The Diabetologist #24+25

a food insulin index, a physiological basis for ranking
foods according to insulin demand for 120 single
foods.67They concluded that the relative insulin
demand evoked by mixed meals consumed by lean
healthy subjects is best predicted by a physiological
index (food insulin index) based on integrating insulin
responses to isoenergetic portions of single foods.
Eating patterns that provoke less insulin secretion
may be helpful in managing diabetes. In 2011, another
Australian study compared a novel algorithm based
on the food insulin index for estimating mealtime insulin
dose to carbohydrate counting in T1D adults using
CSII.68 The study concluded that, when compared
with carbohydrate counting, the food insulin index
algorithm improved acute postprandial glycemia in
well-controlled T1D subjects. The authors acknowledge
that clinical application of these findings is not
currently feasible, since the food insulin index does
not presently appear on food labels and the food insulin
index database includes only ~120 foods.12
Another group collected data on food intake, physical
activity, insulin administration, and blood glucose
test results in T1D patients using self-administered
questionnaires.69Sixty-four percent of the participants
incorrectly estimated their prandial insulin, revealing
that optimal prandial insulin dosing is not easy and requires
continuous assessment and related education
and support, even after a long duration of diabetes.12
Insulin dosing aids such as bolus insulin calculation
cards and dosing guides have been developed to
reduce potential calculation errors.70–72 Bolus calculators
with personalized insulin-dosing algorithms
can be programmed in a wide range of devices, such
as personal digital assistants (PDAs), smartphone
applications, or insulin pumps.12,73,74
The Diabetes Interactive Diary is an automatic carbohydrate
and insulin bolus calculator installed on
a mobile phone, using patient-physician communication
via text messages. When compared with
a standard carbohydrate-counting education program,
the Diabetes Interactive Diary was as effective
as a traditional carbohydrate-counting education
program, without an increased hypoglycemia
risk.75 Technology has reduced education time
while significantly improving treatment satisfaction
and several quality-of-life dimensions. Adaptive
aids are popular with the tech-savvy but may be
useful for those with health literacy and numeracy
concerns, such as young children or adults who
cannot perform complex mathematical equations
required for intensive insulin therapy.76Technology
may allow more people with insulin-requiring diabetes
to have access to diabetes self-management
tools, education, and support.12
Factors that May Affect Long-Term
Adherence to Carbohydrate Counting
Three studies have explored the food and eating
practices of T1D subjects who converted to flexible
intensive insulin therapy (FIIT) as part of the DAFNE
course.5,16,77Ironically, in efforts to simplify food
choices for easier carbohydrate estimation, patients
may rely on prepackaged foods, with higher saturated
fats and salt, but with nutrition labels, rather
than calculate the carbohydrate content for fresh
fruits, vegetables, and other unprocessed items that
do not have food labels. FIIT participants also expressed
anxieties about miscalculating carbohydrate
amounts and injecting the wrong dose. This caused
participants to eat the same foods repeatedly, limiting
intake of new foods or foods with difficult-todetermine
carbohydrate content. Some participants
intentionally choose low- or no-carbohydrate foods
to simplify prandial dose calculations. Despite formal
intensive insulin therapy classes, many subjects
feared hypoglycemia when matching mealtime insulin
to desired food (carbohydrate) intake.5 These
data raise factors that need to be addressed during
initial and ongoing nutrition therapy. Strategies
are needed to successfully sustain this therapy on a
daily basis.12,77
One study interviewed DAFNE program participants
at 6 weeks and 6 and 12 months on assimilating
course principles.16 Subjects initially (6 weeks) felt
support from other participants, for example, by sharing
experiences. However, after 6 months, subjects
valued support from responsive health care professionals
that focused on collaborative decision making.
The investigators concluded that diabetes educators
must clearly communicate to participants that
FIIT principles take time (perhaps over 12 months).
Support at 6 months appeared to be an important
timeframe for subjects, since motivation at this point
was lowest for many.12
People with insulin-requiring diabetes may also diligently
perform dose calculations using their individualized
algorithms when beginning intensive insulin
therapy.73 However, adherence to the ongoing determination
of the prandial insulin dose may become
relaxed as the individual with diabetes gains familiarity
with the self-adjustment of the insulin. As time passes,
there may be the tendency to begin to approximate
premeal doses by titrating insulin based on the standard
or usual carbohydrate content of the meal. In addition,
many people with insulin-requiring diabetes
may actually be hesitant to take on the responsibility
of increasing or decreasing their insulin doses on the
basis of their carbohydrate intake and premeal blood
glucose level.12,73
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issue 24 - 25 < SEP./OCT. 2013