New Insulin Dose Calculation Method Reduces Postprandial Hyperglycemia in Children

Fran Lowry

July 02, 2010

July 2, 2010 (Orlando, Florida) — Children with type 1 diabetes can have their pizza and eat it, too, if they calculate their premeal insulin dose according to carbohydrate, fat, and protein intake rather than carbohydrate intake alone, researchers reported here at the American Diabetes Association 70th Scientific Sessions.

Calculating the insulin requirement according the new method reduces the incidence of postprandial hyperglycemia after fat- and protein-rich meals, a German team says.

"Everybody reports very high postprandial glucose levels after the ingestion of meals which are high not only in carbohydrates but in fat and protein," Olga Kordonouri, MD, from Hannover Childrens' Hospital, Germany, told Medscape Medical News. "This glucose rise happens 3 to 4 hours after the meal and is very hard to correct."

Hoping to give teenagers and adolescents a better way of adjusting their insulin so they could more safely indulge in favorites such as pizza, lasagna, and ice cream, Dr. Kordonouri and her team developed the new formula and then tested it in 42 patients ranging in age from 6 to 20 years with type 1 diabetes of at least 1 year duration who had been on pump therapy for at least 3 months.

The test meal consisted of a standardized meal of salami pizza, comprising 50% carbohydrate, 34% fat, and 16% protein. It was given at lunchtime on 4 different days with normal and dual-wave bolus using carbohydrate (CARB) and carbohydrate, fat, and protein (CFP) counting in a randomized sequence.

For CARB counting, the dose of insulin was calculated from the carbohydrate content of the test meal. For CFP counting, additional insulin was calculated from the fat and protein content.

In dual-wave bolus, 30% of insulin was given either during a fixed period of 2 hours in the CARB group or during a prolonged period of 3 to 6 hours, depending on additional insulin, in the CFP group. Sensor-augmented insulin pumps were used for continuous glucose monitoring of 6-hour postprandial glucose profiles.

With CFP counting, the mean 6-hour postprandial glucose area under the curve (AUC) was 805 ± 261 mg/dL, and the average glucose (AV) was 137.8 ± 46.2 mg/dL. With CARB counting, the mean AUC was 926 ± 285 mg/dL, and the AV was 160.5 ± 51.9 mg/dL. "Both AUC and AV were significantly lower with CFP counting, with a P value less than .001 for both measures," Dr. Kordonouri said.

However, significantly more episodes of hypoglycemia (<70 mg/dL) occurred with CFP than with CARB (35.7% vs 9.5%; P <.001), although no severe hypoglycemic episodes were reported.

Asked about this by Medscape Medical News, Dr. Kordonouri replied that this occurred because the children's original basal rates were not changed for the study.

She added that the kids in the study learned the more complicated CFP calculation quite easily.

Commenting on this study for Medscape Medical News, David Maahs, MD, from the Barbara Davis Center for Childhood Diabetes at the University of Colorado in Denver, said that delivering preprandial insulin is a very important topic in pediatric diabetes.

"We certainly need more information on how to educate and advise our patients to give mealtime boluses. This research furthers our understanding of what happens with common meals, such as pizza, in children. And of course, children love pizza," he said.

Dr. Maahs, who moderated the session at which Dr. Kordonouri gave her presentation, added that he was concerned about the apparent increase in hypoglycemia with this method.

He also thought the method of calculating the premeal dose using CFP might be too complex.

Despite these concerns, Dr. Maahs said the research is moving in the right direction. "We need more information on how to dose insulin more effectively, and this type of research should be encouraged. We need to see how it implements and translates into improved clinical care and quality of life."

The study was supported by a research grant from Medtronic Europe. Dr. Kordonouri and Dr. Maahs have disclosed no relevant financial relationships.

American Diabetes Association 70th Scientific Sessions: Abstract 303-OR. Presented June 28, 2010.

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