Rapid-acting and Regular Insulin are Equal for High Fat-Protein Meal in Individuals with Type 1 Diabetes Treated with Multiple Daily Injections
Rapid-acting and Regular Insulin are Equal for High Fat-Protein Meal in Individuals with Type 1 Diabetes Treated with Multiple Daily Injections
0 K. Safranow Department of Biochemistry and Medical Chemistry, Pomeranian Medical University in Szczecin , Szczecin , Poland
1 K. Jabłon ́ ska P. Mole ̨da (&) L. Majkowska Department of Diabetology and Internal Medicine, Pomeranian Medical University in Szczecin , Police , Poland
Introduction: The fat and protein content can impact late postprandial glycemia; therefore, prolonged insulin boluses for high-fat/-protein meals are recommended for patients with type 1 diabetes on insulin pump therapy. It is not clear how to translate these findings to multiple daily injection (MDI) therapy. We hypothesized that regular insulin with a slower onset and a longer duration of action might be advantageous for such meals. Methods: Twenty-five patients with well-controlled type 1 diabetes (mean HbA1c 6.8%, 51 mmol/mol, no episodes of hypoglycemia) on MDI therapy, aged 27.9 ± 4.3 years and well trained in flexible intensive insulin therapy, were given three test breakfasts with the same carbohydrate (CHO) content. The amount of fat and protein was low (LFP) or high (HFP). For LFP meals, patients received a rapid-acting insulin; for HFP meals, a rapid-acting or regular insulin was given in individual doses according to the CHO content and individual insulin-CHO ratios. Postprandial glycemia was determined by 6-h continuous glucose monitoring. Results: Acute postprandial glucose levels measured for 2 h were similar after LFP and two HFP meals (7.8 ± 2.0, 8.1 ± 2.1, 8.0 ± 1.9 mmol/l). Late postprandial glycemia measured from 2 to 6 h was significantly lower after the LFP meal (6.7 ± 1.8 mmol/l, p0.05) than after the HFP meals, but there was no difference between the rapid-acting or regular insulin on HFP days (8.6 ± 2.6 and 8.9 ± 2.8 mmol/l, NS). Conclusion: The preliminary results of this study indicate no benefit to cover fat-protein meals with regular insulin in individuals with type 1 diabetes treated with MDI.
Fat-protein meal; Insulin; Multiple daily injection therapy; Type 1 diabetes
INTRODUCTION
Meal carbohydrate counting is widely used in
individuals with type 1 diabetes on functional
intensive insulin therapy treated with a
basalbolus insulin regimen by means of multiple
daily injections (MDI) or continuous
subcutaneous insulin infusion (CSII) by insulin
pumps. Advanced carbohydrate counting is
recommended by official guidelines for type 1
diabetes treatment [
1
]. The prandial dose of
rapid-acting insulin is based on the amount of
carbohydrates in the meal to be consumed (in
grams or carbohydrate exchangers) and an
individualized insulin-to-carbohydrate ratio
(ICR, units/g) [2]. In clinical practice, the meal
carbohydrate amount is usually regarded as the
most important determinant of the acute
postprandial blood glucose level. Glycemia typically
peaks within 60–90 min following a
carbohydrate-based meal [3].
Recent studies have shown that the fat and/
or protein content can impact late postprandial
glycemia, and the effect of both nutrients is
additive [4–6]. After a meal high in protein and
fat added to a constant amount of
carbohydrate, the peak of glycemia is similar in time but
accentuated, and prolonged glucose excursions
are observed from 3 to 6 h after the meal [6, 7].
These findings point to the need for prolonging
insulin delivery with or without an increase in
total mealtime insulin dosage [
7–11
]. The latest
American Diabetes Association
recommendations suggest that selected subjects with type 1
diabetes who have mastered carbohydrate
counting should be educated on the impact of
fat and protein on the glycemic profile [1].
All described strategies of combined
carbohydrate, fat and protein counting and
application of prolonged insulin boluses for mixed
meals are appropriate for patients on CSII. Until
now, there has been no attempt to solve the
problem of adjustment of insulin for a meal
with increased fat and protein content in
patients treated with MDI who constitute the
majority of patients with type 1 diabetes. The
proposed but not verified methods for high-fat/
high-protein meals in this group of patients are
to inject an additional dose of rapid-acting
insulin 1 h after the meal or to cover the meal
with regular insulin [
12, 13
].
The main aim of study was to check if regular
human insulin, which has a slightly later peak
but also a longer total duration of activity,
administered before a high-fat-protein meal,
would give lower and more stable glycemia than
a rapid-acting insulin analog used routinely in
patients with type 1 diabetes treated with
flexible MDI therapy. The additional aim was to
evaluate whether the ICRs calculated in real life
(typically for mixed meals) may lead to hypo- or
hyperglycemia when used for carbohydrate or
high-fat/protein meals.
METHODS
This study included 25 patients with type 1
diabetes, 14 females and 11 (...truncated)