Making insulin work for the diabetic, and not the other way around

Michelle Carrihill educates us on how to use various insulins with their unique actions to meet the desired requirements.


There is no ‘easy-peasy’

As a student, I remember being taught that the only thing wrong with a Type 1 diabetic is that they are deficient in insulin. So, the treatment is simple – replace the insulin, and all is returned to normal. Easy-peasy.

Except it is not. Each person is an individual. Each person has variable insulin requirements, and these may change minute-to-minute, hour-to-hour, day-to-day, week-to-week, and especially year-to-year as the body grows and changes.

Very few people have predictable, regular lives. Nevermind predictable regular metabolic rates. Add the variability that is introduced with different amounts and types of carbohydrates, plus protein and the altered absorption with fat in a meal; throw in exercise, emotions and stress, and it might feel almost impossible to exactly figure out which insulin and how much of it should be given at any one time.

Another factor is that each individual may respond slightly differently to a brand or type of insulin, and that the individual’s response may not be the same at each injection.

Also, unlike the insulin produced naturally, once insulin is injected in the body, it cannot be switched off. Once it is in the body, it will continue working, whether needed or not!

Individualise insulin treatment

The most important thing is to individualise the insulin treatment regimen to best fit the individual’s needs. Obviously, the available insulins, the budget and the willingness of the diabetic (or their carer) to test sugar levels and adjust doses are important to take into consideration when designing insulin replacement therapy.

To understand this, let’s look at the available insulins, and their action times. This information is provided by each of the manufacturers.

 

Type of Insulin & Brand Names

Onset

Peak

Duration

Role in Blood Sugar Management

Rapid-Acting

Lispro (Humalog) 15-30 min. 30-90 min 3-5 hours Rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection.
Aspart (Novorapid) 10-20 min. 40-50 min. 3-5 hours
Glulisine (Apidra) 20-30 min. 30-90 min. 1-2 1/2 hours

Short-Acting

Regular (R)

Actrapid

Biosulin R

Humulin R

Insumam R

30 min. -1 hour 2-5 hours 5-8 hours Short-acting insulin covers insulin needs for meals eaten within 30-60 minutes

Intermediate-Acting

NPH (N)

Biosulin N

Humulin N

Insumam N

Protophane

 

 

1-2 hours

 

 

4-12 hours

18-24 hours Intermediate-acting insulin covers insulin needs for about half the day or overnight.

Long-Acting

Insulin glargine (Basaglar, LantusToujeo, Optisulin) 1-1 1/2 hours No peak time. Insulin is delivered at a steady level. 20-24 hours Long-acting insulin covers insulin needs for up to one full day.
Insulin detemir (Levemir) 1-2 hours 6-8 hours Up to 24 hours
Insulin degludec (Tresiba) 30-90 min. No peak time 42 hours

Pre-Mixed*

Humulin 30/70

Actraphane

30 min. 2-4 hours 14-24 hours These products are generally taken twice a day before main meals.
NovoMix 30 10-20 min. 1-4 hours Up to 24 hours
Humalog mix 25 15 min. 30 min.-2 1/2 hours 16-20 hours
*Premixed insulins combine specific amounts of intermediate-acting and short-acting insulin in one bottle or insulin pen. (The numbers following the brand name indicate the percentage of each type of insulin.)

If you combine these insulin profiles, and superimpose them over what the individual’s insulin requirements are, you then get to understand when the insulin will be working for them, and which combination will suit their needs. These needs may vary from time-to-time and over time, so it is important they monitor their sugars, either with finger-prick tests, or if viable, a continuous glucose monitor.

Let’s look at some regimens:

Twice a day insulin

Benefits: Disadvantages:
Easiest regimen Must be given 30 minutes before the meals.
Only two injections a day Midmorning snack required.
Lunch carbohydrates may not be adequately covered.
No flexibility in meal component of the insulin (if using a premixed insulin combination).
The intermediate-acting insulin given before an early dinner may mean inadequate basal cover by the early morning – a risk of waking up with a high fasting sugar, and some ketosis.

 Three times a day insulin

Benefits: Disadvantages:
Covers overnight requirements better by the later injection of the intermediate insulin, decreasing the chance of morning high levels. Regular insulin must be given 30 minutes before the meals.
Midmorning snack required.
Lunch carbohydrates may not be adequately covered.
Requires a bedtime snack.

 Basal bolus regimen

Benefits: Disadvantages:
Flexible dosing for carbohydrates and correcting. In-between meal carbohydrates need to be counted and dosed for. Or carbohydrate free snacks considered.
More frequent injections (and testing) required.
More expensive.

 Long-acting insulin analogues

Benefits: Disadvantages:
Flexible dosage for carbohydrates and correcting. ‘In-between’ meal carbohydrates need to be counted and dosed for. Or carbohydrate free snacks considered.
Fasting is possible. More frequent injections (and testing) required.
Flexibility in the timing of the meals/snacks. Much more expensive.
Less risk of nocturnal hypoglycaemia.
No need for night time snack.

Continuous sc insulin infusion

Benefits: Disadvantages:
Built in calculator for carbohydrate counting and corrections. Only rapid insulin is used, so any disruption in delivery can rapidly lead to ketoacidosis.
Insulin can be suspended. Very expensive.
Basal rates can be individually set. Needs high quality training and ongoing interaction.
Dawn phenomenon can be covered. Permanently attached to a device.
Fasting easy to achieve.
Temporary increase or decrease in basal requirements easy to achieve.

Mix and match

Mixing and matching of insulins is also possible. For example, a child attending primary school might do well on regular and intermediate-acting insulins half an hour before breakfast, without requiring any insulin for their school break; a rapid insulin analogue for after-school lunch and dinner; and then a long-acting basal analogue for their basal insulin overnight.

As mentioned already, monitoring the blood glucose then opens the eyes to the effect of the insulin doses – both for the individual dose, as well as for the pattern of dosing. Fasting sugars reflect the long-acting doses and post-meal levels reflect the bolused doses for carbohydrates and corrections.

Carbohydrate counting affords the closest-to-physiology use of mealtime insulin, and is to be encouraged. Even if using a fixed-dose insulin regimen, knowing how much carbohydrate is in a meal allows for consistency of insulin to carbohydrate dosing – which then helps prevent sugar variability after meals.

Monitoring sugar levels before and after activities and sports helps with planning of extra carbohydrates or a change in insulin dose for the meal before or after the exercise.

The message is that getting sugars to target is possible by knowing what the individual needs, and using the available insulins to suit those needs. Monitoring sugars and adjusting doses and types of insulin along the way will keep the person with diabetes healthy, and able to get on with living their lives.

MEET OUR EXPERT


Dr Michelle Carrihill is a paediatric endocrinologist working with children and adolescents with diabetes and chronic endocrine and metabolic conditions. She runs the adolescent sub-speciality ward at Groote Schuur Hospital and has a large ambulatory service for the chronic medical needs of these patients.


Workplace wellness – making the workplace a healthy, happy space

Corporate Wellness Week is observed in the first week of July (1-7). With this in mind, Paula Pienaar explains why workplace wellness is of vital importance.

What is corporate wellness?

Corporate, employee or workplace wellness refers to the physical and mental well-being and health of employees, their work environment and workplace culture. Understanding the significance of this concept begins by addressing the health needs of our working population.

State of the nation’s health

Recent data from Statistics SA show that 56% of all deaths annually are attributed to chronic diseases, such as heart disease, cancer, diabetes and stroke. In fact, Type 2 diabetes mellitus is now the second most common cause of death in South Africa (5,4%), after tuberculosis (7,2%)1. The prevention and management of such chronic diseases can be largely accomplished by managing associated health risk factors which include hypertension, high blood sugar levels, high cholesterol, excess body weight and lifestyle behaviours, such as smoking, physical inactivity, poor dietary habits and poor sleep health. One estimate is that eliminating these health risk behaviours would make it possible to prevent 80% of heart disease, stroke, and Type 2 diabetes mellitus, and even 40% of cancers2.

Using the workplace to improve the nation’s health

Recent economic statistics show that 44% of South Africans are employed3 and on average, South Africans who work full-time spend more than one-third of their day, five days a week, at their workplace. It is therefore not surprising that the workplace provides an opportune setting through which a large part of the population can be helped through workplace wellness programmes. Employers have a responsibility to provide a safe, hazard-free workplace for their employees and also the opportunity to foster a happy, productive working environment by promoting a healthy lifestyle.

Workplace Wellness programmes (WWPs)

Healthy employees are more productive and have the lowest cost to organisations. WWPs therefore aim to prevent the development of chronic diseases and support employees with existing chronic medical conditions. Another way in which employees can be supported is by creating a work environment that encourages healthy lifestyle behaviours, such as having quality short breaks away from the desk, physical activity, good nutrition and no smoking. Successful, effective WWPs therefore have significant benefits to the organisation and to employees.

Workplace wellness is beneficial to:

The Organisation

The Employee

Reduces productivity loss. Reduces risk for premature death.
Reduces risk for short-term disability. Reduces risk for cardiovascular disease, diabetes, cancers, back pain, and high cholesterol.
Enhances mood and job satisfaction. Results in greater job satisfaction.
Enhances work performance. May increase annual income.
Reduces healthcare spending. Lowers debt.
Lowers employee turnover rates. Lowers long-term unemployment.

Workplace wellness – the key to a healthy, happy and productive workforce

Workplace wellness is among the most vital investments that a company can make. Businesses that start WWPs aren’t only investing in the physical wellness, safety, and mental health of their employees, but are also taking preventive measures by creating a healthier environment. A recent scientific review concluded that well-designed, comprehensive WWPs have the potential to improve heart health and to reduce mortality and disability resulting from cardiovascular disease and stroke4.

5 evidence-based strategies that have shown to work in successful WWPs:

  1. Wellness screening days (height, weight, waist circumference and finger prick blood tests).
  2. Healthy lifestyle programmes (e.g. smoking cessation, weight loss, fatigue management, and diabetes programmes).
  3. Covering or minimising co-payment of lifestyle-related health programmes.
  4. Onsite exercise facilities and informative health talks.
  5. Fully covered flu vaccinations.

Making workplace wellness enjoyable

Participation in workplace wellness initiatives may often be poor. However, research has shown that by involving employees in the roll-out of such programmes through interest-based surveys and good communication strategies, companies can play a significant role in changing employees’ attitudes to work from a dreary obligation to an exciting health-enhancing part of their day.

Strategies that organisations can take to improve 3 pillars of performance – nutrition, physical activity and adequate rest:

  1. Nutrition
    1. Review the catering menu and vending machines to gently introduce healthier options.
    2. Coordinate a ‘healthy snack of the month’ club.
  2. Physical activity
    1. Arrange for bicycle racks and provide ‘bike to work’ promotional materials.
    2. Make the area around the office building conducive to walks and try to move your meetings from the boardroom to walking paths (walking meetings).
  3. Sleep and fatigue
    1. Invite a sleep health professional to a ‘lunch and learn’ session.
    2. Create a workplace with adequate natural lighting and low noise levels.

For more information, please visit eohworkplacehealth.co.za

MEET OUR EXPERT - Paula R. Pienaar

Paula R. Pienaar
Paula R. Pienaar (BSc (Med)(Hons) Exercise Science (Biokinetics)), MSc (Med) Exercise Science) is the scientific advisor to EOH Workplace Health and Wellness, and a PhD candidate at the University of Cape Town. Her scientific research relates to sleep health and managing daytime fatigue to improve workplace productivity and lower the risk of chronic disease. Her thesis will identify the link between sleep and cardiometabolic diseases (Type 2 diabetes and cardiovascular disease) in South African employees. She aims to design a tailored sleep and fatigue management workplace health intervention to improve employee health risk profiles and enhance work productivity. Contact her at [email protected]

References:

  1. Statistics South Africa, Mortality and causes of death in South Africa, 2015: Findings from death notification. 2017: Pretoria:SSA.
  2. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;121(4): 586-613
  3. https://tradingeconomics.com/south-africa/employment-rate
  4. Fonarow GC, Calitz C, Arena R, et al. Workplace wellness recognition for optimizing workplace health: a presidential advisory from the American Heart Association. Circulation. 2015;131(20): e480-e497.