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

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Beyond Carb

Counting:

Dietary Fat &

Protein in T1D

Dr Kirstie Bell

APD/CDE, PhD

University of Sydney

Carb Counting

• Carb Counting is gold standard method for adjustingmealtime 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

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): 133-140

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

High BGL

Meal

Insulin

Normal BGL

Insulin Meal

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; 38:1008-1015

Dietary Protein

Bell et al. Diabetes Care 2015; 38:1008-1015

• 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

High Fat vs Low Fat Dinner on postprandial

BGL using closed loop insulin

delivery

Dietary Fat Increases BGL

and Insulin Requirements

Wolpert et al. Diabetes Care 2013;36:810-816

Fat and Protein Increase

Insulin Requirements

Smart et al. Diabetes Care 2013; 36: 3897-

3902

CHO (LF/LP)

Protein (LF/HP)

Fat (HF/LP)

Fat & Protein (HF/HP)

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

0 30 60 90 120 150 180 210 240 270 300 330 360

Ch

ange

in B

GL

(mm

ol/

L)

Time (Minutes)

Low Fat, Low Protein High Fat, High Protein

5.5 mmol/L

Bell (2016) Diabetes Care 39(9):1631-1634

Dietary Fat & Protein Raise BGL

Pure Protein Raises BGL

Paterson et al. Diabetic Medicine 2016;33(5)

How should Insulin

Doses be Adjusted for

Protein/Fat?

Warsaw Insulin Pump

Therapy (Pankowska)

Method

• 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

Fat/Protein Unit (FPU) Counting

Pankowska et al Pediatric Diabetes 2009; 10(5): 298-303.

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 insulinDelivered as Dual Wave – 3u upfront (75%), 1u (25%) over 3h

Pankowska et al Pediatric Diabetes 2009; 10(5): 298-303.

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

Model Predicted Boluses

Bell (2016) Diabetes Care 39(9):1631-1634

To optimally define:

•What insulin DOSE is needed?

•What percentage should be

given immediately (Split)?

•How long to extend the

remaining portion (Duration)?

Objective

Bell (2016) Diabetes Care 39(9):1631-1634

• 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

Methods

Bell (2016) Diabetes Care 39(9):1631-1634

Low Fat MealPizza & Tomato Paste

50g Carbohydrate9g Protein

4g Fat

Test Meals

High Fat MealPizza, Tomato Paste & Cheese50g Carbohydrate (equal)36g Protein (+27g)44g Fat (+40g)

Bell (2016) Diabetes Care 39(9):1631-1634

• 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

Methods

Bell (2016) Diabetes Care 39(9):1631-1634

Adding 40g Fat & 27g Protein

Increases Postprandial Glycaemia

No Patients had Hypo

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

0 30 60 90 120 150 180 210 240 270 300 330 360

Blo

od

Glu

cose

Le

vel

(mm

ol/

L)

Time (Minutes)

LFLP HFHP

5.5 mmol/L

Bell (2016) Diabetes Care 39(9):1631-1634

75% More Insulin Required

Dual Wave: 30/70% over 2.5hr

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

0 30 60 90 120 150 180 210 240 270 300 330 360Blo

od

Glu

cose

Le

vel

(mm

ol/

L)

Time (Minutes)

LFLP HFHP HFHP - Optimised

No Patients had Hypo

Bell (2016) Diabetes Care 39(9):1631-1634

Food Insulin Index (FII)

Estimating Mealtime Insulin

Dose in Type 1 Diabetes

Current Thinking Novel Thinking

Carbohydrate Counting

Glycaemic Response

Bolus Insulin Dose

Insulin Response in Healthy Individuals

Insulin Demand

Bolus Insulin Dose

• 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 100

120min AUCInsulin for 1000kJ of ref. food

Food Insulin Index (FII)

Bao et al. Am J Clin Nutr 2011; 93:984–96.

• Published FII represents the average of 10 subjects

• Developed a FII database of 147 foods

FII Varies Over A Wide Range

0

20

40

60

80

100

120

Jelly

bea

ns

Swee

t P

ota

to, s

team

ed

Ori

gin

al S

hre

dd

ed W

hea

t

Bak

ed

Bea

ns

Low

-fat

Str

awb

erry

Yo

ghu

rt

Wh

eati

es

97

% F

at-f

ree

Pre

tze

ls

Wh

ole

-mea

l Bre

ad

Luck

y C

har

ms

Low

-fat

Van

illa

Ice-

Cre

am

Van

illa

Ice

-Cre

am

Ch

eer

ios

Cau

liflo

we

r, s

team

ed

Skim

Milk

Wh

ite

Ric

e (c

oo

ked

)

Fre

nch

Fri

es

Ora

nge

Ju

ice

Fat-

fre

e O

atm

eal

Rai

sin

Co

oki

e

Do

nu

t w

ith

Cin

nam

on

Su

gar

Car

rot,

ste

ame

d

Low

-fat

Co

ttag

e C

hee

se

Ho

ney

smac

ks

Spe

cial

K

Ap

ple

Pie

Ch

oco

late

Milk

Jatz

Cra

cker

Ora

nge

Cin

nam

on

Sw

irl P

astr

y

Car

rot

Juic

e (F

resh

)

We

etb

ix

Ch

icke

n N

ugg

ets

Fro

zen

Co

rn

Snic

kers

Bar

Fro

zen

Pe

as

Mu

esl

i Bar

1%

Fat

Milk

Seed

less

Rai

sin

s

Po

rrid

ge

Full

Cre

am M

ilk

Can

ned

Nav

y B

ean

s

Tofu

Be

er (

4.9

%)

Ch

icke

n, p

anfr

ied

wit

h s

kin

Cre

am C

he

ese

Fran

kfu

rte

r/H

ot

Do

g

Pe

anu

t B

utt

er

Cre

am

Wal

nu

ts

Wh

ite

Win

e (

11

%)

0 20 40 60 80 100 120

GrapenutsSpecial K

White BreadLucky Charms

Honey Bunches of OatsCornflakes

SustainSpecial K

Grain BreadAll-Bran Original

Cous cousLentils with Tomato Sauce

Hokkien NoodlesHoneydew Melon

BananaApple JuicePeach, raw

Potato (peeled, boiled)Cauliflower, steamedTomato Pasta Sauce

Mixed BeansColeslaw

Low-fat Strawberry YoghurtPeach-Mango Frozen Yoghurt

Low-fat Cottage CheeseLow-fat Processed Cheese Slice

Cheddar CheeseCream Cheese

Mars Bar97% Fat-free Pretzels

Raspberry Jam40% Reduced-fat Potato Chips

Potato ChipsSnickers Bar

Blueberry Streusel MuffinChocolate Cake Brownie & Frosting

Donut with Cinnamon SugarReduced-fat Chocolate Chip Cookie

Cinnamon Swirl PastryChocolate Chip Cookie

Sushi (Chicken Roll)Chicken Nuggets

Butter Chicken SauceBattered Fish Fillet

Tuna in waterPrawns

HamFrankfurter/Hot Dog

BolognaBeef Sausage

Gin (40%)Olive Oil

Food Insulin Index (%)

Breads & Cereals

Fruit & Fruit Juice

Dairy Products

Rice, Pasta & Noodles

Vegetables & Legumes

Baked Goods

Mixed Meals

Meat & Protein

Alternatives

Alcohol

Fats & Oils

Snack foods &

Confectionary

Food Examples1000kJ (240kcal) Portions

Boiled Potato

Carbohydrate: 49g

FII: 88

Grain Bread

Carbohydrate: 40g

FII: 41

Mars Bar

Carbohydrate: 38g

FII: 89

Apple

Carbohydrate: 58g

FII: 43

Low Fat Yoghurt

Carbohydrate: 38g

FII: 84

White Bread

Carbohydrate: 44g

FII: 73

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: 984–96

Food Examples1000kJ (240kcal) Portions

Can the Food Insulin Index be

used to Predict Mealtime

Insulin Requirements in

Type 1 Diabetes?

FII Improves Postprandial

Glycaemic Control

Bao et al. Diabetes Care 2011; 34(4):2146-

2151

FII Improves Postprandial

Glycaemic Control

Bao et al. Diabetes Care 2011; 34(4):2146-

2151

FII Improves Postprandial

Glycaemic Control

Bao et al. Diabetes Care 2011; 34(4):2146-

2151

FII improved acute postprandial glycaemia

compared to carbohydrate counting without

increasing the risk of hypo’s

Conclusion

How Would We Use The

FII in Practice?

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.

FII vs FID

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.

Apple

FII: 43

White Bread, 1 Slice

FII: 73

FID: 26

FID = Energy (kJ) x Food Insulin Index (FII)1,000

e.g. 200g low-fat strawberry yoghurt (FII = 84)

FID = 770kJ x 841,000

FID = 65

Food Insulin Demand

• 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

Using FID in Practice

Pictorial Resources

FOOD INSULIN DEMA ND

(FID) COUNTING

FO O D REFEREN CE G UIDE FO R PEO PLE

W ITH TYPE 1 D IA BETES

Pocket-Sized Guides

The$FOODII$Study$

$FID$Counter:$

$Pocket6Sized$

Guide$

$$$

The$FOODII$Study$

$FID$Counter:$

$Pocket6Sized$

Guide$

!

Cereals !

Food Serve Size FID

All-Bran Original 1 Cup (60g) 19

All-Bran Wheat Flakes 1 Cup (40g) 29

Cheerios 1 Cup (30g) 29

Cornflakes 1 Cup (30g) 26

Honey Weets 1 Cup (30g) 23

Porridge (Oats cooked with water)

1 Cup (30g Raw Oats)

15

Rice Bubbles 1 Cup (30g) 27

Special K 1 Cup (40g) 30

Sultana Bran 1 Cup (60g) 56

Sustain 1 Cup (60g) 50

!

5!

!!!!!!!

Confectionary!

Food Serve Size FID

Mars Bar 1 Regular Bar

(53g) 87

Snickers Bar 1 Regular Bar

(60g) 44

Milk Chocolate 6 Squares (30g) 23

Jellybeans 10 Small

Jellybeans 33

Sherbet 1 Sachet (12.5g) 4

!

14!

!!

Dairy Products !

Food Serve Size FID

Skim Milk 250mL 23

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

1 Slice (21g) 4

Low Fat Processed Cheese

1 Slice (20.5g) 6

Cream Cheese 1 Tablespoon

(20g) 5

Reduced Fat Cottage Cheese

½ Cup (120g) 21

Low Fat Cottage Cheese

½ Cup (120g) 24

!

9!

!!!!!!!

Meat, Chicken & Seafood !

Food Serve Size FID

Beef Steak 130g Cooked 30

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 95g Tin, Drained

9

Tuna in Springwater 95g Tin, Drained

9

!

12!

!

Cereals !

Food Serve Size Carb (g)

All-Bran Original 1 Cup (60g) 35

All-Bran Wheat Flakes 1 Cup (40g) 25

Cheerios 1 Cup (30g) 20

Cornflakes 1 Cup (30g) 25

Honey Weets 1 Cup (30g) 23

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!

!!!!!!!

Confectionary !

Food Serve Size Carb (g)

Mars Bar 1 Regular Bar

(53g) 37

Snickers Bar 1 Regular Bar

(60g) 35

Milk Chocolate 6 Squares (30g) 17

Jellybeans 10 Small

Jellybeans 16

Sherbet 1 Sachet (12.5g) 3

!

14!

!!

Dairy Products !

Food Serve Size Carbs (g)

Skim Milk 250mL 13

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

1 Slice (21g) 0

Low Fat Processed Cheese

1 Slice (20.5g) 2

Cream Cheese 1 Tablespoon

(20g) 1

Reduced Fat Cottage Cheese

½ Cup (120g) 4

Low Fat Cottage Cheese

½ Cup (120g) 7

!

9!

!!!!!!!

Meat, Chicken & Seafood !

Food Serve Size Carbs (g)

Beef Steak 130g Cooked 0

Panfried Chicken 130g Cooked 0

Roast Chicken 130g Cooked 0

Short-Cut Bacon 2 Rashers 1

Frankfurter (Hot Dog) 1 Thin 2

White Fish Fillet 130g Cooked 0

Battered Fish Fillet 1 Fillet (70g) 9

Prawns 7 Shelled (50g) 1

Tuna in Olive Oil 95g Tin, Drained

0

Tuna in Springwater 95g Tin, Drained

0

!

12!

The$FOODII$Study$

$Carb$Counter:$

$Pocket8Sized$

Guide$

$$$

The$FOODII$Study$

$Carb$Counter:$

$Pocket8Sized$

Guide$

iPhone Apps Calculate

FID & Carb Contents

5

7

SubjectObserved Insulin

RequirementCHO Counting FII Warsaw/Pankowska

1 7.9 4.5 7.8 5.8

2 5.5 3.8 6.6 4.9

3 11.9 5.3 9.1 6.8

4 8.8 5.0 8.5 6.4

5 4.2 3.6 6.1 4.6

6 5.2 4.2 7.1 5.3

7 5.8 3.3 5.7 4.3

8 5.7 3.3 5.7 4.3

9 7.4 4.2 7.1 5.3

10 17.5 10.0 17.1 12.8

Mean Difference (units of insulin)

-3.3 0.1 -1.9

Comparing Accuracy of

Methods

ADA Guidelines

“Selected individuals who have mastered carbohydrate counting should be educated

on fat and protein gram estimation”

ADA Standards of Medical Care, 2017

Dose

Adjustment

Guidelines

• Healthy eating

• Optimise conventional

insulin therapy

• Identify target meals

• Start small, monitor

closely, review

frequently

Bell et al. Diabetes Care 2015; 38:1008-1015

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?

iBolus:

Study Update

• Recruitment Complete

• End of Trial: May 2018