Exp Clin Endocrinol Diabetes 2021; 129(12): 873-877
DOI: 10.1055/a-1149-8766
Article

Additional Insulin for Coping with Fat- and Protein-Rich Meals in Adolescents with Type 1 Diabetes: The Protein Unit

1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Susann Herrlich
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Martina Lösch-Binder
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Michaela Glökler
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Magdalena Heimgärtner
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Franziska Liebrich
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Katja Meßner
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
2   Department of Pediatrics and Adolescent Medicine, Klinikum am Steinenberg, Reutlingen, Germany
,
Tina Muckenhaupt
2   Department of Pediatrics and Adolescent Medicine, Klinikum am Steinenberg, Reutlingen, Germany
,
Angelika Schneider
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Julian Ziegler
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
,
Andreas Neu
1   Department of Pediatric Endocrinology and Diabetology, Pediatric University Hospital, Tübingen, Germany
› Author Affiliations

Abstract

Objective Dietary proteins raise blood glucose levels; dietary fats delay this rise. We sought to assess the insulin amount required to normalize glucose levels after a fat- and protein-rich meal (FPRM).

Methods Sixteen adolescents (5 female) with type 1 diabetes (median age: 18.2 years; range: 15.2–24.0; duration: 7.1 years; 2.3–14.3; HbA1c: 7.2%; 6.2–8.3%) were included. FPRM (carbohydrates 57 g; protein 92 g; fat 39 g; fibers 7 g; calories 975 Kcal) was served in the evening, with 20 or 40% extra insulin compared to a standard meal (SM) (carbohydrates 70 g; protein 28 g; fat 19 g; fibers 10 g; calories 579 Kcal) or carbohydrates only. Insulin was administered for patients on intensified insulin therapy or as a 4-hour-delayed bolus for those on pump therapy. The 12-hour post-meal glucose levels were compared between FPRM and SM, with the extra insulin amount calculated based on 100 g proteins as a multiple of the carbohydrate unit.

Results Glucose levels (median, mg/dL) 12-hour post-meal with 20% extra insulin vs. 40% vs. insulin dose for SM were 116 vs. 113 vs. 91. Glucose-AUC over 12-hour post-meal with 20% extra insulin vs. 40% vs. insulin dose for SM was 1603 mg/dL/12 h vs. 1527 vs. 1400 (no significance). Glucose levels in the target range with 20% extra insulin vs. 40% were 60% vs. 69% (p=0.1). Glucose levels <60 mg/dL did not increase with 40% extra insulin. This corresponds to the 2.15-fold carbohydrate unit for 100 g protein.

Conclusions We recommend administering the same insulin dose given for 1 carbohydrate unit (10 g carbs) to cover 50 g protein.



Publication History

Received: 31 January 2020
Received: 16 March 2020

Accepted: 25 March 2020

Article published online:
20 May 2020

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Constam GR. Therapie des Diabetes Mellitus. Basel: Schwabe & Co; 1950
  • 2 Rabinowitz D, Merimee TJ, Maffezzoli R. et al. Patterns of hormonal release after glucose, protein, and glucose plus protein. Lancet 1966; 2: 454-456
  • 3 Wolpert HA, Atakov-Castillo A, Smith SA. et al. Dietary fat acutely increases glucose concentrations and insulin requirements in patients with type 1 diabetes: Implications for carbohydrate-based bolus dose calculation and intensive diabetes management. Diabetes Care 2013; 36: 810-816
  • 4 Smart CE, Evans M, O’Connell SM. et al. Both dietary protein and fat increase postprandial glucose excursions in children with type 1 diabetes, and the effect is additive. Diabetes Care 2013; 36: 3897-3902
  • 5 Lodefalk M, Aman J. Food habits, energy and nutrient intake in adolescents with type 1 diabetes mellitus. Diabet Med 2006; 23: 1225-1232
  • 6 Nordt TK, Besenthal I, Eggstein M. et al. Influence of breakfasts with different nutrient contents on glucose, C peptide, insulin, glucagon, triglycerides, and GIP in non-insulin-dependent diabetics. Am J Clin Nutr 1991; 53: 155-160
  • 7 Peters AL, Davidson MB. Protein and fat effects on glucose responses and insulin requirements in subjects with insulin-dependent diabetes mellitus. Am J Clin Nutr 1993; 58: 555-560
  • 8 Pańkowska E, Szypowska A, Lipka M. et al. Application of novel dual wave meal bolus and its impact on glycated hemoglobin A1c level in children with type 1 diabetes. Pediatr Diabetes 2009; 10: 298-303
  • 9 Pańkowska E, Błazik M. Bolus calculator with nutrition database software, a new concept of prandial insulin programming for pump users. J Diabetes Sci Technol 2010; 4: 571-576
  • 10 Neu A, Behret F, Braun R. et al. Higher glucose concentrations following protein- and fat-rich meals – the Tuebingen Grill Study: A pilot study in adolescents with type 1 diabetes. Pediatr Diabetes 2015; 16: 587-591
  • 11 Le Floch JP, Escuyer P, Baudin R. et al. Blood glucose area under the curve, methodological aspects. Diabetes Care 1990; 13: 172-175
  • 12 Delahanty LM, Halford BN. The role of diet behaviors in achieving improved glycemic control in intensively treated patients in the diabetes control and complications trial. Diabetes Care 1993; 16: 1453-1458
  • 13 Pastors JG, Warshaw H, Daly A. et al. The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 2002; 25: 608-613
  • 14 Evans M, Smart CEM, Paramalingam N. et al. Dietary protein affects both the dose and pattern of insulin delivery required to achieve postprandial euglycaemia in Type 1 diabetes: A randomized trial. Diabet Med 2019; 36: 499-504
  • 15 Kordonouri O, Hartmann R, Remus K. et al. Benefit of supplementary fat plus protein counting as compared with conventional carbohydrate counting for insulin bolus calculation in children with pump therapy. Pediatr Diabetes 2012; 13: 540-544
  • 16 Pankowska E, Blazik M, Groele L. Does the fatprotein meal increase postprandial glucose level in type 1 diabetes patients on insulin pump: The conclusion of a randomized study. Diabetes Technol Ther 2012; 12: 16-22
  • 17 Lodefalk M, Aman J, Bang P. Effects of fat supplementation on glycaemic response and gastric emptying in adolescents with type 1 diabetes. Diabet Med 2008; 25: 1030-1035
  • 18 Bell KJ, Chantelle ZF, Twigg S. et al. Amount and type of dietary fat, postprandial glycemia and insulin requirements in Type 1 diabetes: A randomized within-subject trail. Diabetes Care 2020; 43: 59-66
  • 19 Lopez PE, Evans M, King BR. et al. A randomized comparison of three prandial insulin dosing algorithms for children and adolescents with Type 1 diabetes. Diabet Med 2018; 35: 1440-1447
  • 20 Maahs DM, Higgins J. Is carbohydrate counting enough? Towards perfection or unwanted complexity?. Diabetes Technol Ther 2012; 14: 3-5
  • 21 Neu A, Bürger-Büsing J, Danne T. et al. Diagnosis, therapy and follow-up of diabetes mellitus in children and adolescents. Exp Clin Endocrinol Diabetes 2019; 127(S 01): 39-72
  • 22 Paterson MA, King BR, Smart CEM. et al. Impact of dietary protein on postprandial glycaemic control and insulin requirements in type 1 diabetes: A systematic review. Diabet Med 2019; 36: 1585-1599