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Smith TA, Marlow AA, King BR, Smart CE. Insulin strategies for dietary fat and protein in type 1 diabetes: A systematic review. Diabet Med 2021; 38:e14641. [PMID: 34251692 DOI: 10.1111/dme.14641] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/10/2021] [Indexed: 11/26/2022]
Abstract
AIM To identify and report the efficacy of insulin strategies used to manage glycaemia following fat and/or fat and protein meals in type 1 diabetes. METHODS A systematic literature search of medical databases from 1995 to 2021 was undertaken. Inclusion criteria were randomised controlled trials that reported at least one of the following glycaemic outcomes: mean glucose, area under the curve, time in range or hypoglycaemic episodes. RESULTS Eighteen studies were included. Thirteen studies gave additional insulin. Five studies gave an additional 30%-43% of the insulin-to-carbohydrate ratio (ICR) for 32-50 g of fat and 31%-51% ICR for 7-35 g of fat with 12-27 g of protein added to control meals. A further eight studies gave -28% to +75% ICR using algorithms based on fat and protein for meals with 19-50 g of carbohydrate, 2-79 g of fat and 10-60 g of protein, only one study reported a glycaemic benefit of giving less than an additional 24% ICR. Eight studies evaluated insulin delivery patterns. Four of six studies in pump therapy, and one of two studies in multiple daily injections showed the combination of bolus and split dose, respectively, were superior. Five studies examined the insulin dose split, four demonstrated 60%-125% ICR upfront was necessary. Two studies investigated the timing of insulin delivery, both reported administration 15 min before the meal lowered postprandial glycaemia. CONCLUSIONS Findings highlight the glycaemic benefit of an additional 24%-75% ICR for fat and fat and protein meals. For these meals, there is supportive evidence for insulin delivery in a combination bolus with a minimum upfront dose of 60% ICR, 15 min before the meal.
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Affiliation(s)
- Tenele A Smith
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Alexandra A Marlow
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Bruce R King
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Department of Diabetes and Endocrinology, John Hunter Children's Hospital, New Lambton Heights, NSW, Australia
| | - Carmel E Smart
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Department of Diabetes and Endocrinology, John Hunter Children's Hospital, New Lambton Heights, NSW, Australia
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Metwally M, Cheung TO, Smith R, Bell KJ. Insulin pump dosing strategies for meals varying in fat, protein or glycaemic index or grazing-style meals in type 1 diabetes: A systematic review. Diabetes Res Clin Pract 2021; 172:108516. [PMID: 33096184 DOI: 10.1016/j.diabres.2020.108516] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Nutritional composition and food patterns influence postprandial glycaemia in type 1 diabetes (T1D). For optimal glycaemic control, insulin dose and delivery pattern must be matched accordingly. This systematic review aimed to compare insulin dosing strategies for meals varying in fat, protein and glycaemic index (GI), and prolonged meals in T1D. METHODS Studies in adults and/or children with T1D on insulin pump therapy comparing the glycaemic effects of different insulin pump bolus types for these meal types were identified from biomedical databases (MEDLINE, PREMEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials; March 1995-April 2020) and systematically reviewed. RESULTS All eleven publications investigating high-fat meals (234 participants) and all seven studies investigating high-protein meals (129 participants) showed a dual-wave bolus was superior. Additional insulin further improved postprandial glycaemia, although increasing risk of hypoglycaemia in 5 of 14 studies. One study investigating GI found a dual-wave bolus reduced postprandial glycaemia and risk of hypoglycaemia. No studies were identified for grazing/degustation-style meals. Due to heterogeneity, meta-analysis was not possible. CONCLUSION Dual-wave boluses improve postprandial glycaemia in high-fat, high-protein and low-GI meals. Further research is needed to identify optimal bolus delivery split, duration and optimal total dose adjustment.
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Affiliation(s)
- Mariam Metwally
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Tin Oi Cheung
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | | | - Kirstine J Bell
- Charles Perkins Centre, University of Sydney, Sydney, Australia.
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González-Rodríguez M, Pazos-Couselo M, García-López JM, Rodríguez-Segade S, Rodríguez-García J, Túñez-Bastida C, Gude F. Postprandial glycemic response in a non-diabetic adult population: the effect of nutrients is different between men and women. Nutr Metab (Lond) 2019; 16:46. [PMID: 31346341 PMCID: PMC6637571 DOI: 10.1186/s12986-019-0368-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background There is a growing interest in the pathopysiological consequences of postprandial hyperglycemia. It is well known that in diabetic patients 2 h plasma glucose is a better risk predictor for coronary heart disease than fasting plasma glucose. Data on the glycemic response in healthy people are scarce. Objective To evaluate the effect of macronutrients (carbohydrates, fats, and proteins) and fiber on postprandial glycemic response in an observational study of a non-diabetic adult population. Design Cross-sectional study. 150 non-diabetic adults performed continuous glucose monitoring for 6 days. During this period they recorded food and beverage intake. The participants were instructed not to make changes in their usual diet and physical exercise. Variables analyzed included clinical parameters (age, sex, body weight, height, body mass index, blood pressure, and waist measurement), meal composition (calories, carbohydrates, fats, proteins, and fiber) and glycemic postprandial responses separated by sexes. The study period was defined from the start of dinner to 6 h later. Results A total of 148 (51% women) subjects completed all study procedures. Dinner intake was higher in males than in females (824 vs 531 kcal). Macronutrient distribution was similar in both sexes. No significant differences were found in fiber intake between men and women (5.5 g vs 4.5 g). In both sexes, the higher intake of carbohydrates corresponded to a significantly higher glycemic response (p = 0.0001 in women, p = 0.022 in men). Moreover, in women, as fat intake was higher, a flattening of the postprandial glycemic curve was observed (p = 0.003). With respect to fiber, a significantly lower glycemic response was observed in the group of women whose fiber intake at dinner was higher (p = 0.034). Conclusions Continuous glucose monitoring provides important information about glucose levels after meals. In this study, the postprandial glycemic response in women was different from that of men, and carbohydrates were the main determinant of elevated postprandial glucose levels.
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Affiliation(s)
- María González-Rodríguez
- 1Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Santiago de Compostela, Travesía da Choupana, s/n, 15706 Santiago de Compostela, Spain
| | - Marcos Pazos-Couselo
- 1Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Santiago de Compostela, Travesía da Choupana, s/n, 15706 Santiago de Compostela, Spain.,2Psychiatry, Radiology and Public Health Department, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - José M García-López
- 1Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Santiago de Compostela, Travesía da Choupana, s/n, 15706 Santiago de Compostela, Spain.,2Psychiatry, Radiology and Public Health Department, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Santiago Rodríguez-Segade
- 3Department of Biochemistry and Molecular Biology, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Javier Rodríguez-García
- 3Department of Biochemistry and Molecular Biology, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Francisco Gude
- 5Clinical Epidemiology Unit, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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van der Hoogt M, van Dyk JC, Dolman RC, Pieters M. Protein and fat meal content increase insulin requirement in children with type 1 diabetes - Role of duration of diabetes. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2017; 10:15-21. [PMID: 29204367 PMCID: PMC5691219 DOI: 10.1016/j.jcte.2017.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/05/2017] [Accepted: 10/04/2017] [Indexed: 12/13/2022]
Abstract
Calculation of mixed meal insulin need in type 1 diabetes children is challenging. This home-based study demonstrated that for a typical cooked dinner: fat required double the amount of insulin than protein when consumed in a mixed meal. Fat and protein did not significantly increase post-prandial glucose excursion. Fat and protein significantly increased the duration of post-prandial hyperglycaemia. Duration of diabetes influenced mixed meal insulin requirement.
Background and objective Hyperglycaemia remains a challenge in type 1 diabetes since current regimes used to determine meal insulin requirements prove to be ineffective. This is particularly problematic for meals containing high amounts of protein and fat. We aimed to determine the post-prandial glycaemic response and total insulin need for mixed meals, using sensor-augmented insulin pumps in children with type 1 diabetes. Methods Twenty-two children with type 1 diabetes, aged 4–17 years on insulin pump therapy completed this home-based, cross-over, randomised controlled trial. Two meals with identical carbohydrate content – one with low fat and protein (LFLP) and one with high fat and protein (HFHP) contents – were consumed using normal insulin boluses. Blood glucose monitoring was done for 10 h post-meal, with correction bolus insulin given two-hourly if required. Results The HFHP meal required significantly more total insulin (3.48 vs. 2.7 units) as a result of increased post-meal correction insulin requirement (1.2 vs. 0.15 units) spread over a longer duration (6 vs. 3 h). The HFHP meals significantly increased the time spent above target glucose level. Duration of diabetes and total daily insulin use significantly influenced the post-prandial blood glucose response to the two meals. Conclusion When consuming carbohydrate-based mixed meals, children with type 1 diabetes on insulin pump therapy, required significantly more insulin over a longer period of time than the insulin requirement calculated using current regimes. This additional amount required is influenced by the duration of diabetes and total daily insulin use.
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Affiliation(s)
- M van der Hoogt
- Centre of Excellence for Nutrition, North-West University, Potchefstroom 2520, South Africa
| | - J C van Dyk
- Life Groenkloof Hospital, Pretoria 0181, South Africa
| | - R C Dolman
- Centre of Excellence for Nutrition, North-West University, Potchefstroom 2520, South Africa
| | - M Pieters
- Centre of Excellence for Nutrition, North-West University, Potchefstroom 2520, South Africa
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Lopez PE, Smart CE, McElduff P, Foskett DC, Price DA, Paterson MA, King BR. Optimizing the combination insulin bolus split for a high-fat, high-protein meal in children and adolescents using insulin pump therapy. Diabet Med 2017; 34:1380-1384. [PMID: 28574182 DOI: 10.1111/dme.13392] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 12/26/2022]
Abstract
AIMS To determine the optimum combination bolus split to maintain postprandial glycaemia with a high-fat and high-protein meal in young people with Type 1 diabetes. METHODS A total of 19 young people (mean age 12.9 ± 6.7 years) participated in a randomized, repeated-measures trial comparing postprandial glycaemic control across six study conditions after a high-fat and high-protein meal. A standard bolus and five different combination boluses were delivered over 2 h in the following splits: 70/30 = 70% standard /30% extended bolus; 60/40=60% standard/40% extended bolus; 50/50=50% standard/50% extended bolus; 40/60=40% standard/60% extended bolus; and 30/70=30% standard/70% extended bolus. Insulin dose was determined using the participant's optimized insulin:carbohydrate ratio. Continuous glucose monitoring was used to assess glucose excursions for 6 h after the test meal. RESULTS Standard bolus and combination boluses 70/30 and 60/40 controlled the glucose excursion up to 120 min. From 240 to 300 min after the meal, the glucose area under the curve was significantly lower for combination bolus 30/70 compared with standard bolus (P=0.004). CONCLUSIONS High-fat and high-protein meals require a ≥60% insulin:carbohydrate ratio as a standard bolus to control the initial postprandial rise. Additional insulin at an insulin:carbohydrate ratio of up to 70% is needed in the extended bolus for a high fat and protein meal to prevent delayed hyperglycaemia.
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Affiliation(s)
- P E Lopez
- John Hunter Hospital, Newcastle, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Newcastle, NSW, Australia
| | - C E Smart
- John Hunter Hospital, Newcastle, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Newcastle, NSW, Australia
| | - P McElduff
- University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - D C Foskett
- Insulin Pump Angels, Gold Coast, Queensland, Australia
| | - D A Price
- Pacific Private Clinic, Gold Coast, Queensland, Australia
- Bond University, Gold Coast, Queensland, Australia
- Griffith University, Gold Coast, Queensland, Australia
| | - M A Paterson
- John Hunter Hospital, Newcastle, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Newcastle, NSW, Australia
| | - B R King
- John Hunter Hospital, Newcastle, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
- Mothers and Babies Research Centre, Newcastle, NSW, Australia
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Paterson M, Bell KJ, O’Connell SM, Smart CE, Shafat A, King B. The Role of Dietary Protein and Fat in Glycaemic Control in Type 1 Diabetes: Implications for Intensive Diabetes Management. Curr Diab Rep 2015; 15:61. [PMID: 26202844 PMCID: PMC4512569 DOI: 10.1007/s11892-015-0630-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A primary focus of the management of type 1 diabetes has been on matching prandial insulin therapy with carbohydrate amount consumed. However, even with the introduction of more flexible intensive insulin regimes, people with type 1 diabetes still struggle to achieve optimal glycaemic control. More recently, dietary fat and protein have been recognised as having a significant impact on postprandial blood glucose levels. Fat and protein independently increase the postprandial glucose excursions and together their effect is additive. This article reviews how the fat and protein in a meal impact the postprandial glycaemic response and discusses practical approaches to managing this in clinical practice. These insights have significant implications for patient education, mealtime insulin dose calculations and dosing strategies.
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Affiliation(s)
- Megan Paterson
- />Department of Paediatric Diabetes and Endocrinology, John Hunter Children’s Hospital, Newcastle, NSW Australia
- />Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Rankin Park, NSW Australia
| | - Kirstine J. Bell
- />Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Rankin Park, NSW Australia
| | - Susan M. O’Connell
- />Department of Paediatrics and Child Health, Cork University Hospital, Cork, Ireland
| | - Carmel E. Smart
- />Department of Paediatric Diabetes and Endocrinology, John Hunter Children’s Hospital, Newcastle, NSW Australia
- />Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Rankin Park, NSW Australia
| | - Amir Shafat
- />Physiology, School of Medicine, National University of Ireland, Galway, Galway, Ireland
| | - Bruce King
- />Department of Paediatric Diabetes and Endocrinology, John Hunter Children’s Hospital, Newcastle, NSW Australia
- />Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Rankin Park, NSW Australia
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Bell KJ, Smart CE, Steil GM, Brand-Miller JC, King B, Wolpert HA. Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era. Diabetes Care 2015; 38:1008-15. [PMID: 25998293 DOI: 10.2337/dc15-0100] [Citation(s) in RCA: 210] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Continuous glucose monitoring highlights the complexity of postprandial glucose patterns present in type 1 diabetes and points to the limitations of current approaches to mealtime insulin dosing based primarily on carbohydrate counting. METHODS A systematic review of all relevant biomedical databases, including MEDLINE, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, was conducted to identify research on the effects of dietary fat, protein, and glycemic index (GI) on acute postprandial glucose control in type 1 diabetes and prandial insulin dosing strategies for these dietary factors. RESULTS All studies examining the effect of fat (n = 7), protein (n = 7), and GI (n = 7) indicated that these dietary factors modify postprandial glycemia. Late postprandial hyperglycemia was the predominant effect of dietary fat; however, in some studies, glucose concentrations were reduced in the first 2-3 h, possibly due to delayed gastric emptying. Ten studies examining insulin bolus dose and delivery patterns required for high-fat and/or high-protein meals were identified. Because of methodological differences and limitations in experimental design, study findings were inconsistent regarding optimal bolus delivery pattern; however, the studies indicated that high-fat/protein meals require more insulin than lower-fat/protein meals with identical carbohydrate content. CONCLUSIONS These studies have important implications for clinical practice and patient education and point to the need for research focused on the development of new insulin dosing algorithms based on meal composition rather than on carbohydrate content alone.
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Affiliation(s)
- Kirstine J Bell
- Charles Perkins Centre and the School of Molecular Bioscience, The University of Sydney, Sydney, Australia Joslin Diabetes Center, Boston, MA
| | - Carmel E Smart
- Department of Paediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, Australia Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Rankin Park, Australia
| | - Garry M Steil
- Children's Hospital, Boston, MA Harvard Medical School, Boston, MA
| | - Jennie C Brand-Miller
- Charles Perkins Centre and the School of Molecular Bioscience, The University of Sydney, Sydney, Australia
| | - Bruce King
- Department of Paediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, Australia Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Rankin Park, Australia
| | - Howard A Wolpert
- Joslin Diabetes Center, Boston, MA Harvard Medical School, Boston, MA
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Lopez P, Smart C, Morbey C, McElduff P, Paterson M, King BR. Extended insulin boluses cannot control postprandial glycemia as well as a standard bolus in children and adults using insulin pump therapy. BMJ Open Diabetes Res Care 2014; 2:e000050. [PMID: 25489486 PMCID: PMC4256306 DOI: 10.1136/bmjdrc-2014-000050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/14/2014] [Accepted: 11/04/2014] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Insulin pumps are able to deliver bolus insulin as a standard, extended or combination bolus. There is minimal research to determine which bolus is preferable in different settings. Anecdotally, many patients utilizes only the standard bolus (SB) due to uncertainty regarding when and how to program the different bolus types. We compared postprandial glycemia when five different extended boluses (EBs) and an SB were used following a test meal. We sought to determine the impact of varying rates of insulin delivery from an EB on early postprandial glycemia. METHODS We conducted a randomized, repeated measures trial of 20 children and adults comparing postprandial glycemic excursions following EBs given at five different rates with SB as a control. All EBs were delivered over 2 h. Rates of EBs were chosen to reflect EBs used in clinical practice: EB1HR=100% of insulin:carbohydrate ratio (ICR) per hour (200% ICR total dose); EB2HR=50% of ICR per hour; EB3HR=33% of ICR per hour; EB4HR=25% of ICR per hour; EB6HR=16% ICR per hour. A standardized breakfast was given and activity was standardized. Continuous glucose monitoring was used to assess glycemia for 2 h after the meal. RESULTS The mean postprandial glycemic excursions were lower at 30, 60, and 90 min (p<0.05) for SB compared with all EBs. The mean peak postprandial glycemic excursion and the area under the curve was lower for SB compared with all EBs (p<0.05). DISCUSSION EBs resulted in higher postprandial glycemic excursions than SB for 2 h after the meal. For a moderate glycemic index meal EBs are unable to control glycemia for 2 h after a meal as well as SB. Further studies with different meal types are required to determine the impact of differential delivery of the EB on postprandial glycemia. TRIAL REGISTRATION NUMBER ACTRN12612000609853.
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Affiliation(s)
- Prudence Lopez
- Paediatric Endocrinology Department , John Hunter Children's Hospital , Newcastle, New South Wales , Australia ; Faculty of Health and Medicine , The University of Newcastle , Newcastle, New South Wales , Australia ; Hunter Medical Research Institute , Newcastle, New South Wales , Australia
| | - Carmel Smart
- Paediatric Endocrinology Department , John Hunter Children's Hospital , Newcastle, New South Wales , Australia ; Faculty of Health and Medicine , The University of Newcastle , Newcastle, New South Wales , Australia ; Hunter Medical Research Institute , Newcastle, New South Wales , Australia
| | - Claire Morbey
- AIM Diabetes Centre , Newcastle, New South Wales , Australia
| | - Patrick McElduff
- Faculty of Health and Medicine , The University of Newcastle , Newcastle, New South Wales , Australia
| | - Megan Paterson
- Paediatric Endocrinology Department , John Hunter Children's Hospital , Newcastle, New South Wales , Australia ; Faculty of Health and Medicine , The University of Newcastle , Newcastle, New South Wales , Australia ; Hunter Medical Research Institute , Newcastle, New South Wales , Australia
| | - Bruce R King
- Paediatric Endocrinology Department , John Hunter Children's Hospital , Newcastle, New South Wales , Australia ; Faculty of Health and Medicine , The University of Newcastle , Newcastle, New South Wales , Australia ; Hunter Medical Research Institute , Newcastle, New South Wales , Australia
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Heinemann L. Insulin pump therapy: what is the evidence for using different types of boluses for coverage of prandial insulin requirements? J Diabetes Sci Technol 2009; 3:1490-500. [PMID: 20144405 PMCID: PMC2787051 DOI: 10.1177/193229680900300631] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Bolus infusion of insulin along with a meal is a standard procedure with continuous subcutaneous insulin infusion. Modern insulin pumps allow applying this bolus in four different ways: infusion of the total dose at once or splitting the dose into two boluses, infusion of a part of the bolus in the usual manner plus infusion of the other part over a prolonged period of time (with a higher infusion rate than the basal rate), or infusion of the total dose in the form of an elevated basal rate. Depending on the composition of the given meal and its glycemic index, this is an attempt to match the circulating insulin levels to the rate of glucose absorption from the gut in order to minimize postprandial glycemic excursions. However, in the framework of evidence-based medicine, the benefits of this approach should be proven in appropriately designed clinical studies. Performance of meal-related studies requires careful attention to many aspects in order to allow meaningful evaluation of a given intervention (i.e., type of bolus). Critical evaluation of the clinical experimental studies and the one clinical study published about the impact of different types of boluses on postprandial metabolic control revealed fundamental shortcomings in study design and performance in these studies. Insufficient establishment of comparable preprandial glycemia and insulinemia on the different study days within and between the patients studied is one key aspect. Therefore, the recommendation made in most of these studies (i.e., use of dual-wave bolus) has to be accepted with care, until we have better evidence.
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Affiliation(s)
- Lutz Heinemann
- Profil Institut für Stoffwechselforschung, GmbH, Neuss, Germany.
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