Dr Kirstie Bell APD/CDE, PhD University of Sydney. Beyond Carb Counting: Dietary Fat & Protein in T1D

Transcription

1 Dr Kirstie Bell APD/CDE, PhD University of Sydney Beyond Carb Counting: Dietary Fat & Protein in T1D

2 Carb Counting Carb Counting is gold standard method for adjusting mealtime insulin doses Carbohydrates don t affect blood glucose levels equally (Glycemic Index) Evidence for the efficacy of carbohydrate counting is limited Treating symptoms vs. cause Lots of factors stimulate insulin production

3 Carbohydrate Counting Does Not Significantly Improve HbA1c Overall change in HbA1c: -0.35% points (p = 0.096) Bell et al, Lancet Diab & Endo 2014; 2(2):

4 Dietary Fat, Protein & BGL Dietary fat & protein are insulin secretagogues In healthy individuals, minimal impact on BGL but significant insulin response In T1D, insufficient mealtime insulin = substantial postprandial hyperglycaemia Normal BGL High BGL Insulin Meal Insulin Meal

5 Dietary Fat Seven studies (103 patients) All studies showed dietary fat influenced glycaemia Reduces early postprandial glucose rise (first 2-3h) Delays peak glucose level Leads to late postprandial hyperglycaemia ( 3h) High fat meals ( 35g of fat) requires insulin adjustment Bell et al. Diabetes Care 2015; 38:

6 Dietary Protein Seven studies (125 patients) All studies showed dietary protein influenced glycaemia Delayed effect on glycaemia (>100 mins) Different effect with and without carbohydrate Insulin adjustment needed for: 30g protein with carbs 75g protein alone Bell et al. Diabetes Care 2015; 38:

7 Dietary Fat Increases BGL and Insulin Requirements High Fat vs Low Fat Dinner on postprandial BGL using closed loop insulin delivery Wolpert et al. Diabetes Care 2013;36:

8 Fat and Protein Increase Insulin Requirements Fat & Protein (HF/HP) Fat (HF/LP) Protein (LF/HP) CHO (LF/LP) Smart et al. Diabetes Care 2013; 36:

9 Change in BGL (mmol/l) Dietary Fat & Protein Raise BGL Low Fat, Low Protein High Fat, High Protein 5.5 mmol/l Time (Minutes) Bell (2016) Diabetes Care 39(9):

10 Pure Protein Raises BGL Paterson et al. Diabetic Medicine 2016;33(5)

11 How should Insulin Doses be Adjusted for Protein/Fat?

12 Warsaw Insulin Pump Therapy (Pankowska) Method

13 Fat/Protein Unit (FPU) Counting Warsaw School of Insulin Pump Therapy have developed a novel algorithm to calculate the total insulin dose needed to cover carbohydrate plus protein & fat. Fat and Protein is counted together as a Fat and Protein Unit (FPU), where 1 FPU = 100kCal of fat and/or protein. How to dose insulin: 1. Normal wave bolus for carbohydrate using usual ICR 2. Dual or square wave bolus for FPU using same ICR and run over 3-8hr depending on number of FPU Pankowska et al Pediatric Diabetes 2009; 10(5):

14 Example: Cheese Pizza 2 Slices = 45g Carbs = 9g Fat (81Kcal) = 20g Protein (80Kcal) If ICR is 1u:1x 15g Carb Exchange Then need 3 units for Carbs 161 Kcal = 1 FPU = +1 unit of insulin Delivered as Dual Wave 3u upfront (75%), 1u (25%) over 3h Pankowska et al Pediatric Diabetes 2009; 10(5):

15 Model Predicted Boluses

16 Model Predicted Boluses Optimised insulin dose is determined through mathematical modelling Observe the effect of insulin dose & nutrients on glycaemia Predict insulin dose needed to optimise blood glucose level Trial the predicted insulin dose to see if accurate Bell (2016) Diabetes Care 39(9):

17 Objective To optimally define: What insulin DOSE is needed? What percentage should be given immediately (Split)? How long to extend the remaining portion (Duration)? Bell (2016) Diabetes Care 39(9):

18 Methods 10 adults with type 1 diabetes using insulin pump therapy & CGM Admitted to the Joslin Diabetes CRC on 3 to 7 occasions On the first 2 occasions, subjects were given a Low Fat and a High Fat meal with the insulin dose calculated using Carbohydrate: Insulin Ratio (CIR) with dual wave 50/50% over 2 hrs 6 hour postprandial venous BGL monitoring Bell (2016) Diabetes Care 39(9):

19 Test Meals Low Fat Meal Pizza & Tomato Paste 50g Carbohydrate 9g Protein 4g Fat High Fat Meal Pizza, Tomato Paste & Cheese 50g Carbohydrate (equal) 36g Protein (+27g) 44g Fat (+40g) Bell (2016) Diabetes Care 39(9):

20 Methods Subsequent sessions, subjects were given the same high fat/high protein meal with insulin dose, split and duration calculated using Model Predicted Bolus (MPB) For safety, insulin dose was limited to a 75% increase per session High fat/high protein meal repeated with new MPB until BG response optimised Bell (2016) Diabetes Care 39(9):

21 Blood Glucose Level (mmol/l) Adding 40g Fat & 27g Protein Increases Postprandial Glycaemia LFLP HFHP No Patients had Hypo Time (Minutes) 5.5 mmol/l Bell (2016) Diabetes Care 39(9):

22 Blood Glucose Level (mmol/l) 75% More Insulin Required Dual Wave: 30/70% over 2.5hr LFLP HFHP HFHP - Optimised Time (Minutes) No Patients had Hypo Bell (2016) Diabetes Care 39(9):

23 Food Insulin Index (FII)

24 Estimating Mealtime Insulin Dose in Type 1 Diabetes Current Thinking Carbohydrate Counting Novel Thinking Insulin Response in Healthy Individuals Glycaemic Response Insulin Demand Bolus Insulin Dose Bolus Insulin Dose

25 Food Insulin Index (FII) Relative measure of the normal insulin demand of a food Insulin response measured in healthy adults Foods measured in 1000kJ portions Relative to a reference food FII = 120min AUCInsulin for 1000kJ of test food x min AUCInsulin for 1000kJ of ref. food Published FII represents the average of 10 subjects Developed a FII database of 147 foods Bao et al. Am J Clin Nutr 2011; 93:

26 Jellybeans Sweet Potato, steamed Original Shredded Wheat Baked Beans Low-fat Strawberry Yoghurt Wheaties 97% Fat-free Pretzels Whole-meal Bread Lucky Charms Low-fat Vanilla Ice-Cream Vanilla Ice-Cream Cheerios Cauliflower, steamed Skim Milk White Rice (cooked) French Fries Orange Juice Fat-free Oatmeal Raisin Cookie Donut with Cinnamon Sugar Carrot, steamed Low-fat Cottage Cheese Honeysmacks Special K Apple Pie Chocolate Milk Jatz Cracker Orange Cinnamon Swirl Pastry Carrot Juice (Fresh) Weetbix Chicken Nuggets Frozen Corn Snickers Bar Frozen Peas Muesli Bar 1% Fat Milk Seedless Raisins Porridge Full Cream Milk Canned Navy Beans Tofu Beer (4.9%) Chicken, panfried with skin Cream Cheese Frankfurter/Hot Dog Peanut Butter Cream Walnuts White Wine (11%) FII Varies Over A Wide Range

27 Fats & Oils Alcohol Meat & Protein Alternatives Mixed Meals Baked Goods Snack foods & Confectionary Olive Oil Gin (40%) Beef Sausage Bologna Frankfurter/Hot Dog Ham Prawns Tuna in water Battered Fish Fillet Butter Chicken Sauce Chicken Nuggets Sushi (Chicken Roll) Chocolate Chip Cookie Cinnamon Swirl Pastry Reduced-fat Chocolate Chip Cookie Donut with Cinnamon Sugar Chocolate Cake Brownie & Frosting Blueberry Streusel Muffin Snickers Bar Potato Chips 40% Reduced-fat Potato Chips Raspberry Jam 97% Fat-free Pretzels Mars Bar Dairy Products Vegetables & Legumes Fruit & Fruit Juice Rice, Pasta & Noodles Breads & Cereals Cream Cheese Cheddar Cheese Low-fat Processed Cheese Slice Low-fat Cottage Cheese Peach-Mango Frozen Yoghurt Low-fat Strawberry Yoghurt Coleslaw Mixed Beans Tomato Pasta Sauce Cauliflower, steamed Potato (peeled, boiled) Peach, raw Apple Juice Banana Honeydew Melon Hokkien Noodles Lentils with Tomato Sauce Cous cous All-Bran Original Grain Bread Special K Sustain Cornflakes Honey Bunches of Oats Lucky Charms White Bread Special K Grapenuts Food Insulin Index (%)

28 Food Examples 1000kJ (240kcal) Portions Grain Bread Carbohydrate: 40g FII: 41 White Bread Carbohydrate: 44g FII: 73 Boiled Potato Carbohydrate: 49g FII: 88 Low Fat Yoghurt Carbohydrate: 38g FII: 84 Apple Carbohydrate: 58g FII: 43 Mars Bar Carbohydrate: 38g FII: 89

29 Food Examples 1000kJ (240kcal) Portions Beef Steak Carbohydrate: 0g FII: 37 Poached Eggs Carbohydrate: 1g FII: 23 Chicken Carbohydrate: 0g FII: 19 Bao et al. Am J Clin Nutr 2011; 93:

30 Can the Food Insulin Index be used to Predict Mealtime Insulin Requirements in Type 1 Diabetes?

31 FII Improves Postprandial Glycaemic Control Bao et al. Diabetes Care 2011; 34(4):

32 FII Improves Postprandial Glycaemic Control Bao et al. Diabetes Care 2011; 34(4):

33 FII Improves Postprandial Glycaemic Control Bao et al. Diabetes Care 2011; 34(4):

34 Conclusion FII improved acute postprandial glycaemia compared to carbohydrate counting without increasing the risk of hypo s

35 How Would We Use The FII in Practice?

36 FII vs FID Food Insulin Index (FII) is a measure of a food s relative insulin demand compared with other foods I.e. The FII is a fixed value that doesn t change as the food portion size changes. Apple FII: 43 Food Insulin Demand (FID) combines a food s FII with the kj in the portion size I.e. The FID changes as the food portion size changes and can therefore be used to determine the mealtime insulin dose. White Bread, 1 Slice FII: 73 FID: 26

37 Food Insulin Demand FID = Energy (kj) x Food Insulin Index (FII) 1,000 e.g. 200g low-fat strawberry yoghurt (FII = 84) FID = 770kJ x 84 1,000 FID = 65

38 Using FID in Practice Jane eats 200g of her low-fat strawberry yoghurt Insulin Demand (FID) = 65 Jane s Insulin: FID ratio is 1:16 Therefore, Jane needs 4 units of insulin to cover her yoghurt

39 Pictorial Resources FOOD INSULIN DEMA ND (FID) COUNTING FO O D REFEREN CE G U I D E FO R PEO PLE W I TH TYPE 1 DI A BETES

40 All-Bran Wheat Flakes 1 Cup (40g) 25 Honey Weets 1 Cup (30g) 23 Pocket-Sized Guides! Cheerios 1 Cup (30g) 20 Cornflakes 1 Cup (30g) 25 Porridge (Oats cooked with water) 1 Cup (30g Raw Oats) 19 Rice Bubbles 1 Cup (30g) 26 Special K 1 Cup (40g) 26 Sultana Bran 1 Cup (60g) 40 Sustain 1 Cup (60g) 41 5! Dairy Products!!! Food Serve Size FID! od Food Serve Size FID Dairy Products!!! Food Serve Size Carbs (g) Skim Milk 250mL 23 Beef Steak 130g Cooked 30 Skim Milk 250mL 13 The$FOODII$Study$ $ FID$Counter:$ $ Pocket6Sized$ Guide$ Full Cream Milk 250mL 17 Low Fat Fruit Yoghurt 175g Tub 57 Vanilla Ice-Cream 1 Scoop (50g) 27 Low Fat Vanilla Ice-Cream 1 Scoop (50g) 19 Fruit Frozen Yoghurt 1 Scoop (50g) 18 Chedar Cheese 1 Slice (25g) 14 Low Fat Cheddar Cheese Low Fat Processed Cheese Cream Cheese Reduced Fat Cottage Cheese Low Fat Cottage Cheese 1 Slice (21g) 4 1 Slice (20.5g) 6 1 Tablespoon (20g) ½ Cup (120g) 21 ½ Cup (120g) 24 5! Panfried Chicken 130g Cooked 26 Roast Chicken 130g Cooked 20 Short-Cut Bacon 2 Rashers 6 Frankfurter (Hot Dog) 1 Thin 12 White Fish Fillet 130g Cooked 17 Battered Fish Fillet 1 Fillet (70g) 34 Prawns 7 Shelled (50g) 4 Tuna in Olive Oil Tuna in Springwater The$FOODII$Study$ $ Carb$Counter:$ $ Pocket8Sized$ Guide$ 95g Tin, Drained 95g Tin, Drained 9 9! Full Cream Milk 250mL 13 Low Fat Fruit Yoghurt 175g Tub 26 Vanilla Ice-Cream 1 Scoop (50g) 11 Low Fat Vanilla Ice-Cream 1 Scoop (50g) 12 Fruit Frozen Yoghurt 1 Scoop (50g) 11 Chedar Cheese 1 Slice (25g) 0 Low Fat Cheddar Cheese Low Fat Processed Cheese Cream Cheese Reduced Fat Cottage Cheese Low Fat Cottage Cheese 1 Slice (21g) 0 1 Slice (20.5g) 2 1 Tablespoon (20g) ½ Cup (120g) 4 ½ Cup (120g) 7 1 9! 9! 12! $$$ The$FOODII$Study$ $

41 iphone Apps Calculate FID & Carb Contents 5 7

42 Comparing Accuracy of Methods Subject Observed Insulin Requirement CHO Counting FII Warsaw/Pankowska Mean Difference (units of insulin)

43 ADA Guidelines Selected individuals who have mastered carbohydrate counting should be educated on fat and protein gram estimation ADA Standards of Medical Care, 2017

44 Dose Adjustment Guidelines Healthy eating Optimise conventional insulin therapy Identify target meals Start small, monitor closely, review frequently Bell et al. Diabetes Care 2015; 38:

45 Key Clinical Questions 1. What is the threshold for fat & protein? 2. What is the dose-response relationship between fat/protein and BGL? 3. What affect does the type of fat or protein have? 4. How do insulin doses need to be adjusted for fat and/or protein?

46 ibolus: Study Update Recruitment Complete End of Trial: May 2018