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.

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Specific use of CSII during enteral nocturnal nutrition in a child with type 1 diabetes, Hashimoto's thyroiditis, and Down syndrome

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302013000500009 ◽

2013 ◽

Vol 57 (5) ◽

pp. 388-392 ◽

Cited By ~ 3

Author(s):

Barbara Piccini ◽

Sonia Toni ◽

Lorenzo Lenzi ◽

Federica Barni ◽

Monica Guasti ◽

...

Keyword(s):

Type 1 Diabetes ◽

Insulin Therapy ◽

Enteral Feeding ◽

Case Reports ◽

Scientific Evidence ◽

Nutrition Therapy ◽

Artificial Nutrition ◽

Diabetic Patients ◽

Glucose Levels

The management of insulin therapy in diabetic patients who have comorbidities that involve nutritional aspects, is a major challenge for diabetes care teams. In diabetic patients with compromised nutritional status, artificial nutrition, both enteral or parenteral, may help in the treatment of chronic and acute diseases, leading to better and faster recover of the health status but, if not adequately associated with insulin therapy, it may negatively affect blood glucose levels and lead to poorer metabolic control. In particular, evidence-based recommendations for the treatment of diabetic patients during enteral nutrition therapy are not currently available and, therefore, medical practices are often based on case reports, rather than outcomes of research. We report our experience with a diabetic patient receiving nocturnal enteral feeding due to comorbidities and malnutrition, who was followed up at our centre and precociously treated with continuous subcutaneous insulin infusion after the onset of type 1 diabetes. There is great need for adequately powered randomized controlled trials to provide scientific evidence for the insulin treatment of diabetic patients undergoing enteral feeding.

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Effects of Dietary Fat and Protein on Glucoregulatory Hormones in Adolescents and Young Adults With Type 1 Diabetes

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgab614 ◽

2021 ◽

Author(s):

Amelia J Harray ◽

Sabrina Binkowski ◽

Barbara L Keating ◽

Michael Horowitz ◽

Scott Standfield ◽

...

Keyword(s):

Type 1 Diabetes ◽

Dietary Fat ◽

Glucagon Secretion ◽

Postprandial Glucose ◽

High Protein ◽

Low Protein ◽

Insulin Clamp ◽

Glucoregulatory Hormones ◽

The Impact

Abstract Context Dietary fat and protein impact postprandial hyperglycemia in people with type 1 diabetes, but the underlying mechanisms are poorly understood. Glucoregulatory hormones are also known to modulate gastric emptying and may contribute to this effect. Objective Investigate the effects of fat and protein on glucagon-like peptide (GLP-1), glucagon-dependent insulinotropic polypeptide (GIP) and glucagon secretion. Methods 2 crossover euglycemic insulin clamp clinical trials at 2 Australian pediatric diabetes centers. Participants were 12-21 years (n = 21) with type 1 diabetes for ≥1 year. Participants consumed a low-protein (LP) or high-protein (HP) meal in Study 1, and low-protein/low-fat (LPLF) or high-protein/high-fat (HPHF) meal in Study 2, all containing 30 g of carbohydrate. An insulin clamp was used to maintain postprandial euglycemia and plasma glucoregulatory hormones were measured every 30 minutes for 5 hours. Data from both cohorts (n = 11, 10) were analyzed separately. The main outcome measure was area under the curve of GLP-1, GIP, and glucagon. Results Meals low in fat and protein had minimal effect on GLP-1, while there was sustained elevation after HP (80.3 ± 16.8 pmol/L) vs LP (56.9 ± 18.6), P = .016, and HPHF (103.0 ± 26.9) vs LPLF (69.5 ± 31.9) meals, P = .002. The prompt rise in GIP after all meals was greater after HP (190.2 ± 35.7 pmol/L) vs LP (152.3 ± 23.3), P = .003, and HPHF (258.6 ± 31.0) vs LPLF (151.7 ± 29.4), P < .001. A rise in glucagon was also seen in response to protein, and HP (292.5 ± 88.1 pg/mL) vs LP (182.8 ± 48.5), P = .010. Conclusion The impact of fat and protein on postprandial glucose excursions may be mediated by the differential secretion of glucoregulatory hormones. Further studies to better understand these mechanisms may lead to improved personalized postprandial glucose management.

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The Role of Age and Excess Body Mass Index in Progression to Type 1 Diabetes in At-Risk Adults

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/jc.2017-01490 ◽

2017 ◽

Vol 102 (12) ◽

pp. 4596-4603

Author(s):

Christine T Ferrara ◽

Susan M Geyer ◽

Carmella Evans-Molina ◽

Ingrid M Libman ◽

Dorothy J Becker ◽

...

Keyword(s):

Body Mass Index ◽

Type 1 Diabetes ◽

Body Mass ◽

Protective Factor ◽

Diabetes Incidence ◽

Increased Risk ◽

Diabetes Progression ◽

The Impact

Abstract Background Given the global rise in both type 1 diabetes incidence and obesity, the role of body mass index (BMI) on type 1 diabetes pathophysiology has gained great interest. Sustained excess BMI in pediatric participants of the TrialNet Pathway to Prevention (PTP) cohort increased risk for progression to type 1 diabetes, but the effects of age and obesity in adults remain largely unknown. Objective To determine the effect of age and sustained obesity on the risk for type 1 diabetes in adult participants in the TrialNet PTP cohort (i.e., nondiabetic autoantibody-positive relatives of patients with type 1 diabetes). Research Design and Methods Longitudinally accumulated BMI >25 kg/m2 was calculated to generate a cumulative excess BMI (ceBMI) for each participant, with ceBMI values ≥0 kg/m2 and ≥5 kg/m2 representing sustained overweight or obese status, respectively. Recursive partitioning analysis yielded sex- and age-specific thresholds for ceBMI that confer the greatest risk for type 1 diabetes progression. Results In this cohort of 665 adults (age 20 to 50 years; median follow-up, 3.9 years), 49 participants developed type 1 diabetes. Age was an independent protective factor for type 1 diabetes progression (hazard ratio, 0.95; P = 0.008), with a threshold of >35 years that reduced risk for type 1 diabetes. In men age >35 years and women age <35 years, sustained obesity (ceBMI ≥5 kg/m2) increased the risk for type 1 diabetes. Conclusions Age is an important factor for type 1 diabetes progression in adults and influences the impact of elevated BMI, indicating an interplay of excess weight, age, and sex in adult type 1 diabetes pathophysiology.

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Improved Nocturnal Glycaemia and Reduced Insulin Use Following Clinical Exercise Trial Participation in Individuals With Type 1 Diabetes

Frontiers in Public Health ◽

10.3389/fpubh.2020.568832 ◽

2021 ◽

Vol 8 ◽

Author(s):

Olivia McCarthy ◽

Rachel Deere ◽

Max L. Eckstein ◽

Jason Pitt ◽

Ben Wellman ◽

...

Keyword(s):

Clinical Trial ◽

Type 1 Diabetes ◽

Clinical Research ◽

Insulin Therapy ◽

Insulin Dose ◽

Moderate Intensity ◽

Trial Participation ◽

Acting Insulin ◽

The Impact

Aim: To explore the influence of clinical exercise trial participation on glycaemia and insulin therapy use in adults with type 1 diabetes (T1D).Research Design and Methods: This study involved a secondary analysis of data collected from 16 individuals with T1D who completed a randomized clinical trial consisting of 23-h in-patient phases with a 45-min evening bout of moderate intensity continuous exercise. Participants were switched from their usual basal-bolus therapy to ultra-long acting insulin degludec and rapid-acting insulin aspart as well as provided with unblinded interstitial flash-glucose monitoring systems. To assess the impact of clinical trial participation, weekly data obtained at the screening visit (pre-study involvement) were compared against those collated on the last experimental visit (post-study involvement). Interstitial glucose [iG] data were split into distinct glycaemic ranges and stratified into day (06:00–23:59) and night (00:00–05:59) time periods. A p-value of ≤ 0.05 was accepted for significance.Results: Following study completion, there were significant decreases in both the mean nocturnal iG concentration (Δ-0.9 ± 4.5 mmol.L−1, p < 0.001) and the time spent in severe hyperglycaemia (Δ-7.2 ± 9.8%, p = 0.028) during the night-time period. The total daily (Δ-7.3 ± 8.4 IU, p = 0.003) and basal only (Δ-2.3 ± 3.8 IU, p = 0.033) insulin dose requirements were reduced over the course of study involvement.Conclusions: Participation in clinical research may foster improved nocturnal glycaemia and reduced insulin therapy use in people with T1D. Recognition of these outcomes may help encourage volunteers to partake in clinical research opportunities for improved diabetes-related health outcomes.Clinical Trial Registration:DRKS.de; DRKS00013509.

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Exploring the Burden of Mealtime Insulin Dosing in Adults and Children With Type 1 Diabetes

10.2337/figshare.14932911.v1 ◽

2021 ◽

Author(s):

Wendy Lane ◽

Emma Lambert ◽

Jesso George ◽

Naveen Rathor ◽

Nandu Thalange

Keyword(s):

Quality Of Life ◽

Type 1 Diabetes ◽

Online Study ◽

Attitudes And Behaviors ◽

Adults And Children ◽

Mealtime Insulin ◽

Bolus Insulin ◽

The Impact

Timely and accurate mealtime insulin dosing can be an ongoing challenge for people with type 1 diabetes. This multinational, online study aimed to explore attitudes and behaviors around mealtime insulin dosing and the impact of mealtime dose timing, particularly with regard to premeal dosing (15–20 minutes before a meal). Although the majority of surveyed participants (96%) recognized the importance of accurate mealtime bolus insulin dosing, only a small proportion (35%) reported being “very confident” in accurate bolus insulin estimation. Given the choice, the majority of participants would prefer to administer insulin immediately before or after a meal, as this timing would improve their quality of life.<b></b>

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Exploring the Burden of Mealtime Insulin Dosing in Adults and Children With Type 1 Diabetes

10.2337/figshare.14932911 ◽

2021 ◽

Author(s):

Wendy Lane ◽

Emma Lambert ◽

Jesso George ◽

Naveen Rathor ◽

Nandu Thalange

Keyword(s):

Quality Of Life ◽

Type 1 Diabetes ◽

Online Study ◽

Attitudes And Behaviors ◽

Adults And Children ◽

Mealtime Insulin ◽

Bolus Insulin ◽

The Impact

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The Effect of Lockdown and Physical Activity on Glycemic Control in Italian Children and Young Patients With Type 1 Diabetes

Frontiers in Endocrinology ◽

10.3389/fendo.2021.690222 ◽

2021 ◽

Vol 12 ◽

Author(s):

Nicola Minuto ◽

Marta Bassi ◽

Carolina Montobbio ◽

Francesco Vinci ◽

Claudia Mercuri ◽

...

Keyword(s):

Physical Activity ◽

Type 1 Diabetes ◽

Glycemic Control ◽

Insulin Therapy ◽

Young Patients ◽

Lifestyle Changes ◽

Reduced Physical Activity ◽

Italian Children ◽

The Impact

AimsThe purpose of the study was to evaluate the impact of the lockdown established by the Italian government to limit the spread of Coronavirus disease (COVID-19) on glycemic control in a large sample of patients with type 1 diabetes (T1D) based on age, type of insulin therapy, number of telemedicine visits and physical activity.Material and MethodsWe retrospectively evaluated glycemic control in young T1D patients using the DexcomG6® system before the Italian lockdown (February 10–23, 2020—Time 0) and during lockdown (April 17–30, 2020—Time 1). Data on age, type of insulin therapy, number of telemedicine visits and physical activity of 202 patients with T1D and a median age of 18.2 years (range: 6–39) were collected.ResultsData showed a significant improvement of TIR from 54.58% at T0 to 59.09% at T1 (p ≤0.0001). Glycemic control improved significantly in patients ≥14 years old, showing the best outcome in the “university students and young adults” group (55.40% at T0 and 61.37% at T1, p ≤0.001). All patients reduced physical activity during lockdown; in the 56 patients of “intense physical activity” group both at T0 and T1 TIR increased from ±56.91 to 64.11% (p ≤0.0001).ConclusionsOverall, the lockdown led to an unexpected improvement in glycemic control of young patients with T1D. A healthier and stressless lifestyle changes in association with the maintenance of physical activity resulted in a significant age-proportional improvement in glycemic control.

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OPTIMAL REGIMENS OF THE BASAL-BOLUS INSULIN THERAPY IN ADOLESCENTS WITH TYPE 1 DIABETES MELLITUS

Bulletin of Siberian Medicine ◽

10.20538/1682-0363-2015-5-15-21 ◽

2015 ◽

Vol 14 (5) ◽

pp. 15-21

Author(s):

G. A. Galkina ◽

A. A. Voropay ◽

M. A. Levkovich ◽

S. V. Vorobiov ◽

M. V. Komkova ◽

...

Keyword(s):

Diabetes Mellitus ◽

Type 1 Diabetes ◽

Insulin Therapy ◽

Type 1 Diabetes Mellitus ◽

Bolus Insulin ◽

Basal Bolus

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Facilitation of motivation to self-management in pediatric diabetes health care consultations with adolescents with type 1 diabetes. A qualitative triangulation study

10.21203/rs.2.15261/v2 ◽

2020 ◽

Author(s):

Rose Marie Teyken ◽

Johanne Jeppesen Lomholt ◽

Anders Jørgen Schou

Keyword(s):

Health Care ◽

Type 1 Diabetes ◽

Health Care Professionals ◽

Developmental Process ◽

Self Management ◽

Care Clinic ◽

Qualitative Research Design ◽

Pediatric Diabetes ◽

The Impact

Abstract Background. The impact of health care professionals on the motivation for self-management in adolescents with type 1 diabetes has been highlighted as important. It is, however, not well understood how pediatric diabetes health care practitioners can help adolescents become more motivated to self-management. The aim of the study was to investigate how practitioners can motivate their patients to self-management in consultation and how adolescents with type 1 diabetes experienced that consultation could facilitate motivation to self-management. Methods. Based on a qualitative research design, the study triangulated participant observations of 11 consultations at a pediatric health care clinic and 10 interviews of the adolescents (15-17 years of age) about their experiences of consultations. Using Giorgi’s phenomenological method, the analysis showed five categories important to consultation-facilitated motivation to self-management: 1. Consultation setting, 2. Consultation conversation, 3. Roles in treatment, 4. Assuming consultation-facilitated responsibility for self-management, and 5. Relationship in treatment. Results from the analysis were compared to fulfilment of the motivational needs for autonomy, competence and relatedness described in Self-Determination Theory. Results. Overall findings showed that the adolescent’s developmental process of becoming autonomous in relation to self-management was influenced by consultations, and that the need for relatedness was experienced as valued by the adolescents. Conclusions. The conclusion of the study was that relatedness and development of autonomy were experienced as important for how consultations could facilitate motivation to self-management in 15-17-year-olds and may be fundamental to adolescents’ experience of competence in relation to self-management.

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