INSULIN DOSING FOR

FAT AND PROTEIN

Current research and recommendations for patients with Type 1 Diabetes
 Fat and Protein Counting in Type 1 Diabetes 2016
• Evidence from CGMs
• Increasing obesity in T1D,
hypoglycemia as a barrier to weight
loss
• Key is macronutrient content of meals
• Protein effect on blood glucose is
delayed by 1.5 hours
• A small amount of protein will effect
blood glucose when consumed with at
least 30 gm CHO but without CHO at
least 75 gm protein but be consumed to
see an effect on bgl.
• Monounsaturated fat reduced post
prandial glucose response produced by
meal containing high glycemic index
 ADA Standards Of Medical Care in
Diabetes-2018

“Selected individuals who have mastered carbohydrate

counting should be educated on fat and protein gram
estimation.”
8. Pharmacologic Approaches to Glycemic Treatment, S64
 Dietary Fat Acutely Increases Glucose Concentrations and Insulin
Requirements in Patients With Type 1 Diabetes. 2013

• Cross-over design with 2 18-hr closed-

loop sessions following high or low fat
meals
• 10 gm vs. 60 gm fat meals with identical
CHO and protein content within subjects
• 7 subjects completed trial (5 M, 2 F)
• No bgl < 70 mg/dl in any subject at any
time
• HF dinners required more insulin and
resulted in more hyperglycemia
• Elevated insulin levels 5-10 hrs after a
meal
• Insulin needs were increased 42% with
HF dinner (although, clear individual
differences)
Figure 1. Top is venous plasma glucose during the two 18-hr sessions. Middle is
insulin delivery during closed-loop control. Bottom is insulin concentration during
closed-loop control.
 Optimized mealtime insulin dosing for fat and protein in Type 1
Diabetes: Application of a Model-Based Approach to Derive insulin
Doses for Open-Loop Diabetes Management. 2016
• Goal was to determine how much
extra insulin was required for HFHP
meals
• Identical boluses given for HFHP and
LFLP meals using optimized ICR
• Model predictive bolus used on
subsequent visit for HFHP meal and
repeated until glucose criteria were
met
• Pizza base with or without added
cheese
• Glucose AUC in HFHP was > double
that of LFLP diet
• Insulin need increased average of 65%
± 10% (range of 17%-124%)
• Optimal delivery: 30%/70% dual wave
over 2.4 hrs
 Bell et al. continued
• Recommendation:
• For HFHP meals (> 40 g fat, >25 g pro) patients should consider
increasing insulin dose from ICR ratio by 25-30% and using combo
bolus with 30-50% given initially and the remainder over 2-2.5
hours.
 Impact of Fat, Protein, and Glycemic Index od Postprandial Glucose
Control in Type 1 Diabetes: Implications for Intensive Diabetes
Management in the Continuous Glucose Monitoring Era 2015
• Systematic review of studies looking at insulin dosing
techniques for dietary fat and protein
• 7 studies identified for each of the 3 topics- widely varied
methods
• 10 studies specifically looking at bolus dosing and
delivery for HFHP
• Only general conclusion is that more insulin is needed
• Adding 35 gm fat and 40 gm protein to a meal is
equivalent to adding 20 gm CHO
• Use of FPU seen in 2 studies but high rates of
hypoglycemia were noted
Warsaw Pump Therapy School
• 1 Fat Protein Unit (FPU) = 100 kcal from fat or protein
• The effect on blood glucose of 1 FPU is estimated to be that of 10 g CHO

1. Normal 1 time bolus for CHO content of meal using individualized

ICR
2. Use square wave bolus to dose for FPU using the following
guidelines:
# FPU x 10 = # CHO equivalents
# CHO equivalents x ICR = insulin dose

# of FPU Hours for Square Wave

1 FPU 3 hours
2 FPU 4 hours
3 FPU 5 hours
4+ FPU 8 hours
 WPTS Example
Estimated Macronutrients: 1. Standard bolus of 2.5u for
CHO: 30 gm CHO content 15 minutes pre-
Fat:11 gm + 11 gm + 2gm = 24 gm meal
216 kcal from fat
Protein: 9 gm + 12 gm + 4 gm = 26 gm 2. 320 kcal from fat and protein
104 kcal from protein 3. 320/100= 3.2 FPU  3 FPU
320 kcal from fat and protein 4. 3 x 10 = 30 CHO equivalents
*ICR 1u:12 CHO 5. 30 CHO / 12 CHO = 2.5 u
Square wave of 2.5u over 5
hours
 Quick Note on FPU Dosing
• Benefit of supplementary fat plus protein counting as
compared with conventional carbohydrate counting
for insulin bolus calculation in children with pump
therapy.
• Decreased post prandial glucose using FPU based dosing but
increased rates of hypoglycemia (no severe hypoglycemia).

• Does the Fat-Protein Meal Increase Postprandial

Glucose Level in Type 1 Diabetes Patients on Insulin
Pump: The Conclusion of a Randomized Study
• Dual wave bolusing with FPU based algorithm reduced post
prandial glucose. 1 in 3 patients with hypoglycemic events.
 Late to the Party: Importance of Dietary Fat and Protein in the
Intensive Management of Type 1 Diabetes. A Case Report. 2017

• One subject with poor glycemic control and frequent post-

prandial hyperglycemia
• Switched to LCHFHP diet with FPU dosing and extended dual
wave boluses
• Improved glycemic control
• Use of WPTS theory
• Initial increased frequency of post prandial hypoglycemic
events.
• Decreased from 10g CHO/1 FPU estimate to 5g CHO/1 FPU
and this effect was resolved
• Significant inter-individual variation in insulin requirements in
response to fat
 Bolus calculator with nutrition database software, a new
concept of prandial insulin programming for pump users. 2010
• Software designed that incorporates FPU algorithm into
bolus calculator and food database
• The Diabetics System- only for windows, not available in
the US
• Does not consider insulin sensitivity or target BGL
• Useful for CSII and MDII patients
 The effect of bolus and food calculator Diabetics on glucose
variability in children with type 1 diabetes treated with insulin
pump: the results of RCT. 2012
• Participants education on FPU counting using WPTS methods
• 1 group used software, 1 group did manual calculations
• Measured: 2-hr postprandial glucose, hypoglycemic events, and TDD and basal needs
• 48 total participants with comparable HgbA1c
• Software using group:
• Significantly lower 2-hr post pranrial and greater time in range
• Significantly lower risk of hyperglycemia in group that used software
• No difference in hypoglycemic events
• TDD and basal comparable
 Food Insulin Index
• FII looks at how much insulin the pancreas would
normally produce in response to a meal in people without
diabetes
• Postprandial glycaemia is significantly improved when
insulin is dosed according to FII but there are non-
significant trends regarding hypoglycemia (increased in
acute studies but decreased in 3 month RCT)
• Suggest: starting with 15-20% increase for high protein
meals and a 30-35% increase for high fat meals (not
additive) using a dual wave or second dose and hour after
the meal commences
 Other Factors To Consider
• Different types of protein have
different rates of digestion
• Major inter-individual
differences seen in every study
• Small sample sizes across the
board
• Quality of carbohydrates
• Original WPTS study induced
hypoglycemia in 1/3
participants
 Implications for Practice
• No evidence based recommendations at this time
• Educate appropriate patients on effect of fat and protein
on blood glucose
• Ensure pump users are aware of dual and square wave
boluses, especially how and when to use them
• Use the aforementioned algorithm in patients you think
are eating a HFHP diet and could benefit from additional
insulin
• In highly motivated patients with good control and no
hypoglycemia unawareness who are interested WPTS
may be useful but requires close monitoring.
References
1. Hibbert-Jones, Elaine. “Fat and Protein Counting in Type 1 Diabetes.” Practical Diabetes, vol. 33, no. 7, 2016,
pp. 243–247., doi:10.1002/pdi.2049.
2. “2018 Standards of Medical Care in Diabetes.” Diabetes Care, Jan. 2018, p. S64., doi:10.2337/dc08-s012.
3. Wolpert, H. A., et al. “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.” Diabetes Care, vol. 36, no. 4, 2012, pp. 810–816., doi:10.2337/dc12-0092.
4. Bell, Kirstine J., et al. “Optimized Mealtime Insulin Dosing for Fat and Protein in Type 1 Diabetes: Application of a
Model-Based Approach to Derive Insulin Doses for Open-Loop Diabetes Management.” Diabetes Care, vol. 39,
no. 9, 2016, pp. 1631–1634., doi:10.2337/dc15-2855.
5. Bell, Kirstine J., et al. “Impact of Fat, Protein, and Glycemic Index on Postprandial Glucose Control in Type 1
Diabetes: Implications for Intensive Diabetes Management in the Continuous Glucose Monitoring Era.” Diabetes
Care, vol. 38, no. 6, 2015, pp. 1008–1015., doi:10.2337/dc15-0100.
6. Kordonouri, Olga, et al. “Benefit of Supplementary Fat plus Protein Counting as Compared with Conventional
Carbohydrate Counting for Insulin Bolus Calculation in Children with Pump Therapy.” Pediatric Diabetes, vol. 13,
no. 7, 2012, pp. 540–544., doi:10.1111/j.1399-5448.2012.00880.x.
7. PaÅ„kowska, Ewa, et al. “Does the Fat-Protein Meal Increase Postprandial Glucose Level in Type 1 Diabetes
Patients on Insulin Pump: The Conclusion of a Randomized Study.” Diabetes Technology & Therapeutics, vol.
14, no. 1, 2012, pp. 16–22., doi:10.1089/dia.2011.0083.
8. Herron, Ann, et al. “Late to the Party: Importance of Dietary Fat and Protein in the Intensive Management of
Type 1 Diabetes. A Case Report.” Journal of the Endocrine Society, vol. 1, no. 8, 2017, pp. 1002–1005.,
doi:10.1210/js.2017-00158.
9. PaÅ„kowska, Ewa, and Marlena BÅ‚azik. “Bolus Calculator with Nutrition Database Software, a New Concept of
Prandial Insulin Programming for Pump Users.” Journal of Diabetes Science and Technology, vol. 4, no. 3, 2010,
pp. 571–576., doi:10.1177/193229681000400310.
10. BÅ‚azik, Marlena, and Ewa PaÅ„kowska. “The Effect of Bolus and Food CalculatorDiabeticson Glucose Variability
in Children with Type 1 Diabetes Treated with Insulin Pump: the Results of RCT.” Pediatric Diabetes, vol. 13, no.
7, 2012, pp. 534–539., doi:10.1111/j.1399-5448.2012.00876.x
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