Creative Bolus Strategies Result in Better Glycemic Control (ADA 2020)

Creative Bolus Strategies Result in Better Glycemic Control (ADA 2020)


At the American Diabetes Association (ADA) 80th scientific sessions on Friday afternoon, Margaret Pellizzarri, RN, MS, MBA, CDE along with the Integrated Diabetes Services team, including Gary Scheiner, MS, CDE delivered a unique presentation on clever insulin bolusing techniques for people living with diabetes who use a pump or multiple daily injections, when dosing for high-protein and high-fat meals.

Bolus Options

  • Normal bolusing–delivers insulin all at once and is used for most meals
  • Square bolusing–delivers insulin over a period of time. This is especially useful in situations where there is a buffet or you are eating over a longer period of time. Patients with gastroparesis also can benefit from square bolusing since their digestion is slowed down.
  • Combination or dual-wave bolus–delivers a portion of the insulin as a normal bolus and the rest as an extended or square bolus. This can be particularly helpful with meals that are high in fat, high in both fat and carbs, as well as for high-protein meals.

Insulin Dosing for Protein and Fat: Studies and Strategies

Studies conducted in both people living with type 1 and type 2 diabetes indicate that fat slows down gastric emptying and slows down glucose absorption. This can result in hypoglycemia for patients after a fat-laden meal. Several studies demonstrate that both high-fat and high-protein meals require more insulin to achieve target postprandial blood glucose levels. Furthermore, glycemic responses vary depending on the specific macronutrient profile of the meal, with higher-protein meals tending to cause prolonged hyperglycemia (if not accounted for). Altogether, this indicates that the insulin delivery strategy must be optimized in dose and timing to achieve the most optimal results when consuming such meals. 

Here are the highlights from the presentation:

  • One study showed that high-protein, high-fat meals required 30% more insulin over 6 hours and suggested using a glucose meter or continuous glucose monitor (CGM) to adjust as needed.
  • Another investigation demonstrated that consuming a mixed protein mixed meal (36 g protein, 30 g carbs, 5 g fat) when dosing only for the carb content, resulted in higher postprandial glucose values. By using a protein-fat insulin dosing algorithm, they suggested that adding 66% more insulin delivered in a combination bolus over three hours resulted in improved glucose levels. The impact of a meal that was higher in protein and fat, showed to be additive to postprandial glucose levels.
  • One study showed that mealtime doses for individuals with type 1 diabetes need to be individualized. For high-fat meals (more than 40 g), patients should consider additional mealtime insulin, around 30-35% of the initial dose. For individuals using pumps, it is recommended to try a combination bolus with half the dose before eating and half delivered over 2-2.5 hours after eating.
  • One investigation suggested that high-protein and high-fat meals require a >60% ICR (insulin-carb ratio) as a standard bolus before the meal with an additional ICR up to 70% in an extended bolus starting at 1.5-5 hours after the meal.

Conclusions

  • Experts suggest altering your insulin dosing and changing the timing of insulin delivery can help better navigate tricky meals that are high in fat and/or protein.
  • Using the bolus techniques presented above, those on an insulin pump can experiment to achieve what works best (Note: If low blood glucose occurs, it is recommended to extend the duration of the remainder of the extended dose.)
  • Those using multiple daily injections can also vary the timing and dose of their insulin according to the specific meal (although this may be more tedious). You could also consider different insulin based on their activity profiles (make sure to discuss any changes with your healthcare provider!).
  • Despite the manufacturer’s recommendations of dosing insulin within 15 minutes of meal consumption or immediately after, research shows that best postprandial glycemic results are achieved when taking the specific macronutrient distribution of the meal into account and adjusting both insulin amounts and timing to best match that food profile.
  • Recent research shows that injecting 15-20 minutes before meals is safe, and results in 30% lower glucose levels and less post-meal hyperglycemia when premeal glucose levels were in range.

Whether you use a pump and can take advantage of the special bolusing features or are on multiple daily injections, there are strategies to try when consuming high-protein, high-fat meals. With some trial and error, we can all benefit these creative tactics to strive for improved postprandial glucose levels when it comes to the always challenging high-protein, high-fat meals. Be sure to always consult your healthcare provider before making any changes to your insulin dosing regimen.

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What are your thoughts on the subject? Do you use any of these strategies? How do you navigate complex meals?

Stay tuned for more from the ADA 80th scientific sessions!

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Read more about ADA2020, American Diabetes Association (ADA), bolus, diabetes management, high-protein diets, insulin, insulin pumps, Intensive management, low blood sugar (hypoglycemia).



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