A randomized comparison of three prandial insulin dosing algorithms for children and adolescents with Type 1 diabetes

Lopez, P. E.; Evans, Megan C.; King, Bruce R.; Jones, Timothy W.; Bell, Kirstine J.; McElduff, Patrick; Davis, Elizabeth A.; Smart, Carmel E.

doi:10.1111/dme.13703

Cited by 29 publications

(69 citation statements)

References 20 publications

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“…No significant differences in postprandial glucose excursions were found when using the food insulin index compared with carbohydrate-counting. The Pankowska equation did demonstrate a reduction in glucose excursions from 90 to 240 min; however, there were significantly increased rates of hypoglycaemia, as seen in previous research [12].…”

Section: Introductionsupporting

confidence: 72%

Dietary protein affects both the dose and pattern of insulin delivery required to achieve postprandial euglycaemia in Type 1 diabetes: a randomized trial

et al. 2019

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Aim To quantify the insulin requirement for a high‐protein meal compared with a low‐protein meal, controlling for carbohydrate and fat content. Methods In this crossover study, young people with Type 1 diabetes were randomized to consume a high‐ (60 g) or low‐protein meal (5 g), each containing 30 g carbohydrate and 8 g fat. A variation of the insulin clamp technique was used to determine the insulin requirements to maintain euglycaemia for the following 5 h. Results A total of 11 participants (mean ± sd age 16.5 ± 2.7 years, HbA1c 52 ± 8.7 mmol/mol [6.9 ± 0.8%], diabetes duration 6.9±5.1 years) completed the study. The mean insulin requirements for the high‐protein meal were higher than for the low‐protein meal [10.3 (CI 8.2, 12.57) vs 6.7 units (CI 4.7, 8.8); P=0.001], with inter‐individual requirements ranging from 0.9 to six times the low‐protein meal requirement. Approximately half the additional insulin [1.1 units/h (CI 0.5, 1.8; P=0.001)] was given in the first 2 h, compared with an additional 0.5 units/h (CI –0.2, 1.2; P=0.148) in the second 2 h and 0.1 units (CI –0.6, 0.8; P=0.769) in the final hour. Conclusions A high‐protein meal requires ~50% more insulin to maintain euglycaemia than a low‐protein meal that contains the same quantity of carbohydrate. The majority is required within the first 2 h. Inter‐individual differences exist in insulin requirements for dietary protein.

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Section: Introductionsupporting

confidence: 72%

Dietary protein affects both the dose and pattern of insulin delivery required to achieve postprandial euglycaemia in Type 1 diabetes: a randomized trial

et al. 2019

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“…Results from recent high-fat and/or high-protein mixed meal studies continue to support previous findings that glucose response to mixed meals high in protein and/or fat along with carbohydrate differ among individuals; therefore, a cautious approach to increasing insulin doses for high-fat and/or high-protein mixed meals is recommended to address delayed hyperglycemia that may occur 3 h or more after eating (277)(278)(279)(280)(281)(282)(283)(284)(285)(286)(287)(288)(289)(290). If using an insulin pump, a split bolus feature (part of the bolus delivered immediately, the remainder over a programmed duration of time) may provide better insulin coverage for high-fat and/or high-protein mixed meals (278,281).…”

Section: Mnt and Antihyperglycemic Medications (Including Insulin)supporting

confidence: 54%

Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report

Dennison²,

et al. 2019

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This Consensus Report is intended to provide clinical professionals with evidencebased guidance about individualizing nutrition therapy for adults with diabetes or prediabetes. Strong evidence supports the efficacy and cost-effectiveness of nutrition therapy as a component of quality diabetes care, including its integration into the medical management of diabetes; therefore, it is important that all members of the health care team know and champion the benefits of nutrition therapy and key nutrition messages. Nutrition counseling that works toward improving or maintaining glycemic targets, achieving weight management goals, and improving cardiovascular risk factors (e.g., blood pressure, lipids, etc.) within individualized treatment goals is recommended for all adults with diabetes and prediabetes. Though it might simplify messaging, a "one-size-fits-all" eating plan is not evident for the prevention or management of diabetes, and it is an unrealistic expectation given the broad spectrum of people affected by diabetes and prediabetes, their cultural backgrounds, personal preferences, co-occurring conditions (often referred to as comorbidities), and socioeconomic settings in which they live. Research provides clarity on many food choices and eating patterns that can help people achieve health goals and quality of life. The American Diabetes Association (ADA) emphasizes that medical nutrition therapy (MNT) is fundamental in the overall diabetes management plan, and the need for MNT should be reassessed frequently by health care providers in collaboration with people with diabetes across the life span, with special attention during times of changing health status and life stages (1-3). This Consensus Report now includes information on prediabetes, and previous ADA nutrition position statements, the last of which was published in 2014 (4), did not. Unless otherwise noted, the research reviewed was limited to those studies conducted in adults diagnosed with prediabetes, type 1 diabetes, and/or type 2 diabetes. Nutrition therapy for children with diabetes or women with gestational diabetes mellitus is not addressed in this review but is covered in other ADA publications, specifically Standards of Medical Care in Diabetes (5,6).

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“…However, the amount of extra insulin for a FPU has never been tested, as far as we understand. A study by Lopez et al showed that using the FPU for calculation of insulin requirements in FPRM would increase the risk for postprandial hypoglycemia [19]. Our intention was to find a solid basis for the recommendation of calculating extra insulin, as well as to provide simple and feasible instructions on how to deal with a FPRM, as the tightrope walk between optimizing control and the complexity of regulations is a well-known problem [20].…”

Section: Discussionmentioning

confidence: 99%

Additional Insulin for Coping with Fat- and Protein-Rich Meals in Adolescents with Type 1 Diabetes: The Protein Unit

Schweizer

Herrlich

Lösch-Binder

et al. 2020

Exp Clin Endocrinol Diabetes

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Objective Dietary proteins raise blood glucose levels; dietary fats delay this rise. We sought to assess the insulin amount required to normalize glucose levels after a fat- and protein-rich meal (FPRM). Methods Sixteen adolescents (5 female) with type 1 diabetes (median age: 18.2 years; range: 15.2–24.0; duration: 7.1 years; 2.3–14.3; HbA1c: 7.2%; 6.2–8.3%) were included. FPRM (carbohydrates 57 g; protein 92 g; fat 39 g; fibers 7 g; calories 975 Kcal) was served in the evening, with 20 or 40% extra insulin compared to a standard meal (SM) (carbohydrates 70 g; protein 28 g; fat 19 g; fibers 10 g; calories 579 Kcal) or carbohydrates only. Insulin was administered for patients on intensified insulin therapy or as a 4-hour-delayed bolus for those on pump therapy. The 12-hour post-meal glucose levels were compared between FPRM and SM, with the extra insulin amount calculated based on 100 g proteins as a multiple of the carbohydrate unit. Results Glucose levels (median, mg/dL) 12-hour post-meal with 20% extra insulin vs. 40% vs. insulin dose for SM were 116 vs. 113 vs. 91. Glucose-AUC over 12-hour post-meal with 20% extra insulin vs. 40% vs. insulin dose for SM was 1603 mg/dL/12 h vs. 1527 vs. 1400 (no significance). Glucose levels in the target range with 20% extra insulin vs. 40% were 60% vs. 69% (p=0.1). Glucose levels <60 mg/dL did not increase with 40% extra insulin. This corresponds to the 2.15-fold carbohydrate unit for 100 g protein. Conclusions We recommend administering the same insulin dose given for 1 carbohydrate unit (10 g carbs) to cover 50 g protein.

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A randomized comparison of three prandial insulin dosing algorithms for children and adolescents with Type 1 diabetes

Abstract: The Pankowska Equation resulted in reduced postprandial hyperglycaemia at the expense of an increase in hypoglycaemia. There were no significant differences when carbohydrate counting was compared to the Food Insulin Index. Further research is required to optimize prandial insulin dosing.

Cited by 29 publications

References 20 publications

Dietary protein affects both the dose and pattern of insulin delivery required to achieve postprandial euglycaemia in Type 1 diabetes: a randomized trial

Dietary protein affects both the dose and pattern of insulin delivery required to achieve postprandial euglycaemia in Type 1 diabetes: a randomized trial

Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report

Additional Insulin for Coping with Fat- and Protein-Rich Meals in Adolescents with Type 1 Diabetes: The Protein Unit

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