Clinical Application of the Food Insulin Index for Mealtime Insulin Dosing in Adults with Type 1 Diabetes: A Randomized Controlled Trial

A collectanea of food insulinaemic index: 2023

BACKGROUND AND AIMS

To systematically update and publish the lnsulinaemic Index (II) value compilation of food/beverages.

METHODS

A literature search identified around 400 scholarly articles published between inception and December 2023. II values were pooled according to the selection criteria of at least 10 healthy, non-diabetic subjects with normal BMI. In addition, the II reported should have been derived from incremental area under the curve (iAUC) calculation of the insulin concentration over time. The reference food used from the pooled articles were either glucose or bread.

RESULTS

The II of 629 food/beverage items were found from 80 distinct articles. This is almost a five-fold increase in the number of entries from a previous compilation in 2011. Furthermore, these articles originated from 32 different countries, and were cleaved into 25 food categories. The II values ranged from 1 to 209. The highest overall recorded II was for a soy milk-based infant formula while the lowest was for both acacia fibre and gin. Upon clustering to single food, the infant formula retained the highest II while both acacia fibre and gin maintained the lowest recording. As for mixed meal, a potato dish served with a beverage recorded the highest II while a type of taco served with a sweetener, vegetable and fruit had the lowest II. Our minimum and maximum II data values replace the entries reported by previous compilations.

CONCLUSION

Acknowledging some limitations, these data would facilitate clinical usage of II for various applications in research, clinical nutrition, clinical medicine, diabetology and precision medicine. Future studies concerning II should investigate standardisation of reference food, including glucose and the test food portion. Although this collectanea adds up new food/beverages II values, priority should be given to populate this database.

Carbohydrate counting knowledge and ambulatory glucose profile in persons living with type 1 diabetes

CONTEXT

The amount of consumed carbohydrates is the strongest factor influencing glucose levels during the four hours following a meal. Our aim was to evaluate the association between carbohydrate counting knowledge and continuous glucose monitoring (CGM) parameters in patients with type 1 diabetes (T1D) using different insulin regimens.

METHOD

In this multicenter prospective study, the GluciQuizz questionnaire was used to evaluate carbohydrate knowledge. CGM data for the 14 days preceding completion of the questionnaire were analyzed. The primary endpoint was evaluation of the correlation between the GluciQuizz total score and time in range (TIR) in the study population.

RESULTS

The mean age of the 170 participants was 40.7 ± 14.8 years and duration of T1D 18.8 ± 12.1 years. The mean GluciQuizz total score for all participants was 66 ± 13 %. Mean TIR was 58.6 ± 18.7 %. GluciQuizz total score positively correlated with TIR (r = 0.3001; p < 0.0001). This correlation was observed in CSII users (r = 0.2526; p < 0.05) but not in MDI (r = 0.2510; p = 0.1134) and HCL users (r = -0.1065; p = 0.4914). TIR was also negatively correlated with the mean carb count error in all study participants (r = -0.2317; p < 0.01).

CONCLUSION

In conclusion, as the Gluciquizz score was associated with metabolic control, this easy-to-use self-administered questionnaire could be used widely on a routine basis to assess the carbohydrate knowledge of T1D patients and to offer them targeted education tailored to their needs.

The Application of the Food Insulin Index in the Prevention and Management of Insulin Resistance and Diabetes: A Scoping Review

The food insulin index (FII) is a novel algorithm used to determine insulin responses of carbohydrates, proteins, and fats. This scoping review aimed to provide an overview of all scientifically relevant information presented on the application of the FII in the prevention and management of insulin resistance and diabetes. The Arksey and O'Malley framework and the PRISMA Extension for Scoping Reviews 22-item checklist were used to ensure that all areas were covered in the scoping review. Our search identified 394 articles, of which 25 articles were included. Three main themes emerged from the included articles: 1. the association of FII with the development of metabolic syndrome, insulin resistance, and diabetes, 2. the comparison of FII with carbohydrate counting (CC) for the prediction of postprandial insulin response, and 3. the effect of metabolic status on the FII. Studies indicated that the FII can predict postprandial insulin response more accurately than CC, and that a high DII and DIL diet is associated with the development of metabolic syndrome, insulin resistance, and diabetes. The FII could be a valuable tool to use in the prevention and management of T1DM, insulin resistance, and T2DM, but more research is needed in this field.

Postprandial glucose metabolism in children and adolescents with type 1 diabetes mellitus: potential targets for improvement

The main goal of therapeutic management of type 1 Diabetes Mellitus (T1DM) is to maintain optimal glycemic control to prevent acute and long-term diabetes complications and to enable a good quality of life. Postprandial glycemia makes a substantial contribution to overall glycemic control and variability in diabetes and, despite technological advancements in insulin treatments, optimal postprandial glycemia is difficult to achieve. Several factors influence postprandial blood glucose levels in children and adolescents with T1DM, including nutritional habits and adjustment of insulin doses according to meal composition. Additionally, hormone secretion, enteroendocrine axis dysfunction, altered gastrointestinal digestion and absorption, and physical activity play important roles. Meal-time routines, intake of appropriate ratios of macronutrients, and correct adjustment of the insulin dose for the meal composition have positive impacts on postprandial glycemic variability and long-term cardiometabolic health of the individual with T1DM. Further knowledge in the field is necessary for management of all these factors to be part of routine pediatric diabetes education and clinical practice. Thus, the aim of this report is to review the main factors that influence postprandial blood glucose levels and metabolism, focusing on macronutrients and other nutritional and lifestyle factors, to suggest potential targets for improving postprandial glycemia in the management of children and adolescents with T1DM.

14. Children and Adolescents: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Efficacy and safety of carbohydrate counting versus other forms of dietary advice in patients with type 1 diabetes mellitus: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND AND AIMS

Diabetes mellitus (DM) is one of the most prevalent chronic non-communicable diseases globally, and the only way to reduce its complications is good glycemic control. Insulin remains the only approved treatment for type 1 DM (T1DM) and is used by many with Type 2 DM (T2DM). Carbohydrate counting is considered the ideal way to calculate meal-related insulin doses since it allows greater flexibility in diet and could, in some people, reduce the burden of the disease. This systematic review's primary objective was to assess carbohydrate counting efficacy in reducing glycated hemoglobin (HbA_1c ) and safety by not increasing hypoglycemia risk, inducing an increase in body weight or blood lipids, and reducing the quality of life of people with T1DM.

METHODS

We included randomized controlled clinical trials with a parallel-group design comparing any carbohydrate counting forms with standard care or other forms of dietary advice or insulin dose calculation in people with T1DM with a follow up period of at least three months and with no restrictions in language, age, or settings. As a primary outcome, we consider the change of HbA_1c within at least three months. Secondary outcomes were hypoglycemia events, body weight changes, blood lipids levels, and the total daily insulin dose. We also evaluated health-related quality of life changes and diabetes treatment satisfaction questionnaires.

RESULTS

Data from 11 studies with 899 patients were retrieved with a mean follow of 52 ± 35.5 weeks. Carbohydrate counting is not better in reducing HbA_1c , SMD - 0.24% (95%CI -0.68 to 0.21) than all dietary advice forms. However, this finding was highly heterogeneous. We identified three studies that account for most of the heterogeneity using clustering algorithms. A second analysis excluding these studies shows a meaningful HbA_1c reduction, SMD - 0.52% (95%CI -0.82 to -0.23) with low heterogeneity. In the subgroup analysis, carbohydrate counting significantly reduces HbA_1c compared to usual diabetes education. Carbohydrate counting doesn't relate to any substantial change in blood lipids, body weight, hypoglycemia risk, or daily insulin dose. Finally, we analyzed the effect of trial duration with HbA_1c reduction and found no significant change related to time.

CONCLUSIONS

Carbohydrate counting is an efficacious technique to safely reduce HbA_1c in adults and children compared to standard diabetes education. And its effect doesn't seem to change with prolonged time. Standardization in reporting important outcomes like hypoglycemia and quality of life is vital to produce comparable evidence in carbohydrate counting clinical trials. This SR was registered in PROSPERO under code: CRD42020218499. This article is protected by copyright. All rights reserved.

Super Bolus: a remedy for a high glycemic index meal in children with type 1 diabetes on insulin pump therapy?-study protocol for a randomized controlled trial

Background

Postprandial hyperglycemia (PPH) is a common clinical problem among patients with type 1 diabetes (T1D), which is related to high glycemic index (h-GI) meals. The main problem is linked to high, sharp glycemic spikes following hypoglycemia after h-GI meal consumption. There is a lack of effective and satisfactory solutions for insulin dose adjustment to cover an h-GI meal. The goal of this research was to determine whether a Super Bolus is an effective strategy to prevent PPH and late hypoglycemia after an h-GI meal compared to a Normal Bolus.

Methods

A total of 72 children aged 10–18 years with T1D for at least 1 year and treated with continuous subcutaneous insulin infusion for more than 3 months will be enrolled in a double-blind, randomized, crossover clinical trial. The participants will eat a h-GI breakfast for the two following days and receive a prandial insulin bolus in the form of a Super Bolus 1 day and a Normal Bolus the next day. The glucose level 90 min after the administration of the prandial bolus will be the primary outcome measure. The secondary endpoints will refer to the glucose levels at 30, 60, 120, 150, and 180 min postprandially, the area under the blood glucose curve within 180 min postprandially, peak glucose level and the time to peak glucose level, glycemic rise, the mean amplitude of glycemic excursions, and the number of hypoglycemia episodes.

Discussion

There are still few known clinical studies on this type of bolus. A Super Bolus is defined as a 50% increase in prandial insulin dose compared to the dose calculated based on the individualized patient’s insulin-carbohydrate ratio and a simultaneous suspension of basal insulin for 2 h. Our patients reported the best experience with such a combination. A comprehensive and effective solution to this frequent clinical difficulty of PPH after an h-GI meal has not yet been found. The problem is known and important, and the presented solution is innovative and easy to apply in everyday life.

Trial registration

ClinicalTrials.gov NCT04019821

Impact of Fat Intake on Blood Glucose Control and Cardiovascular Risk Factors in Children and Adolescents with Type 1 Diabetes

Nutrition therapy is a cornerstone of type 1 diabetes (T1D) management. Glycemic control is affected by diet composition, which can contribute to the development of diabetes complications. However, the specific role of macronutrients is still debated, particularly fat intake. This review aims at assessing the relationship between fat intake and glycemic control, cardiovascular risk factors, inflammation, and microbiota, in children and adolescents with T1D. High fat meals are followed by delayed and prolonged hyperglycemia and higher glycated hemoglobin A1c levels have been frequently reported in individuals with T1D consuming high amounts of fat. High fat intake has also been associated with increased cardiovascular risk, which is higher in people with diabetes than in healthy subjects. Finally, high fat meals lead to postprandial pro-inflammatory responses through different mechanisms, including gut microbiota modifications. Different fatty acids were proposed to have a specific role in metabolic regulation, however, further investigation is still necessary. In conclusion, available evidence suggests that a high fat intake should be avoided by children and adolescents with T1D, who should be encouraged to adhere to a healthy and balanced diet, as suggested by ISPAD and ADA recommendations. This nutritional choice might be beneficial for reducing cardiovascular risk and inflammation.

Factors Beyond Carbohydrate to Consider When Determining Meantime Insulin Doses: Protein, Fat, Timing, and Technology

For many years, carbohydrate counting has been a popular strategy for determining mealtime insulin doses for people with diabetes who are on a multiple daily injection regimen or continuous subcutaneous insulin infusion. This approach assumes that only carbohydrate-containing foods and beverages affect postprandial glucose levels. However, many studies have indicated that the fat and protein content of a meal can play an important role in delaying postprandial hyperglycemia and should be considered when trying to optimize postprandial glucose levels. This article reviews research on making insulin dose adjustments for high-fat and high-protein meals, as well as the timing of mealtime insulin doses.

Safety and effectiveness of stoss therapy in children with vitamin D deficiency

AIM

Paediatric vitamin D (25-hydroxyvitamin D (25OHD)) deficiency can lead to nutritional rickets and extra-skeletal complications. Compliance with daily therapy can be difficult, making high-dose, short-term vitamin D (stoss) therapy attractive to correct vitamin D deficiency. We compared the effectiveness and safety of standard versus stoss therapy in treating childhood 25OHD deficiency.

METHODS

Children aged 2-16 years with 25OHD <50 nmol/L were randomised to either standard (5000 IU daily for 80 days) or stoss (100 000 IU weekly for 4 weeks) cholecalciferol. Participants underwent an evaluation of effectiveness and safety. The 25OHD level, random spot calcium: creatinine ratio (Ca:Cr) and compliance were measured at 12 weeks.

RESULTS

A total of 151 children were enrolled in the study (68 standard and 83 stoss), median age 9 years (inter-quartile range (IQR): 6-12 years). Baseline 25OHD levels were 26 nmol/L (IQR: 19-35 nmol/L) and 32 nmol/L (IQR: 24-39 nmol/L) in the standard and stoss groups, respectively. At 12 weeks, the median 25OHD level was significantly greater in the standard versus stoss group (81 vs. 67 nmol/L; P = 0.005); however, >80% of participants in both groups achieved sufficiency (25OHD > 50 nmol/L) and had normal urinary Ca:Cr, with no significant difference seen between groups. Compliance was similar in the two groups.

CONCLUSIONS

Compared to stoss, standard therapy achieved higher 25OHD levels at 12 weeks; however, in both groups, there was a similar proportion of participants who achieved 25OHD sufficiency, with no evidence of toxicity. Unlike other studies, simplifying the treatment regimen did not improve compliance. These results support stoss therapy as an effective and safe alternative therapy for the treatment of paediatric vitamin D deficiency.

Effects of basic carbohydrate counting versus standard outpatient nutritional education (The BCC Study): study protocol for a randomised, parallel open-label, intervention study focusing on HbA1c and glucose variability in patients with type 2 diabetes

INTRODUCTION

Recommendations on energy intake are key in body weight management to improve glycaemic control in people with type 2 diabetes (T2D). International clinical guidelines recommend a variety of eating patterns to promote energy restriction as the primary dietetic approach to body weight control in managing T2D. In addition, individualised guidance on self-monitoring carbohydrate intake to optimise meal timing and food choices (eg, basic carbohydrate counting (BCC)) is recommended to achieve glycaemic control. However, the evidence for this approach in T2D is limited. The objective of this study was to compare the effect of an educational programme in BCC as add-on to the usual dietary care on glycaemic control in people with T2D.

METHODS AND ANALYSES

The study is designed as a randomised, controlled trial with a parallel-group design. The study duration is 12 months with data collection at baseline, and after 6 and 12 months. We plan to include 226 adults with T2D. Participants will be randomised to one of two interventions: (1) BCC as add-on to usual dietary care or (2) usual dietary care. The primary outcome is changes in glycated haemoglobin A1c or mean amplitude of glycaemic excursions from baseline and after 6-month intervention between and within study groups. Further outcome measures include changes in time in range, body weight and composition, lipid profile, blood pressure, mathematical literacy skills, carbohydrate estimation accuracy, dietary intake, diet-related quality of life, perceived competencies in diet and diabetes and perceptions of an autonomy supportive dietician-led climate, physical activity and urinary biomarkers.

ETHICS AND DISSEMINATION

The protocol has been approved by the Ethics Committee of the Capital Region, Copenhagen, Denmark. Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03623139.

The dietary education trial in carbohydrate counting (DIET-CARB Study): study protocol for a randomised, parallel, open-label, intervention study comparing different approaches to dietary self-management in patients with type 1 diabetes

INTRODUCTION

Clinical guidelines recommend that patients with type 1 diabetes (T1D) learn carbohydrate counting or similar methods to improve glycaemic control. Although systematic educating in carbohydrate counting is still not offered as standard-of-care for all patients on multiple daily injections (MDI) insulin therapy in outpatient diabetes clinics in Denmark. This may be due to the lack of evidence as to which educational methods are the most effective for training patients in carbohydrate counting. The objective of this study is to compare the effect of two different educational programmes in carbohydrate counting with the usual dietary care on glycaemic control in patients with T1D.

METHODS AND ANALYSIS

The study is designed as a randomised controlled trial with a parallel-group design. The total study duration is 12 months with data collection at baseline, 6 and 12 months. We plan to include 231 Danish adult patients with T1D. Participants will be randomised to one of three dietician-led interventions: (1) a programme in basic carbohydrate counting, (2) a programme in advanced carbohydrate counting including an automated bolus calculator or (3) usual dietary care. The primary outcome is changes in glycated haemoglobin A1c or mean amplitude of glycaemic excursions from baseline to end of the intervention period (week 24) between and within each of the three study groups. Other outcome measures include changes in other parameters of plasma glucose variability (eg, time in range), body weight and composition, lipid profile, blood pressure, mathematical literacy skills, carbohydrate estimation accuracy, dietary intake, diet-related quality of life, perceived competencies in dietary management of diabetes and perceptions of an autonomy supportive dietician-led climate, physical activity and urinary biomarkers.

ETHICS AND DISSEMINATION

The protocol has been approved by the Ethics Committee of the Capital Region, Copenhagen, Denmark. Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03623113).

Postprandial Glucose Control in Type 1 Diabetes: Importance of the Gastric Emptying Rate

The achievement of optimal post-prandial (PP) glucose control in patients with type 1 diabetes (T1DM) remains a great challenge. This review summarizes the main factors contributing to PP glucose response and discusses the likely reasons why PP glucose control is rarely achieved in T1DM patients. The macronutrient composition of the meal, the rate of gastric emptying and premeal insulin administration are key factors affecting the PP glucose response in T1DM. Although the use of continuous insulin infusion systems has improved PP glucose control compared to conventional insulin therapy, there is still need for further ameliorations. T1DM patients frequently present a delayed gastric emptying (GE) that produces a lower but more prolonged PP hyperglycemia. In addition, delayed GE is associated with a longer time to reach the glycemic peak, with a consequent mismatch between PP glucose elevation and the timing of premeal insulin action. On this basis, including GE time and meal composition in the algorithms for insulin bolus calculation of the insulin delivery systems could be an important step forward for optimization of PP glucose control in T1DM.