University College Hospital. Managing meals high in protein and/or fat a guide for Omnipod pump users

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1 University College Hospital Managing meals high in protein and/or fat a guide for Omnipod pump users Children and Young people s diabetes service This information is based on the research and experience of Dr Carmel Smart and her team at the John Hunter Childrens Hospital, Newcastle, Australia. We thank them for their support in producing this resource. We know that two meals with the same amount of carbohydrate may have a different impact on blood glucose levels. This may depend on a variety of factors such as: How quickly the carbohydrate is digested and released (the glycaemic index, see our factsheet on glycaemic index for more information) How much fat and protein is in the meal. To manage meals you can adjust: Insulin timing, insulin should be given 15minutes before all meals, some meals need insulin to be given minutes before eating The type of bolus The insulin dose Meals that contain large amounts of protein (25g or more) and/or fat (20g or more) may cause high blood glucose levels 3-5+ hours after eating. High fat and protein meals delay digestion and absorption of carbohydrate and cause some insulin resistance after the meal. Smaller amounts of fat or protein may impact the blood glucose levels of younger children. Use the Carbs & Cals book/app or food labels to identify the fat and protein content of meals. High fat and protein meals may require larger insulin doses.

2 The types of meals that you may find difficult to manage include; 1. Creamy or cheesy pasta dishes 2. Fast food, e.g. pizza, burgers, fries etc. 3. Curries and other Asian meals 4. Pastries 5. Desserts How to identify which meals impact blood glucose levels: 1. Is your insulin to carbohydrate ratio correct? If the blood glucose level is in target 2 hours after eating your ratio is probably correct. 2. Are you carbohydrate counting accurately? It s good practice to regularly weigh your portions; your portion sizes can increase as you grow without you realising. 3. Is your blood glucose level raised repeatedly 3-5 hours after the meal? Check your blood glucose levels after meals you think may be a problem, for example 3, 5 and 7 hours after eating. 4. If you use a continuous glucose sensor, this can be a useful way to check post meal blood glucose levels. 5. Make a note of the foods that have resulted in high blood glucose levels at these times and try changing insulin delivery to manage these meals. 6. Meals containing lower amounts of carbohydrate, that are high in protein and fat may increase blood glucose levels more than meals with larger carbohydrate amounts Steps to manage high fat/high protein meals causing delayed high blood glucose levels:

3 Step 1 - Trial an extended bolus 1. Calculate the carbohydrate content of the meal. 2. Give the insulin required for the carbohydrate content as an extended bolus (if you also require a correction dose of insulin, this will be automatically added to the immediate bolus) 3. Give 60% of the insulin immediately now as a bolus and 40% over a 3hour duration as the extended bolus 1. Test and record your blood glucose level at 3, 5 and 7 hours after you have finished your meal Extended bolus Immediately now = 60% Later extend = 40% After using an extended bolus, if blood glucose levels remain elevated at 3, 5 and 7 hours after eating you may need to consider giving extra insulin.

4 Step 2- Try extra insulin 20% increase We recommend you wear a sensor when trying increased insulin doses 1. Research shows that some meals require extra insulin. 2. Talk to your dietitian first before you do this for individual advice. 3. Try increasing the dose the pump suggests for the carbohydrate by 20%, the easiest way to do this is to enter 20% more carbohydrate than you are eating into the pump (use the table at the back to help calculate this amount). 4. Enter your blood glucose level and use the table to help guide how many extra grams of carbs to enter into the pump. 5. Continue to use the 60%:40% extended bolus over a 3hour duration with the increased insulin dose If after trying steps 1 and 2 you still find blood glucose levels are elevated you should slowly increase the total insulin further, in 5-10% increments. Step 3- Slowly increase the insulin dose further 1. You should never increase the insulin without first testing at 3, 5 and 7 hours after the meal. Wear a sensor if possible. 2. You should always discuss with your dietitian as you increase. 3. You should begin with adding an additional 10%, and build up in no more than 10% increments at a time. Do not go above a 40% increase 4. Very high in fat (>40g) and protein (>75g) meals may need a 40% increase. Bigger increases are associated with delayed hypoglycaemia so are not recommended. 5. You should carefully increase and always monitor at 3, 5 and 7-8 hours after the meal to ensure you do not have hypoglycaemia. 6. Continue to use the 60%:40% extended bolus over a 3hour duration with the increased insulin doses The table at the back will help you gradually increase the insulin by increasing the amount of carbohydrate entered into the pump

5 Step 4: Extending the duration You may also find for some meals you need the insulin delivered over longer than three hours. For some meals you may find after trying additional insulin you also need to extend the time which the insulin will be delivered over. This may be needed for the meals which you found required 30% or more insulin than what was suggested for the food bolus. Start with extending the duration to 4hours. Remember, if you eat these meals following very active days, you may find you do not need any additional dose or you may find you need less additional insulin than you would on less active days. Please consult your diabetes team for guidance on specific foods and how to individualise your management for different meal types.

6 . Start with 20% and slowly increase the insulin dose only if needed Amount of carbohydrate to use for bolus calculation (g) Meal carbohydrate amount (g) 20% 30% 40% Contact Details: You can contact the Childrens Diabetes Dietitians on or You can find expert advice and information about children and young people's type 1 diabetes at If you need a large print, audio or translated copy of this document, please contact us on. We will try our best to meet your needs. First published: December 2018 Date last reviewed: December 2018 Date next review due: December 2020 Leaflet code: UCLH/SH/PAED/CYPDS/MEALSOMNIPOD/1 University College London Hospitals NHS Foundation Trust