Volume 23, Number 4 - December 2020

Dosing for Protein and Fat in Type 1 Diabetes: The OzDAFNE experience

By
Dr Carmel E Smart,

APD PhD

Senior Paediatric Diabetes Dietitian

John Hunter Children’s Hospital

Dr Carmel Smart is a leading authority on diet and Type 1 Diabetes who has worked as a Specialist Endocrinology Dietician at the John Hunter Children’s Hospital, Newcastle, NSW for over 25 years. She was awarded a Clinical Research Fellowship and is a conjoint senior lecturer at the University of Newcastle

carmel.smart@hnehealth.nsw.gov.au

Dianne Harvey,

Bsc, Grad Dip Dietetics

Coordinator Education Services- Barwon Region and Accredited Practising Dietitian

Diabetes Victoria

dharvey@diabetesvic.org.au

Dianne Harvey is an Accredited Practising Dietitian and has worked at Diabetes Victoria for 13 years, currently as the Coordinator of Education Services- Barwon Region. She has a special interest in type 1 diabetes and was one of the original Australian team trained in the UK to become OzDAFNE trained.

Lauren Bais,

BAppSci, Master Nutr & Diet, Grad Cert DM Edu, APD, DE

Dietitian

Diabetes Victoria

 

Lauren Bais is an Accredited Practising Dietitian at Diabetes Victoria. She is an OzDAFNE Facilitator and the dietitian lead for the OzDAFNE Pump pilot program. She enjoys helping people make positive changes to their health and is passionate about supporting people with diabetes to self-manage their diabetes.

Dr Brigid Knight,

BSc, Grad Dip Nutr Diet, Grad Cert Diab Ed, PhD

Senior Paediatric Diabetes Dietitian

Qld Children’s Hospital

 

Brigid works as an accredited practising dietitian and credentialed diabetes educator, in the public and private practice settings. Her focus is on intensive therapy for type 1 and type 2 diabetes, in adults and children, using multiple injection and insulin pump therapy.

Eileen Collins and

RN RM CDE

National OzDAFNE Coordinator

Diabetes Victoria

 

Eileen Collins, RN CDE has been working as a diabetes educator for 30 years. She works at Diabetes Victoria as the National Co-coordinator of the OzDAFNE program; an evidence based, structured self-management program for adults living with type 1 diabetes. Eileen also facilitates a nurse led diabetes clinic in general practice.

Prof Bruce R King

MBBS FRACP PhD

Paediatric Endocrinologist

John Hunter Children’s Hospital

Bruce has 19 years experience as a full time paediatric endocrinologist. He directly manages over 300 children with diabetes at John Hunter Children’s Hospital and rural outreach centres (average HbA1c = 7.1%). Bruce is a board member of Diabetes NSW & ACT and past member of the ISPAD advisory council and APEG diabetes subcommittee. Bruce researches factors influencing post prandial BGLs and technology to improve diabetes management.

Introduction

Research has shown that high protein and high fat meals cause delayed hyperglycaemia in some people with type1 diabetes. This delayed rise in blood glucose can occur up to five to six hours after eating high protein and high fat meals despite accurate carbohydrate counting and optimisation of basal insulin, insulin-to-carbohydrate mealtime ratios and correction factors.1,2,3  In 2017, the American Diabetes Association (ADA) Standards of Medical Care in Diabetes recommended for the first time that protein and fat estimation could be used for some people on flexible insulin therapy.4 

In light of this research and the ADA recommendation, it was decided to translate this research into clinical practice in the OzDAFNE program (Dose Adjustment for Normal Eating in Australia) which  is a structured five-day group program for adults with type 1 diabetes (T1D) using multiple daily insulin injections (MDI).5 

More recently, in January 2020, the ADA advised that the meal time insulin determination process should include consideration of protein and fat in the meal and suggested checking blood glucose levels three hours after meals or using continuous blood glucose monitoring to guide decision making for protein and fat dosing.6

First steps 

To translate the research on protein and fat into clinical practice, an expert working group was established in 2018. This included lead researchers from the John Hunter Children’s Hospital in Newcastle, plus experienced OzDAFNE facilitators.

Key research papers on protein and fat dosing were reviewed and based on the research 1,7,8 the working group agreed on the following:

  • The thresholds for the amount of protein and fat in meals that may cause a delayed rise in blood glucose levels in the majority of adults are: 
    • 30g fat or more when eaten with carbohydrate
    • 40 g protein or more, when eaten with carbohydrate 
    • 50 g protein or more when eaten without carbohydrate (or carbohydrate is less than 10 g in the whole meal)
  • Steps to identify if a Protein/Fat insulin supplement (P/F supplement) is needed 
  • Steps for using a P/F supplement in high protein and high fat meals with carbohydrate
  • Steps for using a P/F supplement with high protein meals without carbohydrate

The working group followed a stepwise approach to incorporate the protein and fat research into the OzDAFNE program using the comprehensive learnings from the OzDAFNE literacy and numeracy review conducted in 2015. This included using plain language, using clear and simple sentences, organising information effectively and simplifying numerical concepts.

A “protein and fat awareness” session was developed to help participants with diabetes identify high protein and high fat meals that may cause delayed hyperglycaemia. This session is delivered to participants on day five of the program, after the core concepts of carbohydrate dosing are taught and practiced. It is important to note that the OzDAFNE curriculum encourages healthy eating, and high protein and high fat meals are put into context in the healthy eating session.

In addition, a protein and fat dosing session was developed to teach participants how to calculate and apply a P/F supplement. It was noted that there were few research papers on protein and fat dosing for people with T1D using MDI9 so clinical experience10 and new findings from our group11 were used to guide practice. The protein and fat dosing session was offered as an optional session for participants at the group review, six weeks after the initial program. The deliberate delay in delivery of this session gave participants time to consolidate their carbohydrate counting skills and also optimise their basal insulin doses, insulin-to-carbohydrate ratios and correction factors before learning new dietary concepts. 

 

Next Step: OzDAFNE facilitator training

In July 2019, at the annual OzDAFNE collaborative meeting, facilitators gave feedback on the draft protein and fat sessions. Their feedback was included in the revised curriculum and included clarifying that correction doses are not used in the calculation of the P/F supplement and how to record the P/F supplement in the tracker (diary).

In November 2019, via a live webinar, facilitators were provided with training on the new protein and fat sessions in readiness for them to deliver these sessions. This webinar was available as a recording and all facilitators were required to view this webinar as an essential part of the 2019 quality assurance process. A five-point Likert scale was used to evaluate facilitator confidence in their knowledge of the new protein and fat sessions. The majority (82 %; n= 74) reported high or extremely high levels of confidence.

 

The key learnings from the webinar feedback fell into two themes.

  • Use of the tracker to identify blood glucose patterns:
    • Participants will use the step-by-step assessment process to identify if there is a pattern in their tracker. This establishes whether they are a “responder” i.e. if they have a blood glucose response to high protein and high fat meals before dosing a P/F supplement
    • Responders use tracking to assess the outcome of the P/F supplement
    • A stepwise approach is used to assess, record and dose for protein and fat
    • The blood glucose response to protein and fat is very individual
  • When using a P/F supplement:
    • Participants will not be required to count protein and fat 
    • The P/F supplement is given before a meal 
    • Supplemental dosing thresholds differ depending on whether protein and fat is with or without carbohydrate
    • Start with an additional 20% P/F supplement and increase to 30% if required for high protein and high fat meals eaten with carbohydrate
    • For high protein meals (≥ 50g) without carbohydrate, the protein is counted as 10 g carbohydrate and the ratio of that meal is used. This is because research has shown that approximately 10g glucose appears in the circulation following ingestion of 50 g protein
    • The protein and fat dosing guidelines are a safe approach where insulin is increased incrementally in small doses

After the webinar, facilitators raised questions about using the P/F supplement, including:

  • What is the rationale for injecting the P/F supplement before the meal and not later when the blood glucose rise is occurring?
  • Do postprandial hypos occur when dosing the full P/F supplement before the meal?
  • Will participants with delayed gastric emptying need to take any extra precautions when using the P/F supplement?
  • Why is the threshold for protein higher when eaten without carbohydrate compared to eaten with carbohydrate?

In response to these questions, a “Frequently Asked Questions” (FAQs) presentation was delivered at the 2020 OzDAFNE collaborative meeting and a written protein and fat FAQ document was developed for inclusion in the curriculum. 

 

Final Step: Delivering the protein and fat sessions.

The first protein and fat awareness sessions were delivered to OzDAFNE participants in November 2019 followed by the protein and fat dosing sessions approximately six weeks later. 

In total, three protein and fat dosing sessions were delivered to participants before COVID-19 halted delivery of all programs.

Facilitator feedback on the protein and fat dosing sessions were collected via a survey.  The facilitators (n=3) reported that all participants (n=15) who attended the six-week review opted to stay for the optional protein and fat dosing session, which is an indicator of the interest in this session. The facilitators reported that the participants were accepting of the number of steps required to firstly identify and then to use the P/F supplement and that the examples and activities in the workbook worked well. The meals that participants identified as causing delayed hyperglycaemia and therefore meals where the P/F supplement could be used were pizza, fish and chips, curries, omelettes, avocado on toast and creamy pasta dishes. These foods were also identified by children, adolescents and their families with type 1 diabetes.11    

The facilitators reported a range of confidence levels in delivering the protein and fat dosing session, from not sure, to quite confident and very confident.  However, the co-facilitator who observed the session with the facilitator who reported being ‘not sure’ observed good responsiveness from the group.  To boost facilitators’ confidence, the protein and fat sessions were reviewed at the 2020 OzDAFNE collaborative meeting.

 

Stepping into protein and fat dosing using insulin pumps

In 2019, a working group developed a curriculum and resources for a pump version of the OzDAFNE program. Research on protein and fat in relation to insulin pumps was reviewed.12-19 The protein and fat resources developed for the MDI program were modified to incorporate pump language and concepts and to utilise the various features of the pump such as the multi wave bolus option.

The protein and fat awareness session is included on day four of the pump program following the bolus wave options session.  Protein and fat dosing is an optional session at the six-week group review and is structured in a similar way to the MDI program.

The first OzDAFNE pump program was piloted in Australia in November 2019. Due to COVID-19, only three pump programs have been delivered. All participants (n = 16)  opted to stay for the protein and fat dosing session and commented that they appreciated the protein and fat information and how this was  linked to the previous bolus wave session. The three facilitators felt confident in delivering the dosing session. 

 

Next steps

Facilitators plan to collect contact details from participants who consent to be contacted about their experiences with using the protein and fat information in both the MDI and pump programs. 

Phone interviews will be conducted and participants asked:

  • If they have used the steps to identify if a P/F supplement is needed?
  • Did they follow the steps for using a P/F supplement for the meals that they identified?
  • Did the P/F supplement work for them?  
  • Did they need to titrate their doses?
  • Do they feel like they need more information about managing high protein and high fat meals? 

The protein and fat working group is currently working on further publications and presentations and plan to develop pictorial resources to compliment the new written resources.

Conclusion

OzDAFNE, in partnership with researchers from the John Hunter Children’s Hospital, have formulated structured processes for identifying and dosing high protein and high fat meals in both the MDI and insulin pump programs. 

This provides facilitators and participants with a practical step-by-step guide for this advanced diabetes management. The facilitator and participant feedback, along with new evidence as it becomes available, will be collated to inform us of any revisions and improvements that are required for the OzDAFNE protein and fat sessions.

Acknowledgements

We would like to acknowledge the OzDAFNE participants who attended the program and the 

OzDAFNE facilitators who delivered the program.

References

1.

Paterson M, Bell KJ, O’Connell SM, Smart CE, Shafat A, King B. The role of dietary protein and fat in glycaemic control in type 1 diabetes: implications for intensive diabetes management. Current diabetes reports. 2015;15(9):61.

2.

Smart CEM, King BR, Lopez PE. Insulin Dosing for Fat and Protein: Is it Time? Diabetes Care. 2020;43(1):13-5. 

3.

Bell KJ, Smart CE, Steil GM, Brand-Miller JC, King B, Wolpert HA. Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era. Diabetes Care. 2015;38(6):1008-15. 

4.

American Diabetes Association,(2017) Standards of Medical Care in Diabetes, Volume 40, Supplement 1, January 2017,pp35

5.

Speight J, Holmes-Truscott E, Harvey DM, Hendrieckx C, Hagger VL, Harris SE, et al. Structured type 1 diabetes education delivered in routine care in Australia reduces diabetes-related emergencies and severe diabetes-related distress: The OzDAFNE program. Diabetes research and clinical practice. 2016;112:65-72. 

6.

American Diabetes Association,(2020) Standards of Medical Care in Diabetes, Volume 43, Supplement 1, January 2020,S53

7.

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(12):3897-902.

8.

Paterson MA, Smart CEM, Lopez PE, et al. Increasing the protein quantity in a meal results in dose-dependent effects on postprandial glucose levels in individuals with Type 1 diabetes mellitus. Diabet Med. 2017;34(6):851-4.

9.

Campbell MD, Walker M, King D, et al. Carbohydrate Counting at Meal Time Followed by a Small Secondary Postprandial Bolus Injection at 3 Hours Prevents Late Hyperglycemia, Without Hypoglycemia, After a High-Carbohydrate, High-Fat Meal in Type 1 Diabetes. Diabetes Care. 2016;39(9):e141-2.

10.

Paterson M, Smith TA, King BR. Managing the ups and downs from dietary protein and fat: The John Hunter Children’s Hospital Approach in type 1 diabetes care. The Australian Diabetes Educator. 2019 

11.

Smith T, Blowes A, King B, Howley P, Smart C. Families’ reports of problematic foods, management strategies and continuous glucose monitoring in type 1 diabetes: A cross-sectional study. Nutrition and Dietetics. DOI: 10.1111/1747-0080 2020 

12.

Lee SW, Cao M, Sajid S, et al. The dual-wave bolus feature in continuous subcutaneous insulin infusion pumps controls prolonged post-prandial hyperglycaemia better than standard bolus in Type 1 diabetes. Diabetes Nutr Metab. 2004;17(4):211-6. 

13.

Wolpert HA, Atakov-Castillo A, Smith SA, Steil GM. 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(4):810-6. 

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Bell KJ, Toschi E, Steil GM, Wolpert HA. Optimized Mealtime Insulin Dosing for Fat and Protein in Type 1 Diabetes: Application of a Model-Based Approach to Derive Insulin Doses for Open-Loop Diabetes Management. Diabetes Care. 2016;39(9):1631-4. 

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Piechowiak K, Dżygało K, Szypowska A. The additional dose of insulin for high‐protein mixed meal provides better glycemic control in children with type 1 diabetes on insulin pumps: randomized cross‐over study. Pediatric diabetes. 2017;18(8):861-8.

16.

Gingras V, Bonato L, Messier V, Roy-Fleming A, Smaoui MR, Ladouceur M, et al. Impact of macronutrient content of meals on postprandial glucose control in the context of closed-loop insulin delivery: A randomized cross-over study. Diabetes Obes Metab. 2018;20(11):2695-9. 

17.

Lopez PE, Smart CE, McElduff P, et al. Optimizing the combination insulin bolus split for a high-fat, high-protein meal in children and adolescents using insulin pump therapy. Diabet Med. 2017;34(10):1380-4. 

18.

Bell KJ, Fio CZ, Twigg S, et al. Amount and type of dietary fat, postprandial glycemia, and insulin requirements in type 1 diabetes: a randomized within-subject trial. Diabetes care. 2020;43(1):59-66. 

19.

Paterson M, Smart C, Howley P, Price D, Foskett D, King B. High‐protein meals require 30% additional insulin to prevent delayed postprandial hyperglycaemia. Diabetic Medicine. 2020.

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