Carbohydrate Counting

Type 1 Diabetes Mellitus

The Interactions Between Physicians and Dentists in Managing the Care of Patients With Diabetes Mellitus

ISPAD Clinical Practice Consensus Guidelines 2022: Ramadan and other religious fasting by young people with diabetes.

Medical nutrition therapy (MNT) is a vital aspect of management of type 1 diabetes mellitus (T1DM) and should be tailored to ethnic and family traditions and the socioeconomic and educational status of the patient. In this article, we discuss the unique aspects of MNT in children and adolescents with T1DM in the Indian setting, with focus on the challenges faced by patients, dieticians and physicians and how these can be overcome. The authors reviewed the available literature on MNT in T1DM from India and prepared the document based on their vast collective clinical experience in treating patients with T1DM from different regions in India. Indian diets are predominantly carbohydrate-based with high glycemic index (GI) and low protein content. Various methods are available to increase the protein and fiber content and reduce the GI of food in order to limit glycemic excursions. Insulin regimens need to be tailored to the child's school timings, meal schedule, and the availability of a responsible adult to supervise/administer insulin. All patients, irrespective of economic and education background, should be taught the broad principles of healthy eating, balanced diet and carbohydrate counting. There are various barriers to dietary compliance, including joint family system, changing lifestyles, and other factors which need to be addressed. There is a need to customize dietary management according to patient characteristics and needs and develop standardized patient educational material on principles of healthy eating in various regional languages.

Backgrounds: Carbohydrate intake is a major determinant of blood glucose stability in patients with type 1 diabetes. Carbohydrate counting as a meal planning approach for patients with type 1 diabetes is known to have flexibility in controlling blood glucose by regulating the amount of carbohydrate intake and insulin dose, yet a good understanding about carbohydrate counting practices is still needed in order to achieve blood glucose control targeted blood glucose control.Objectives: this article aims to review the result of previous studies relating to effect, impact and benefits in metabolic control, anthropometry, also impact and practices of education relating to carbohydrate counting in type 1 diabetes.Discussion: Carbohydrate counting has an impact on HbA1c, body mass index, waist circumference, diabetes-related quality of life and type 1 diabetes therapy satisfaction. Effects of carbohydrate counting depends on age, diet management, ability to calculate ideal insulin requirements, provided education, patient readiness to apply carbohydrate counting, family support, and additional interventions provided to support improved metabolic control. The use of Automated Bolus Calculator (ABC) with carbohydrate counting and FIIT simultaneously was thought to be able to support the effectiveness of type 1 diabetes mellitus therapy.Conclusions: Carbohydrate counting can improve metabolic control in children, adolescents and adults with type 1 diabetes. It is necessary to emphasize continuous education by registered dietitian using media in estimating the portion of food and insulin doses, also involving parents to improve the accuracy of carbohydrate counting in children and adolescents.The combination of Automated Bolus Calculator (ABC) and Flexible Intensive Insulin Therapy (FIIT) is known to increase carbohydrate counting effectiveness in type 1 DM therapy.

The prevalence of diabetes mellitus is rising globally and even more in low and middle-income countries such as Nigeria. Optimal management of the disease is important to improve survival and prevent or delay its complications. Lifestyle management is a standard universal approach in optimizing the care given to diabetic patients. Dietary management is the central link in lifestyle modifications of individuals living with diabetes. Medical nutrition therapy (MNT) is a systematic therapeutic approach of assessing the nutritional needs of an individual, determining nutritional goals, counselling the clients on how to achieve the goals, prescribing and monitoring meal plans to achieve the goals. It is evidence-based, effective and highly recommended. All carers of the diabetes patient, including the health workers and the family members of the patients, need to have basic understanding of medical nutrition therapy but the efforts should be coordinated by licensed dietitians. There are evidences that adherence to prescribed calories is effective in the control of cardiovascular risk factors such as blood glucose, weight, lipid profile and blood pressure. However, prescription of calories should be based on thoughtful consideration of the nutritional needs, weight goal, personal preferences and tastes and cultural practices of individuals living with diabetes mellitus. Food pyramids give a graphical illustration on the recommended classes and servings of food. Six to eleven servings per day of carbohydrates, 3-5 servings per day of vegetables, 2-4 servings per day of fruit, 2-3 servings per day of dairy products and 2-3 servings per day of fish are the recommended proportions of the different classes of foods for an adult on an average of 2000 calories. Carbohydrate counting, taken with appropriate insulin dosing and physical activity, has been demonstrated to be effective in optimizing the glycaemic control of patients on multiple daily insulin injections. There are challenges in doing this in Nigeria due to lack of food labels. The caloric contents of common Nigerian foods are highlighted so as to help in achieving dietary goals.

IntroductionEvidence on the effects of structured nutrition education is weak in adults with type 1 diabetes mellitus (T1D) with moderately impaired glycemic control. Objective was to compare the effects of...

IntroductionThe successful treatment of type 1 diabetes (T1D) requires those affected to employ insulin therapy to maintain their blood glucose levels as close to normal to avoid complications in the...

Tracking Diabetes Therapy Into The 21st Century

Underlying this question of whether to inform licensing authorities is the deep unrest felt by physicians, patients who have experienced hypoglycemia, and if they have given it some thought, society in general regarding the true safety of the driver taking hypoglycemic agents. An American Diabetes Association position statement includes “employment/licensure” in its title but does not mention licensure in its text.1 What is known about this topic? Cox and colleagues studied 37 type 1 diabetic subjects with a history of severe hypoglycemia by using a sophisticated driving simulator during the gradual induction of hypoglycemia.2 The subjects were instructed to treat their low blood glucose levels (<72 mg/dL or 4 mmol/L), and to take corrective action if they felt that their driving was impaired. In this study, even mild hypoglycemia led to impaired driving. But only 30% of subjects took corrective action, such as pulling off the road or eating a high carbohydrate snack. The authors concluded that there appears to be no connection between awareness of driving impairment and corrective action. The Diabetes Control and Complications Trial (DCCT), which showed a 50% to 75% reduction in microvascular end points (eg, diabetic retinopathy) in the intensive treatment arm, also highlighted the risks and limitations of current therapy, namely hypoglycemia.3,4 Hypoglycemia is the limiting factor in the pharmacologic treatment of diabetes mellitus.5 DCCT patients receiving intensive therapy were over 3 times more likely to develop severe hypoglycemia.4 This translates into episodes requiring assistance from others in 25% of intensively treated patients per year compared to 10% on conventional therapy. Furthermore, those on intensive treatment averaged 2 mild, self-treated hypoglycemia episodes per week compared to 1 per week on conventional treatment. Many type 1 diabetics who have the disease for up to 10 to 15 years develop hypoglycemia unawareness—that is, they may lapse into coma or have a seizure with no premonitory symptoms. Hypoglycemia awareness is related to loss of counter-regulation by glucagon and epinephrine. In patients without autonomic neuropathy, repeated hypoglycemia during attempts to achieve normoglycemia may be the most common cause of such unawareness. As Cryer has noted, this may be reversed by as little as 2 to 3 weeks of meticulous blood glucose control with scrupulous avoidance of hypoglycemia.5 All of the sulfonylureas and repaglinide can cause hypoglycemia. Fortunately, thiazolidinediones, metformin, α glucosidase inhibitors, and diet alone do not. What can be done? Cox and colleagues note that blood glucose awareness training increases awareness of blood glucose fluctuations, results in fewer and less extreme hypoglycemic events, and leads to fewer vehicular crashes when compared to subjects in control groups without such training.2 Diabetic patients who drive should be encouraged to treat themselves immediately whenever they think that their blood glucose is low or their driving is impaired. We should remember, however, that 45% of subjects in Cox and colleagues' study were willing to drive when their blood glucose was <50 mg/dL (2.8 mmol/L), while 43% of significantly impaired drivers never took corrective action. Loss of judgment may be a cardinal sign of hypoglycemia. It is prudent for a person with diabetes taking insulin, sulfonylureas, or repaglinide to check their blood sugar level before driving and if it is in or below the 72-90 mg/dL (4-5 mmol/l) range, not to start driving until they have normalized their blood sugar level. All diabetic drivers taking these agents should have a readily absorbable source of sugar available—but those also using an α glucosidase inhibitor may have slower absorption of sucrose (table sugar) and should use pure glucose tablets. It also makes sense to periodically test blood glucose levels on long drives. If available, blood glucose awareness training may reduce the risk of hypoglycemia as a cause of accidents and “near misses.” Education of family and friends regarding recognition of hypoglycemia and its treatment is useful. To paraphrase a well-known advertisement, “Friends don't let friends drive hypoglycemic.” If only insulin use was reportable to licensing authorities, there would be enormous resistance and reluctance on the part of diabetic drivers to take insulin, even when needed, and on the part of physicians to prescribe this hypoglycemic agent. Therefore, since it is unclear what licensing agencies would or could do with the information, there appears to be nothing to gain and much to lose with mandatory notification. It would be better to disseminate the guiding principles alluded to in this commentary.

Background: The prevalence of diabetes mellitus (DM) is increasing globally, including in Indonesia. Studies by Diabetes Control and Complication Trial (DCCT) and U.K. Prospective Diabetes Study Group (UKPDS) prove the benefit of medical nutrition therapy (MNT) to glycemic control. Similar studies have not been done much in Indonesia.Objective: To identify the effects of MNT to nutrient intake, control of nutrition status, blood glucose and blood pressure of type 2 DM outpatients.Method: This was a randomized controlled trial. Subject of the study consisted of 60 people. The experiment group got MNT; whereas the control group got conventional nutrition counseling. Data were processed using computer, nutrients were analyzed using nutrisurvey. Statistical t-test was done to identify the effect of intervention.Result: Intake of energy, fat and carbohydrate of the experiment group decreased signifcantly close to the necessity at subsequent decrease as much as -14.05 (p= 0. 009), -35.64 (p=0.019) and -19.14 (p=0.035). Body mass index In the experiment group decreased -0.41kg/m and waist circumference -0.24cm, where as the control group -0.23 kg/m and -014cm. Blood glucose level during fasting decreased -23.6 mg/dl in the experiment group and -14.03 mg/dl in the control group (p=0.036). Systolic and dyastolic blood pressure of the experiment group decreased -3.33 mmHg (p=0.035) and 2 2 -1.67 mmgHg (p=0.895), whereas the control group + 0.5 mmHg and -1.33 mmHg; the change was insignificant.Conclusion: Intake of nutrient, nutrition status, blood glucose level and blood pressure of type 2 DM patients that got MNT was more controllable than of those that got conventional nutrition counseling.

Potential advantages of continuous subcutaneous insulin infusion (CSII) over multiple daily injections (MDI) include improved glycaemia, and reduced frequency and severity of hypoglycaemia. In our hospital, to be considered for CSII, patients must be using MDI, and then undergo a Dose Adjustment For Normal Eating (DAFNE) structured education course.We reviewed the records of the 21 patients with type 1 diabetes who had sequentially undergone MDI, then DAFNE and are now treated with CSII.HbA1c improved as patients increased the intensity of the management of diabetes despite reductions in total daily insulin dose. Patients did a similar number of home blood glucose tests per day and spent a similar amount of time managing their diabetes.Contacts with health care team members were the same for all modalities in the first three months but reduced for those on MDI with or without having completed a structured education course, while contacts with the health care team remained higher on pumps. Patients were generally satisfied with all modalities of treatment and would recommend each modality.The input into the management of diabetes from both patients and health care professionals remained high even after the initial stages of being commenced on CSII therapy. This reflects the additional input needed in assessing the various basal rates and other ratios. However, patient preference was in favour of pumps in this select group who had sequentially experienced all three options. Copyright © 2011 John Wiley &amp; Sons.

Background: Automated insulin calculators (AICs) with carbohydrate counting (CHC) have been shown to be effective in improving glycated haemoglobin (HbA1c) levels. By contrast, use of AICs without CHC, with predetermined prandial insulin doses modified according to a correction factor and modulated as a function of glycaemia, has not yet been investigated.Methods: This comparative, retrospective, observational and non-randomized study took place over a 6-month period of routine clinical practice. It evaluated the use of Free-style InsuLinx® and Free-style Neo® Abbott Diabetes Care (AIC) in easy mode (no CHC). All patients performed a basal–prandial insulin dosing schedule, and were not educated as to how to determine carbohydrate intake. Changes in HbA1c and capillary blood glucose levels, insulin therapy, frequency of blood glucose tests and body weight were analyzed 6 months prior to inclusion (T−6), at the time of inclusion (T0) and 6 months later (T+6). From T−6 to T0 (period A), patients used a standard blood glucose meter and adjusted their insulin doses themselves, and from T0 to T+6 (period B), each patient was provided with an AIC on easy mode function.Results: Of the 230 patients, 221 were retained at the end of the study (126 type 1 diabetes mellitus (T1DM) and 95 type 2 diabetes mellitus (T2DM)).At T−6, average (±standard error of mean) HbA1c level was 8.3 ± 0.1%; T1DM: 8.5 ± 0.1% and T2DM: 8.0 ± 0.1%, respectively.At T0, the average HbA1c level was 8.4 ± 0.1% (p = 0.02); T1DM: 8.5 ± 0.1% (ns) and T2DM: 8.2 ± 0.1% (p = 0.004).At T+6, with AIC in easy mode, average HbA1c level decreased significantly to 7.7 ± 0.1% (p < 0.0001); T1DM: 8.0 ± 0.1% (p < 0.0001) and T2DM: 7.5 ± 0.1% (p < 0.0001).At T+6, in all diabetics, blood glucose monitoring frequency increased by 0.4/day (p < 0.0001). Insulin correction amounted to 14% of changes in predetermined prandial insulin doses.Conclusion: Routine clinical use of an AIC without CHC improved self-management of blood glucose and on average, decreased HbA1c levels by 0.52% in T1DM and 0.80% in T2DM after 6 months.

AimsSustained engagement in type 1 diabetes self‐management behaviours is a critical element in achieving improvements in glycated haemoglobin (HbA1c) and minimising risk of complications. Evaluations of self‐management programmes, such as Dose Adjustment for Normal Eating (DAFNE), typically find that initial improvements are rarely sustained beyond 12 months. This study identified behaviours involved in sustained type 1 diabetes self‐management, their influences and relationships to each other.MethodsA mixed‐methods study was conducted following the first two steps of the Behaviour Change Wheel framework. First, an expert stakeholder consultation identified behaviours involved in self‐management of type 1 diabetes. Second, three evidence sources (systematic review, healthcare provider‐generated ‘red flags’ and participant‐generated ‘frequently asked questions’) were analysed to identify and synthesise modifiable barriers and enablers to sustained self‐management. These were characterised according to the Capability‐Opportunity‐Motivation‐Behaviour (COM‐B) model.Results150 distinct behaviours were identified and organised into three self‐regulatory behavioural cycles, reflecting different temporal and situational aspects of diabetes self‐management: Routine (e.g. checking blood glucose), Reactive (e.g. treating hypoglycaemia) and Reflective (e.g. reviewing blood glucose data to identify patterns). Thirty‐four barriers and five enablers were identified: 10 relating to Capability, 20 to Opportunity and nine to Motivation.ConclusionsMultiple behaviours within three self‐management cycles are involved in sustained type 1 diabetes self‐management. There are a wide range of barriers and enablers that should be addressed to support self‐management behaviours and improve clinical outcomes. The present study provides an evidence base for refining and developing type 1 diabetes self‐management programmes.

Type 1 diabetes in adults: new <scp>NICE</scp> guidance on diagnosis and management