BOLUSING FOR fat?

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BOLUSING FOR fat?


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Old 05-13-2013, 13:36   #1
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Default BOLUSING FOR fat?

Dietary Fat Acutely Increases Glucose Concentrations and Insulin Requirements in Patients With Type 1 Diabetes: Implications for carbohydrate-based bolus dose calculation and intensive diabetes management
Wolpert, Howard A, MDView Profile; Atakov-Castillo, Astrid; Smith, Stephanie A, MPHView Profile; Steil, Garry M, PHDView Profile. Diabetes Care36. 4 (Apr 2013): 810-6.
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Current guidelines for intensive treatment of type 1 diabetes base the mealtime insulin bolus calculation exclusively on carbohydrate counting. There is strong evidence that free fatty acids impair insulin sensitivity. We hypothesized that patients with type 1 diabetes would require more insulin coverage for higher-fat meals than lower-fat meals with identical carbohydrate content. We used a crossover design comparing two 18-h periods of closed-loop glucose control after high-fat (HF) dinner compared with low-fat (LF) dinner. Each dinner had identical carbohydrate and protein content, but different fat content (60 vs. 10 g). Seven patients with type 1 diabetes (age, 55 ± 12 years; A1C 7.2 ± 0.8%) successfully completed the protocol. HF dinner required more insulin than LF dinner (12.6 ± 1.9 units vs. 9.0 ± 1.3 units; P = 0.01) and, despite the additional insulin, caused more hyperglycemia (area under the curve >120 mg/dL - 16,967 ± 2,778 vs. 8,350 ± 1,907 mg/dbmin; P < 0001). Carbohydrate-to-insulin ratio for HF dinner was significantly lower (9 ± 2vs. 13 ± 3g/unit; P = 0.01). There were marked interindividual differences in the effect of dietary fat on insulin requirements (percent increase significantly correlated with daily insulin requirement; R^sup 2^ = 0.64; P = 0.03). This evidence that dietary fat increases glucose levels and insulin requirements highlights the limitations of the current carbohydrate-based approach to bolus dose calculation. These findings point to the need for alternative insulin dosing algorithms for higher-fat meals and suggest that dietary fat intake is an important nutritional consideration for glycemic control in individuals with type 1 diabetes.

Food for thought, for us all ... not sure if author has an anti-fat agenda ... but interesting. Need to look at his other publications, too.

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Old 05-13-2013, 13:39   #2
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OMG this cannot be "right!"

"All subjects had the same foods for the LF dinner (grilled chicken breast, rice, broccoli, carrots, green salad, and grapes) and for the HF dinner (grilled cheese sandwich, green salad with added cheese, croutons, and grilled chicken, and orange slices). By design, the carbohydrates in the LF dinner and HF dinner had similar glycemie indexes. The lunch meals received by each subject on days 1 and 2 were identical and LF to minimize any possible cany-over effect that an HF lunch could have on the insulin requirements of the subsequent dinner. The breakfast received by each subject on days 2 and 3 were identical and LF, with high-carbohydrate load. The caloric content for breakfast and lunch was calculated to compensate for the 450-kcal difference in the two dinner meals and to keep total calories consumed during the 48-h "

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Old 05-13-2013, 13:41   #3
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I use the dual eave setting on my pump to take care of high fat foods. About 3-4 hours later it can affect my bs.

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Old 05-13-2013, 13:46   #4
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Author also uses the example of Pizza.

I would like to see isocaloric HF meals compared to HC ...

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Old 05-13-2013, 14:25   #5
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Quote:
Originally Posted by foxl View Post
Author also uses the example of Pizza.

I would like to see isocaloric HF meals compared to HC ...
In general, my bolus for mostly carbs is 10 carbs per 1 unit insulin, and with more fat I use 7 carbs per 1 unit insulin. I am Type 2.

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Old 05-13-2013, 15:10   #6
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My carb to unit ratio is 1-85.

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Old 05-13-2013, 15:15   #7
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Anyone who regularly reads Peter's (Hyperlipid) blog is muttering, "Well, DUH!" right now.

Yes, abundant fat induces temporary insulin resistance. That's by design. Throughout our history, our diets have been different but consistent in any particular time and place. It would not shift from 10g of fat to 60g of fat from one day to the next - let alone one meal to the next.

Fat signals cells to turn away glucose for a good reason. Higher fat would (normally) mean lower availability of glucose. Thus, the glucose needs to be reserved for the 5% of cells which can't function without it - red blood cells and a few other things.

Here's the problem: The 95% of cells which can utilize fat metabolites (FFAs and ketones) have to ADAPT to doing so over a period of days or even weeks. In a normal setting, where diet is consistent day to day, this adaptation would have occurred. When people eat meals with a lot of fat and not much carbohydrate (and only normal amounts of protein), everything works perfectly. The 95% reject glucose as fuel ("insulin resistance", but the good kind) and take in the FFAs and ketones instead with the exact same energy result: ATP. If the change is sudden or one-time, they haven't had time to adapt and can't do so.

What, if anything can we learn from this "finding"?

1. High-fat should be accompanied by low-carb. High-both is a bad idea. This is especially true for, but not limited to, diabetics.

2. LC/HF should be a way of life, not a one-meal excursion. The body can't adapt in minutes and the predictable results are what is described in the study.

3. Even a Type 1 who was eating ketogenically would find no issue here. The fat-induced insulin resistant would be a constant and not a sudden change. The 95% of cells would be energized without glucose. The small amount present is mostly taken up by the 5% - most of which as I recall take it up without insulin anyway. Insulin needs are drastically lower overall because of LC/HF and ketosis also, making the margin of error for calculating insulin a lot easier anyway. (Dr. Bernstein's "Law of Small Numbers")

Finally, doing this and then adding more insulin to force the glucose into the 95% is a really bad idea. The FFAs and ketones they should have been using for energy will be left hanging. This could raise blood lipids too much since they have nowhere to go.

In short consistency is a good idea for human diets. Furthermore, it is probably the best idea to CHOOSE - do you want to get cellular energy mainly from glucose or from FFAs and ketones. Most diabetics - both T1 and T2 - would likely be better off choosing the latter.

T1s have more of a choice than T2s - at least T2s with high pathological insulin resistance vs. typical T1s with little or no IR. At least as far as BG maintenance is concerned, T1s could afford to eat very low fat and simply use insulin to get all their energy from glucose. On the other hand, a T2 with severe (pathological) insulin resistance might not be able to get sufficient cellular energy without high-fat AND ketosis and/or would need too much insulin to get it done.

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Old 05-13-2013, 19:42   #8
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Quote:
Originally Posted by smorgan View Post
ATP
That one wasn't on the acronyms page, or on the site where I usually look this type of stuff up, internetslang.com.

Just want to make sure I'm not missing anything.

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Old 05-13-2013, 20:24   #9
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Quote:
Originally Posted by sine View Post
That one wasn't on the acronyms page, or on the site where I usually look this type of stuff up, internetslang.com.

Just want to make sure I'm not missing anything.
It's not internet slang but the abbreviation for some chemical I can't remember how to spell. It is the actual source of energy within our cells. Glucose can get turned into ATP by any cell in the body. Many, notably major customers like skeletal muscle can also make it from FFAs (free fatty acids) and about 95% of the body's cells (including most of the brain) can make it from ketones.

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Old 05-13-2013, 20:37   #10
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The meal plan has a couple of holes in it. One, as Salim has said it will raise your insulin but also it will hold the food in your stomach for a much longer time. This will increase digestion of the available glucose in the meal and deliver it at a later time. Take the HF meal, remove the fat, bolus for the meal as normal, 2 hrs later eat the fat, pretty sure you will not have to bolus for that by much if any.

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