Old age should be no barrier to carb counting and insulin pump use

Type 1 diabetes

By Michael Woodhead

17 May 2022

Negative perceptions about the potential carbohydrate counting skills of older patients should not be barriers to insulin pump therapy, Victorian researchers say.

Contrary to expectations held by some clinicians, experience in an Australian trial of closed loop therapy has shown that most older patients with type 1 diabetes were already proficient in carb counting or could be brought up to proficiency with minimal education.

Patients enrolled in the OldeR Adult Closed-Loop (ORACL) trial had an average age of 68 years and duration of type 1 diabetes of 38 years.

When dieticians involved in the trial assessed the carb-counting ability and education requirements of 30 participants, they found that most (83%) were already carb counting at enrolment and around 60% were deemed to have proficiency after a single in-person consultation.

All but one of the remaining patients were able to achieve sufficient proficiency and confidence in carb counting to use closed loop therapy after a second consultation, which was either in-person or via telephone, according to study investigators from the Department of Endocrinology & Diabetes at St Vincent’s Hospital, Melbourne.

Many of the patients who required education sessions had not been carb counting prior to trial enrolment, while others requested further in-person education due to their lack of self-confidence even though their carb counting was deemed to be accurate when reviewed by dieticians.

Writing in Nutrition and Dietetics, the study investigators said the common types of food diary errors observed in older patients were similar to those seen among younger adults in clinical practice.

These errors were predominantly miscalculation of carb content when participants over-estimated carbohydrates when using raw rather than cooked values for foods such as rice and pasta, they said. Conversely, some patients underestimated carbohydrate amounts when eating out.

Factors that contributed to carb-counting proficiency in older participants included having regular daily routines, prioritisation  of  personal health, perceived availability of time, and readiness to embrace technology as well as prior carbohydrate-counting  knowledge.

The study authors said the findings were important because manual determination of carbohydrate intake is required for insulin bolus dosing among people with T1D using current insulin therapies such as pumps and injections.

Individuals who have difficulty  accurately  estimating  carbohydrate content of meals are more likely to have higher post-prandial glucose, greater glucose variability and HbA1c levels as well as post-prandial glucose.

Our findings indicate that these older adults with long-duration type 1 diabetes, who were using insulin pumps and enrolled in a clinical trial, required minimal education to bring their carbohydrate-counting skills and confidence to the level of proficiency required to use closed-loop therapy,” they said.

The five key areas of knowledge for carb counting included recognition of foods containing  carbohydrate;  ability  to  read  food  labels; ability to calculate carbohydrate content of meals/food using books or apps; ability to assess carbohydrates in meals/food when eating out and calculating carbohydrate quantities from recipes.

“Older age and acquisition of carbohydrate-counting skills should not necessarily be considered barriers to insulin pump therapy (standard pump or closed-loop therapy),” they concluded.

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