Carbohydrate-counting education for older adults with type 1 diabetes starting first-generation closed-loop therapy: Observations from the ORACL trial

TY - JOUR

T1 - Carbohydrate-counting education for older adults with type 1 diabetes starting first-generation closed-loop therapy

T2 - Observations from the ORACL trial

AU - Roem, Kerryn

AU - Compton, Robyn

AU - Fourlanos, Spiros

AU - McAuley, Sybil A.

N1 - Funding Information: The ORACL Trial was funded by JDRF (3‐SRA‐2018‐667‐M‐R), the Diabetes Australia Research Program, and St Vincent's Hospital (Melbourne) Research Endowment Fund. Medtronic supplied discounted insulin pumps and glucose monitoring devices for the study. The funders of this study had no role in trial design, data collection, data analysis, data interpretation, or writing of the report. Funding Information: The ORACL Trial was funded by JDRF (3-SRA-2018-667-M-R), the Diabetes Australia Research Program, and St Vincent's Hospital (Melbourne) Research Endowment Fund. Medtronic supplied discounted insulin pumps and glucose monitoring devices for the study. The funders of this study had no role in trial design, data collection, data analysis, data interpretation, or writing of the report. St Vincent's Hospital Melbourne Human Research Ethics Committee: HREC 275/18. Skills to accurately estimate the carbohydrate content of meals are central to optimising insulin pump therapy for people with type 1 diabetes.1 First-generation closed-loop systems have glucose-responsive automated basal insulin delivery; users are still required to estimate amounts of carbohydrate being consumed and enter these into their pump for prandial bolus insulin dose calculation.2 However, many individuals with type 1 diabetes have difficulty accurately estimating carbohydrate content of meals3; inaccurate carbohydrate counting is associated with higher post-prandial glucose, glucose variability and glycated haemoglobin (HbA1c).4–7 Estimation errors >10 g carbohydrate have been shown to impact post-prandial glucose.8 For older adults, cognition and co-morbidities may impact type 1 diabetes self-management practices including carbohydrate counting.9 A potential perceived barrier to clinicians prescribing intensive insulin regimens (including pumps) for older adults is the perception of their inability to master carbohydrate counting.10 However, there is limited published evidence regarding carbohydrate-counting abilities of older adults. With increasingly flexible and effective insulin pump features, exploration of any perceived barriers is essential. The OldeR Adult Closed-Loop (ORACL) trial enrolled adults aged >60 years, with long-duration type 1 diabetes and using an insulin pump (ethics approval St Vincent's Hospital Melbourne Human Research Ethics Committee: HREC 275/18).11 Within ORACL, we assessed the carbohydrate-counting ability and education requirements of participants prior to randomisation. Here, we report observations from the ORACL trial regarding the ability of participants to carbohydrate count and to grasp dietitian-led carbohydrate-counting education, with a view to informing health professionals to support older adults with type 1 diabetes. Assessment of carbohydrate-counting ability was a multi-step process, with qualitative and quantitative components, commencing with individualised education (initial or refresher) provided by an experienced dietitian. Five areas of knowledge required for accurate carbohydrate counting were focussed upon: (i) recognition of food containing carbohydrate; (ii) ability to read food labels; (iii) ability to calculate carbohydrate content of meals/food using books or apps; (iv) ability to assess carbohydrates in meals/food when eating out and (v) calculating carbohydrate quantities from recipes.12 Initial consultations provided individualised education in each of these areas. Participants were provided with instructions and asked to complete a 5-day food diary; details of meals and snacks were recorded, along with participants' carbohydrate-counting calculations. Diaries were then reviewed by the study dietitian to assess carbohydrate-counting accuracy. Any meal where the carbohydrate estimate was not within 10 g of the expected carbohydrate amount was designated as an estimation error. For this study, the objective was for participants to have ≤3 estimation errors over the 5-day period. If the diary had >3 estimation errors, participants received further education by the dietitian. Assessment of participants' ability was based upon a combination of in-person and email assessments. Further assessment occurred as required, subject to participant performance at the initial assessment. Thirty adults, median age 68 years (interquartile range 64–71 years) and diabetes duration 38 years (interquartile range 20–47 years), participated in the ORACL trial. Twenty-five participants (83%) were carbohydrate counting at enrolment. Upon dietitian assessment, 17 participants (57%) were deemed to have carbohydrate-counting proficiency after a single in-person consultation (six deemed proficient during the consultation and 11 afterwards via email). Twelve participants (40%) required a second education session; eight were conducted in-person and four via telephone (the latter for only minor clarification of carbohydrate-counting issues). One participant required a third education session, conducted in-person. Of the nine participants requiring multiple in-person sessions, four were not carbohydrate counting pre-enrolment; the other five requested further in-person education due to lack of self-confidence in carbohydrate counting (upon food diary review, their carbohydrate counting was deemed to be accurate despite their low self-confidence). The most common types of food diary errors observed were akin to errors observed among younger adults in our clinical experience. These errors were predominantly miscalculation of carbohydrate content when participants either: (i) over-estimated carbohydrates when using raw rather than cooked values for foods (e.g., rice, pasta), or (ii) underestimated carbohydrate amounts when eating out. The clinicians observed that prior carbohydrate-counting knowledge, high prioritisation of personal health, regular daily routines, perceived availability of time, and readiness to embrace technology all appeared to contribute to the carbohydrate-counting proficiency demonstrated by the older adult participants. 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. Individuals who were not previously carbohydrate counting were able to readily learn the skills required within two education sessions. The factors identified above may be conducive to carbohydrate-counting education uptake by older adults. Moreover, since current insulin therapies (pumps and injections) require manual determination of carbohydrate intake for insulin bolus dosing, carbohydrate-counting proficiency is important for all people with type 1 diabetes using intensive insulin therapy. Older age and acquisition of carbohydrate-counting skills should not necessarily be considered barriers to insulin pump therapy (standard pump or closed-loop therapy).

PY - 2022/11

Y1 - 2022/11

KW - carbohydrate

KW - insulin infusion systems

KW - insulin pumps

KW - nutrition therapy

KW - patient education

KW - technology

KW - type 1 diabetes

UR - http://www.scopus.com/inward/record.url?scp=85129747065&partnerID=8YFLogxK

U2 - 10.1111/1747-0080.12744

DO - 10.1111/1747-0080.12744

M3 - Letter

C2 - 35543111

AN - SCOPUS:85129747065

SN - 1446-6368

VL - 79

SP - 647

EP - 649

JO - Nutrition & Dietetics

JF - Nutrition & Dietetics

IS - 5

ER -