starch Sugar Bread, chapatti, naan, rice, Sucrose: biscuits, cakes, pasta, potato and potato sweets, chocolate, products e.g. crisps, puddings, jam, soft drinks waffles, yam, noodles, grains e.g. couscous, Fructose: fruit- fresh, quinoa, bulgar frozen,btinned, dried wheat, barley, cereals, crackers, flour, pastry, Lactose: milk, yoghurt, beans, pulses and lentils ice cream

  5. Effect of carbohydrate on glucose levels After a meal or snack, the body breaks down carbohydrates into glucose (sugar) This enters the blood stream and causes a rise in blood glucose levels The body’s cells need glucose for energy Cells can only take up glucose when there is enough insulin present in the blood In someone without diabetes this would happen automatically. In Type 1 Diabetes carbohydrate counting is the tool used to do work out how much quick acting insulin to give.

  6. Glycaemic Index (GI) Different sources of carbohydrate are digested at different rates. They can be ranked according to the speed with which the glucose rises after a particular food. Most foods are digested in 1-2.5 hours, low GI foods may take much longer. High GI Low GI Rapid and more Gradual and less significant rise in significant rise in glucose (quickly glucose (slowly absorbed) absorbed) GI has limitations- foods eaten at the same time, fat/protein content and cooking methods

  7. Glycaemic Index (GI) It can be useful to use GI to determine if insulin is needed: High GI Low GI Rapid rise Minimal rise Hypo treatment: fruit juice, cola, Lentils, beans and pulses, nuts, lucozade, glucose/dextrose barley, grapefruit tablets, jellied and boiled sweets Quick acting insulin is too slow Quick acting insulin is often too to match these foods/drinks. quick for these foods. Result = high glucose levels Result = risk of hypos All other sources of carbohydrate can be matched with your quick acting insulin regardless of the GI. For more information on GI speak with your diabetes team.

  8. Carbohydrate Counting Working out the correct dose of quick acting insulin according to how much carbohydrate is eaten and the current glucose value to maintain target glucose levels. • Allows freedom to eat various types and amounts of carbohydrate • Allows flexibility to vary the timing of meals and snacks • Requires time to learn about the glucose response to meals

  9. Resources to help with Carbohydrate Counting

  10. Carbohydrate Counting Common Terms I:C ratio - Insulin to Carbohydrate Ratio- Individual glucose response to carbohydrate  How much quick acting insulin is needed to cover the rise from carbohydrate Correction Factor (ISF) - Insulin Sensitivity Factor - Individual glucose response to quick acting (QA) insulin  How much 1 unit of quick acting insulin lowers glucose e.g. ISF 1:3 = 1 unit of QA reduces glucose by 3 mmol/l

  11. I:C ratios Different methods are used by individuals • Some people change the units of insulin for every 10g of carbohydrate or 1 carbohydrate portion (CP) • Some people change the grams of carbohydrate for 1 unit of insulin Units for every 10g Units for every 1CP Grams for every 1 unit 0.5:10 0.5:1 1:20 0.7:10 0.7:1 1:15 1:10 1:1 1:10 1.5:10 1.5:1 1:7 2:10 2:1 1:5 2.5:10 2.5:1 1:4 3:10 3:1 1:3

  12. Typical I:C ratios • Some people use Total Daily Dose of insulin (TDD) to work out I:C ratios e.g 46-55 units  1:10g • Some people use body weight to work out I:C ratios e.g. 78-90kg  1:10g • I:C ratios can be different at different times of the day • Speak with your diabetes team if you are unsure where to start

  13. Carbohydrate Counting • Typically 10g or 1 carbohydrate portion (CP) raise glucose levels by 2-3mmol/L • Typically 1 unit of quick acting insulin lowers glucose levels by 2-3mmol/L Individual responses will vary 21 15 • Underestimating the carbohydrate content or forgetting to inject/bolus for 9 snacks will lead to raised glucose levels 3 16:00 20:00 00:00 • Overestimating the carbohydrate content may lead to low glucose levels 21 (hypoglycaemia) 15 • It is therefore crucial to have accurate carbohydrate counting skills 9 3 16:00 20:00 00:00

  14. Selecting a dose Spaghetti bolognaise with garlic bread Estimated 60g carbs for the pasta and 20g for the garlic bread = 80g carbs Glucose = 12 mmol/l I:C ratio = 1:10 g or 1:1 ISF = 1:2 mmol/l Target glucose 6 mmol/l For food: 80g ÷ 10 = 8 units For correction: 12 – 6 = 6 ÷ 2 = 3 units Total dose: 8 + 3 = 11 units

  15. How can the Freestyle Libre help? You can set up the Libre reader “bolus calculator” to support with the maths • Requires a blood test pre meal • Enter the grams of carbs eaten or CPs • Suggests a dose based on I:C ratio, ISF and target set • Other bolus calculator apps are available

  16. How can the Freestyle Libre help? Libre traces give you more insight into how the carbohydrate you eat affects glucose levels 21 21 15 15 9 9 3 3 16:00 20:00 00:00 10:00 14:00 18:00 You can use this information to: If you want to learn more, • Make changes to the amounts or type of carbohydrate eaten see Dr Jackie Elliott’s • Determine the correct dose or ratio of quick acting insulin module on getting bolus insulin right • Take the insulin at the appropriate time

  17. Conclusion • Carbohydrates have a direct effect on glucose levels • Glycaemic Index determines how quickly and significantly carbohydrate affects glucose levels • Crucial to understand carbohydrate counting to achieve optimal glucose control • The Libre provides more information than traditional blood glucose testing • Not just the amount of carbohydrate that matters…. • See Module 2 online: Fat and Protein and the Freestyle Libre

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