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

The effect of the modified fat-protein unit algorithm compared with that of carbohydrate counting on postprandial glucose in adults with type-1 diabetes when consuming meals with differing macronutrient compositions: a randomized crossover trial

BACKGROUND

The optimization of glucose control in type-1 diabetes is challenged by postprandial glycemic variability. This study aimed to compare the postprandial glycemic effects of carbohydrate counting and the modified fat-protein unit (FPU) algorithms following meals with different protein and fat emphases in adults with type-1 diabetes.

METHODS

Thirty adults with type-1 diabetes aged 18 to 45 years participated in a randomized crossover trial. In a random order, participants consumed four test meals with equivalent energy and different macronutrient emphases on four separate mornings. The modified FPU algorithms and carbohydrate counting were used to determine the insulin dose for the test meals. A continuous glucose monitoring system was used to measured postprandial glycemia.

RESULTS

Compared with carbohydrate counting, the modified FPU algorithm significantly decreased the late postprandial mean glucose levels (p = 0.026) in high protein-fat meals. The number of hypoglycemia episodes was similar between insulin dosing algorithms for the high protein-fat meals; hypoglycemic events were considerably higher for the modified FPU in the normal protein-fat meal (p = 0.042).

CONCLUSIONS

The modified FPU algorithm may improve postprandial glycemic control after consuming high protein-fat meals in adults with type-1 diabetes but may result in increased hypoglycemia risk when used with a normal protein-fat meal.

Pure-protein load for children with type 1 diabetes: is any additional insulin needed? A randomized controlled study

AIMS

Study in adults with T1D showed that delivery of insulin for pure-protein meals may not be obligatory. The aim of this study was to assess the effects of whey isolate protein drink consisting of 50 g/200 kcal from pure protein on postprandial glycemia (PPG) following with square-wave insulin bolus in comparison with no insulin strategy in T1D children on insulin pumps.

METHODS

This was a randomized, double-blind, cross-over study including 58 children with mean: age 14.62 ± 3.64 years. Participants were randomly assigned into two treatment orders: NB-SQ (no bolus on the first day) and SQ-NB (square-bolus on the first day). The primary outcome was PPG during a 5-h follow-up. The secondary outcome was the frequency of hypoglycemia and glycemic variability parameters.

RESULTS

PPG [mg/dl] since 150 min of the follow-up was significantly lower when square-wave bolus was delivered (group SQ vs NB); at 150, 180, 210, 240, 270, 300 min: 130.6 versus 154.5 (p = 0.009), 153.4 versus 124.9 (p = 0.004), 151.0 versus 118.7 (p = 0.003), 146.4 versus 114.2 (p = 0.002), 141.2 versus 107.7 (p = 0.001), 131.0 versus 105.1 (p = 0.005). We observed statistically significant difference in overall rate of hypoglycemia < 70 mg/dl between groups SQ versus NB: 6.8% versus 2.5% (p = 0.001). The overall rate of hypoglycemia below 54 mg/dl was < 1% (p = 0.452).

CONCLUSIONS

A meal containing 50 g of pure protein may be consumed without additional insulin dose. An additional square-wave bolus may be beneficial in reducing PPG. To avoid hypoglycemia, lower insulin dose should be calculated for 100 kcal from protein than for individual insulin-to-carb ratio.

The Role of Protein and Fat Intake on Insulin Therapy in Glycaemic Control of Paediatric Type 1 Diabetes: A Systematic Review and Research Gaps

Carbohydrate counting (CHC) is the established form of calculating bolus insulin for meals in children with type 1 diabetes (T1DM). With the widespread use of continuous glucose monitoring (CGM) observation time has become gapless. Recently, the impact of fat, protein and not only carbohydrates on prolonged postprandial hyperglycaemia have become more evident to patients and health-care professionals alike. However, there is no unified recommendation on how to calculate and best administer additional bolus insulin for these two macronutrients. The aim of this review is to investigate: the scientific evidence of how dietary fat and protein influence postprandial glucose levels; current recommendations on the adjustment of bolus insulin; and algorithms for insulin application in children with T1DM. A PubMed search for all articles addressing the role of fat and protein in paediatric (sub-)populations (<18 years old) and a mixed age population (paediatric and adult) with T1DM published in the last 10 years was performed. Conclusion: Only a small number of studies with a very low number of participants and high degree of heterogeneity was identified. While all studies concluded that additional bolus insulin for (high) fat and (high) protein is necessary, no consensus on when dietary fat and/or protein should be taken into calculation and no unified algorithm for insulin therapy in this context exists. A prolonged postprandial observation time is necessary to improve individual metabolic control. Further studies focusing on a stratified paediatric population to create a safe and effective algorithm, taking fat and protein into account, are necessary.