Insulin management in patients with Type 1 Diabetes (S1/05)
It is important to be careful about what you eat, even if you don’t have diabetes. It will be much more rewarding if you are able to discuss what you can eat with a dietitian who will help you draw up a meal plan based on the mealtimes, routines and preferences that are important to your family. “You should never eat what you don’t like”, says UK dietitian Sherry Waldron.
This study will give you many details about blood glucose and different foods, but you will learn the general aspects of healthy eating from your dietitian.
Based of ADA (America Diabetes Association) and ISPAD (International Society for Pediatric and Adolescent Diabetes) guidelines, Postprandial glucose level is recommended to be less than 180 mg/dl (10 mmol/L)
Current Standard of Care:
Dosing insulin solely based on carbohydrate (CHO) content of meal. (Blood glucose in range might become more feasible)
Glycaemic Effects of Dietary Fat
Effects of GLP-1:
Glycaemic Effects of Dietary Protein
Effects of Cortisol:
Effects of growth hormone:
Therefore, dietary fat and protein should be considered in meal bolusing.
“A conservative starting point for incremental bolus dose increases is an additional 15% to 20% for high fat, high-protein meals.”
The emptying of the stomach is also affected by the blood glucose level. The stomach empties more quickly if the blood glucose is low and more slowly if it is high. Both solid and liquid food are emptied from the stomach twice as fast when the blood glucose drops from a normal level 4-7 mmol/l (70-125 mg/dl) to a hypoglycaemic level (1.6-2.2 mmol/l, 29-40 mg/dl), as was postulated by (Dr Ragnar Hanas, 2019).
Dietary Fat Acutely Increases Glucose Concentrations and Insulin Requirements in Patients with Type 1 Diabetes
On the implications for carbohydrate-based bolus dose calculation and intensive diabetes management: High Fate (HF) required more insulin (about 42% extra) than Low Fat dinner and caused more hyperglycaemia (5-10 hrs) following High fat meals.
Both Dietary Protein and Fat Increase Postprandial Glucose Excursions in Children with Type 1 Diabetes and the Effect is Additive:
Influence of Dietary Protein on postprandial blood glucose levels in individuals with Type 1 diabetes mellitus using intensive insulin therapy:
Summary 1: Postprandial Glucose Excursion
Dietary protein affects both the dose and the pattern of insulin delivery required to achieve postprandial euglycaemia ( a normal blood glucose in the blood) in Type 1 diabetes
Summary 2: Insulin Requirements
Does Type of Fat Matter?
Amount and Type of Dietary Fat, Postprandial Glycaemia, and Insulin Requirements in Type 1 Diabetes:
For Patients on multiple daily Injections (MDI)
Rapid-acting and Regular Insulin are equal for High Fat-Protein Meal in Individuals with Type 1 Diabetes Treated with Multiple Daily Injections (Karolina J, Piotr M, Krzystof Safranow & Diabetes Therapy, 2018).
NB. No benefit to cover fat-protein meals with regular insulin in individuals with Type 1 Diabetes treated on MDI
ADDITIONAL INSULIN BOLUS 1HR AFTER THE MEAL TO MATCH THE DELAYED ABSORPTION
According to Dr. Ragnar Hanas, the reason that individuals with diabetes should be careful with fat intake is that they have an increased risk of arteriosclerosis and heart disease. A key goal for people with diabetes is to decrease the intake of total fat (including saturated fat and trans fatty acids) and cholesterol. Foods that contain large amounts of saturated fats include dairy products and red meats.
Try to use monounsaturated and polyunsaturated fats where possible instead. Ordinary margarine and butter contain only 3% polyunsaturated fat. An increased intake of monounsaturated fats may even improve your HbA1c
Factors that increase the blood glucose level more slowly (decreased glycaemic index)
Factors that increase the blood glucose level more quickly (increased glycaemic index)
1. Starch structure: Boiled and mashed potatoes give a quicker blood glucose response (as fast as ordinary sugar) while rice and pasta give a slower blood glucose response
2. Gel-forming dietary fibre: A high fibre content (as in rye bread) gives a slower rise in blood glucose by slowing down the emptying rate of the stomach and binding glucose in the intestine.
3. Fat content: Fat in the food will delay the emptying of the stomach.
4. Cell structure: Beans, peas and lentils retain their cell structure even after cooking. Whole fruits affect the blood glucose level more slowly than peeled fruits and juice
5. Size of bites: Larger pieces of food take longer to digest in the stomach and intestine. Larger pieces also cause the stomach to empty more slowly.
1. Cooking: Boiling and other types of cooking will break down the starch in food.
2. Preparing food: Prepared food, e.g. polished rice will give a quicker rise in blood glucose than unpolished, mashed potatoes quicker than whole potatoes and grated carrots quicker than sliced. Wheat flour gives a higher blood glucose response when baked in bread than when used for pasta.
3. Fluids with food: Drinking fluids with a meal causes the stomach to empty more quickly.
4. Glucose content: Extra sugar as part of a meal can cause the blood glucose level to rise, but not by as much as was once believed. Particle size and cell structure in different food compounds give them different blood glucose responses in spite of their containing the same amount of carbohydrates.
5. Salt content: Salt in the food increases the absorption of glucose into the bloodstream.
Food rules of thumb
In conclusion, the fat in food must pass into the intestine before it can affect the emptying rate of the stomach. This means that if you start a meal with something rich in fat, the signal that slows down the emptying rate will reach the stomach more quickly. If you eat a meal very rich in fat, you may still have food remaining in your stomach when you are about to have your next meal. If you are using multiple injections, you will need to decrease the amount of food you plan to eat (without changing the insulin dose), if you are to avoid an increase in blood glucose, as was propagated by (Dr Ragnar Hanas, MD)