Carmel E Smart

Hunter New England Health | HNEPH · Endocrinology

Carbohydrate (CHO) counting allows children with Type 1 diabetes to adjust mealtime insulin dose to carbohydrate intake. Little is known about the ability of children to count CHO and whether a particular method for assessing CHO quantity is better than others. We investigated how accurately children and their caregivers estimate carbohydrate, and...

Carbohydrate (CHO) quantification is used to adjust pre-meal insulin in intensive insulin regimens. However, the precision in CHO quantification required to maintain postprandial glycaemic control is unknown. We determined the effect of a +/-10-g variation in CHO amount, with an individually calculated insulin dose for 60 g CHO, on postprandial gly...

A review of the literature was undertaken to identify the nutritional needs of elderly MOW consumers and factors affecting the ability of existing programs to meet those needs. The focus was on the Australian experience but drawing on the world literature. Keyword search of English language based computer databases of the medical and health literat...

The nutritional care of children with diabetes is complex. Diabetes management is set within the context of the family, a surrounding social system, multiple carers, often deteriorating national dietary characteristics, issues of non-compliance, peer pressure, emerging independence, and the ultimate aim of maintaining quality of life. It requires a...

The purpose of this study was to quantify the effects of glycemic index on postprandial glucose excursion (PPGE) in children with type 1 diabetes receiving multiple daily injections and to determine optimal insulin therapy for a low-glycemic index meal. Twenty subjects consumed test breakfasts with equal macronutrient contents on 4 consecutive days...

of what is New or Different 1. This chapter recommends a target HbA1c of ≤6.5% (48mmol/mol) for those who have access to advanced diabetes technologies like continuous glucose monitoring (CGM) and automated insulin delivery (AID). This target should be encouraged for all children and adolescents living with diabetes when safely achievable. In other...

Aims To (1) evaluate the efficacy of OptimAAPP, a smartphone insulin dose calculator for carbohydrate, fat, and protein in managing glycaemia compared with carbohydrate counting in adolescents and adults with type 1 diabetes using flexible multiple daily injection therapy (MDI, ≥4 injections/day) and (2) assess user acceptability of OptimAAPP. Met...

Children who develop diabetes in their first years of life risk being exposed to many decades of hyperglycemia, hence having a high risk of early complications and premature death. An additional age-dependent risk is that dysglycemia, especially hyperglycemia, negatively affects the developing brain. In evaluating the outcome of insulin treatment a...

Objective To determine if a bedtime snack in young children with type 1 diabetes (T1D) prevents nocturnal hypoglycemia, and the impact on glycemia overnight. Methods In this randomized controlled crossover trial, 10 grams of carbohydrate (milk, yogurt, and kefir) was given 150–180 minutes after dinner over three nights to 5-8-year-old children with...

Introduction: The COVID-19 pandemic necessitated worldwide lockdowns in 2020 and 2021, with restrictions on physical activity and changes in eating habits. Aims: To investigate temporal trends in Body Mass Index (BMI) and BMI Standard Deviation Score (SDS) inSDS) in three international T1D registries between 2018-2021. Methods: Data were extracted...

Nutrition therapy is an essential component of effective diabetes management. Healthcare providers need to stay current on new developments in nutrition therapy and specific interventions for a wide range of patient populations and special circumstances in order to provide the best possible outcomes for their patients. Revised and updated to incorp...

Successful management of type 1 diabetes (T1D) requires not only optimal glycemic outcomes, but also a holistic approach that encompasses all aspects of life and recommendations to address needs. Current goals include optimal glycaemic values, quality of life and life expectancy similar to peers, prevention of long-term complications, prevention of...

Aims. This study aimed to identify the quantity and range of protein, fat, and carbohydrate consumed in meals and snacks in children with Type 1 diabetes (T1D), and to explore associations between the variability in fat and protein intakes with the glycemic outcomes. Methods. This was a cross-sectional dietary study of children 6–18 years attending...

The complex treatment for diabetes type 1 (T1D) includes insulin dosing for every meal, which requires education and experience to achieve optimal outcomes. Advanced carbohydrate counting (ACC) is the recommended method. We studied ACC as part of a standard treatment with the aim to explore its associations with glycemic control and empowerment in...

The main goal of therapeutic management of type 1 Diabetes Mellitus (T1DM) is to maintain optimal glycemic control to prevent acute and long-term diabetes complications and to enable a good quality of life. Postprandial glycemia makes a substantial contribution to overall glycemic control and variability in diabetes and, despite technological advan...

Aims: Physical activity (PA) plays an important role in the prevention of cardiovascular disease (CVD), particularly in individuals with type 1 diabetes mellitus (T1DM) who are at increased risk. Our aim was to determine levels of moderate-to-vigorous physical activity (MVPA), sedentary behaviour and sleep in adolescents with T1DM, and identify ba...

Objective: To conduct an Australian community-led survey of adults with type 1 diabetes (T1D), identifying priorities for, and barriers to, optimal use of advanced glucose management technologies. Research design and methods: A 30-question online survey of current or past users of insulin pump therapy (IPT), real-time continuous glucose monitori...

Introduction: Caring for young children with Type 1 diabetes comes with significant burden for parents. We hypothesised that pregnancy and the arrival of a new sibling may be associated with a deterioration in control of type 1 diabetes for older siblings with type 1 diabetes. Research Design and Methods: We identified young children currently unde...

Aims: This study aimed to provide a global insight into initiatives in type 1 diabetes care driven by the COVID-19 pandemic and associations with glycemic outcomes. Methods: An online questionnaire regarding diabetes care before and during the pandemic was sent to all centers (n=97, 66,985 youth with type 1 diabetes) active in the SWEET registry...

OBJECTIVE The relationship between diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes and long-term glycemic control varies between studies. We aimed, firstly, to characterize the association of DKA and its severity with long-term HbA1c in a large contemporary cohort, and secondly, to identify other independent determinants of long-term Hb...

Objectives: During Ramadan, traditional Egyptian Iftar meals have large amounts of high glycemic index carbohydrate and fat. The efficacy of different bolus regimens on optimizing post prandial glucose (PPG) excursion following this Iftar meal was assessed. Methods: A randomized controlled trial evaluating 4-h PPG measured by continuous glucose-...

AIM To assess evening and overnight hypoglycemia risk following late afternoon exercise compared with a non-exercise control day in adults with type 1 diabetes using automated insulin delivery (AID). METHODS Thirty adults with type 1 diabetes (Mean [SD] Age 38[9] Years; 14Female; HbA1c 7.1[1.0] % / 54[11 ] mmol/mol ) using AID (Minimed 670G) perfor...

Purpose The OPTIMISE study uses a Multiphase Optimisation Strategy (MOST) to identify the best combination of four interventions targeting key diabetes self-care behaviours for use in clinical practice to improve short-term glycaemic outcomes. Methods This 4-week intervention trial will recruit 80 young people (aged 13–20 years) with type 1 diabet...

The COVID-pandemic necessitated worldwide lockdowns in 2020, with restrictions on physical activity and changes in eating habits. We investigated temporal trends in BMI in three international T1D registries between 2018-2020. Data were extracted from DPV (Germany/Austria/Luxembourg/Switzerland) , T1D Exchange (T1DX, US) , and Australasian Diabetes...

Introduction: The aim of this study was to compare glycemic control and body mass index standard deviation score (BMI-SDS) before and after implementation of intensive insulin therapy using multiple daily injection (MDI) or continuous subcutaneous insulin infusion (CSII) in adolescents with type 1 diabetes (T1D) attending a large multidisciplinary...

Aims: To report Australian dietetic practice regarding management of Gestational Diabetes Mellitus (GDM) and to compare to findings from a 2009 survey of dietitians and to the Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines (NPG). Methods: Cross-sectional surveys were conducted in 2019 and 2009 of dietitians provi...

Background: Type 1 Diabetes (T1D) is associated with increased risk of eating disorders. This study aimed to (1) assess adherence of Australasian paediatric T1D clinics to international guidelines on screening for disordered eating and (2) identify barriers and enablers to the use of screening tools for the identification of disordered eating. Me...

Objective: To compare glucose control with hybrid closed-loop (HCL) when challenged by high intensity exercise (HIE), moderate intensity exercise (MIE), and resistance exercise (RE) while profiling counterregulatory hormones, lactate, ketones, and kinetic data in adults with type 1 diabetes. Research design and methods: Open-label multisite rand...

Aims To determine the glycaemic impact of dietary fat alone consumed without prandial insulin in individuals with T1D. Methods Thirty participants with T1D (aged 8-18 years) consumed a test drink with either 20g glucose or 1, 13, 26, 39, 51g of fat with negligible carbohydrate/protein on 6 consecutive evenings, in a randomised order without insuli...

Aims To assess the impact of achieving an Institute of Medicine based personalised weight target in addition to conventional glycaemic management after gestational diabetes mellitus diagnosis on maternal and neonatal outcomes. Methods A retrospective audit of clinical data (2016 to 2019) for singleton gestational diabetes pregnancies was conducted...

Objective: To examine the association between the use of diabetes technology [insulin pump (CSII), glucose sensor (CGM) or both] and metabolic control (HbA1c) as well as body adiposity (BMI-SDS) over time in a large cohort of children and adolescents with type 1 diabetes (T1D), that have never used these technologies before. Subjects and methods:...

Objective To determine if the relationship between meal carbohydrate quantity and the insulin to carbohydrate ratio (ICR) required to maintain glycaemia is linear in people with type 1 diabetes. Methods We used an open labelled randomized four-arm cross-over study design. Participants (N=31) aged 12-27 years, HbA1c ≤ 64 mmol/mol (8.0%) received in...

Context Dietary fat and protein impact postprandial hyperglycaemia in people with type 1 diabetes, but the underlying mechanisms are poorly understood. Glucoregulatory hormones are also known to modulate gastric emptying and may contribute to this effect. Objective Investigate the effects of fat and protein on glucagon like peptide (GLP-1), glucag...

Aim To identify and report the efficacy of insulin strategies used to manage glycaemia following fat and/or fat and protein meals in type 1 diabetes. Methods A systematic literature search of medical databases from 1995-2021 was undertaken. Inclusion criteria were randomised controlled trials that reported at least one of the following glycaemic o...

Studies on how a gluten free (GF) diet in youth with T1D and CD impacts glycemic control, quality of life (QoL) and nutrient intake are limited. The study aim was to determine the effects of the introduction of a GF diet in children with T1D and newly diagnosed CD on glycemic control, nutrient intake, QoL and body mass index (BMI). Subjects wore a...

Context The pattern and quantity of insulin required for high protein high fat (HPHF) meals is not well understood. Objective This study aimed to determine the amount and delivery pattern of insulin required to maintain euglycaemia for five hours after consuming a HPHF meal compared to a low protein low fat (LPLF) meal. Design Randomised cross-ov...

We thank Dr Yardley and Dr Sigal for their comments on the position statement pertaining to the use of continuous glucose monitoring (CGM) systems around exercise in type 1 diabetes.

Background: Pediatric diabetes clinics around the world rapidly adapted care in response to COVID-19. We explored provider perceptions of care delivery adaptations and challenges for providers and patients across nine international pediatric diabetes clinics. Methods: Providers in a quality improvement collaborative completed a questionnaire abo...

Aim To determine the glycaemic impact of an increased insulin dose, split insulin dose and regular insulin for a high fat, high protein breakfast in people with type 1 diabetes using multiple daily injections (≥4/day). Methods In this cross‐over trial, participants received the same high fat, high protein breakfast (carbohydrate:30g, fat:40g, prot...

Aim To determine the insulin requirement for a high fat, high protein breakfast to optimise postprandial glycaemic excursions in children and young people with type 1 diabetes using insulin pumps. Methods Twenty‐seven participants age 10‐23 years, BMI <95th percentile (2‐18 years) or BMI <30 kg/m² (19‐25 years) and HbA1c ≤64 mmol/mol (≤8.0%) consu...

We thank Dr Yardley and Dr Sigal for their comments on the position statement pertaining to the use of continuous glucose monitoring (CGM) systems around exercise in type 1 diabetes.

Dietary intake requires attention in the treatment of both eating disorders and type 1 diabetes (T1D) to achieve optimal outcomes. Nutritional management of both conditions involves encouraging a wide variety of healthful foods in the context of usual cultural and family traditions. In recent times, low carbohydrate diets have seen a rise in popula...

Objectives To assess the clinical and demographic characteristics of children and adolescents across Australia and New Zealand with type 2 diabetes. Methods We performed a descriptive audit of data prospectively reported to the Australasian Diabetes Data Network (ADDN) registry. Data were collected from six tertiary paediatric diabetes centres acr...

Background: Nutrition education is central to pediatric type 1 diabetes management. Dietary management guidelines for type 1 diabetes are evidence based, but implementation may be challenging and inconsistent. We describe variation in the practice of nutrition education across pediatric diabetes centers globally and explore associations with A1c a...

Physical exercise is an important component in the management of type 1 diabetes across the lifespan. Yet, acute exercise increases the risk of dysglycaemia, and the direction of glycaemic excursions depends, to some extent, on the intensity and duration of the type of exercise. Understandably, fear of hypoglycaemia is one of the strongest barriers...

Physical exercise is an important component in the management of type 1 diabetes across the lifespan. Yet, acute exercise increases the risk of dysglycaemia, and the direction of glycaemic excursions depends, to some extent, on the intensity and dura- tion of the type of exercise. Understandably, fear of hypoglycaemia is one of the stron- gest barr...

Aims: To determine if the frequency of severe diabetic ketoacidosis at presentation of new-onset type 1 diabetes to an Australian tertiary centre increased during the initial period of restrictions resulting from the COVID-19 pandemic (March to May 2020). Methods: Data were collected on presentations of newly diagnosed type 1 diabetes as well as...

Aims: To identify foods that cause problematic postprandial blood glucose levels (BGLs) in children and young people with type 1 diabetes, the strategies families use to manage these foods and the impact of continuous glucose monitoring (CGM) on nutritional management. Methods: This was a cross-sectional survey of 100 families attending a paedia...

Research on eating patterns in T1D is scarce, especially in youth. This population is in particular need of effective behavioral strategies during adolescence when HbA1c peaks and lifelong behaviors form. Case studies from pediatric T1D clinics suggest SE (consistent frequency, timing and spacing of meals, snacks and macronutrients throughout the d...

Background: To manage hyperglycemia following high fat and protein (HFHP) meals, T1D guidelines recommend additional mealtime insulin. However, guidance regarding dosing adjustments for HFHP meals is unclear. Aim: To determine the amount of additional insulin required for a HFHP meal to optimise 6 h postprandial glucose, in young people with T1D us...

Aim To determine the amount of additional insulin required for a high‐protein meal to prevent postprandial hyperglycaemia in individuals with type 1 diabetes using insulin pump therapy. Methods In this randomized cross‐over study, 26 participants aged 8–40 years, HbA1c < 65 mmol/mol (8.1%), received a 50 g protein, 30 g carbohydrate, low‐fat (< 1...

People with Type 1 diabetes (T1D) have been shown to be an at-risk group for the development of disordered eating behaviours, however, the validity of tools used to assess disordered eating behaviours in T1D is unclear. This review aimed to identify tools used to screen or identify disordered eating behaviours and eating disorders in people with T1...

This paper has two key contributions. The first contribution is a systematic procedure for fitting an envelope of models which captures a range of possible blood glucose level (BGL) responses for a particular individual having Type 1 diabetes. An important aspect of the procedure is that it requires minimal testing on the individual. Moreover, the...

Objective: Conventional gestational diabetes mellitus (GDM) management focuses on managing blood glucose in order to prevent adverse outcomes. We hypothesized that excessive weight gain at first presentation with GDM (excessive gestational weight gain [EGWG]) and continued EGWG (cEGWG) after commencing GDM management would increase the risk of adv...

Aim: Overweight and obesity are frequently reported in young persons with type 1 diabetes, however its relative magnitude in comparison to the general population is not well understood. This study compared the prevalence of overweight and obesity in young persons with type 1 diabetes to a reference population and explored possible associated facto...

Aim: Postprandial hyperglycaemia is a challenge for people living with Type 1 diabetes. In addition to carbohydrate, dietary protein has been shown to contribute to postprandial glycaemic excursions with recommendations to consider protein when calculating mealtime insulin doses. The aim of this review is to identify and synthesize evidence about...

Introduction Young children with type 1 diabetes (T1D) consume more saturated fat and less fruit and vegetables than recommended. A common challenge in this age group is unpredictable appetite potentially impacting the way parents manage diabetes cares at mealtimes. This small study aimed to assess nutritional intake and mealtime routines of young...

Introduction: Type 1 diabetes guidelines recommend that mealtime insulin dosing accounts for fat and protein. However, implementation remains a challenge. Aim: To evaluate an individual’s glycemic response to a high fat, high protein meal (HFHP) and develop a personalized ‘metabolic digital twin’ (MDTwin) capable of predicting an optimal insulin do...

Dietary protein increases the postprandial glycemic response and insulin requirements in people with type 1 diabetes (T1D). The aim of this study was to determine the appropriate amount of additional insulin required for the protein content of a meal to prevent postprandial hyperglycemia. Twenty-nine subjects (12 male) with T1D using CSII (HbA1c<8....

Aim To quantify the insulin requirement for a high‐protein meal compared with a low‐protein meal, controlling for carbohydrate and fat content. Methods In this crossover study, young people with Type 1 diabetes were randomized to consume a high‐ (60 g) or low‐protein meal (5 g), each containing 30 g carbohydrate and 8 g fat. A variation of the ins...

Dietary management has been a mainstay of care in Type 1 diabetes since before the discovery of insulin when severe carbohydrate restriction was advocated. The use of insulin facilitated re‐introduction of carbohydrate into the diet. Current management guidelines focus on a healthy and varied diet with consideration of glycaemic load, protein and f...

To maintain intensive glycemic therapy, families perform a multitude of self‐management tasks on a daily basis responding to changes in activity, food and physiology. The challenge for diabetes health care professionals is to deliver diabetes education that optimizes the families’ knowledge and understanding of the condition and its treatment and a...

Nutritional management is one of the cornerstones of diabetes care and education. Different countries and regions have widely varying cultures and socio‐ economic status that influence and dominate dietary habits. Although there is strong evidence for nutritional requirements in young people the scientific evidence base for many aspects of diabetes...

Aim To compare systematically the impact of two novel insulin‐dosing algorithms (the Pankowska Equation and the Food Insulin Index) with carbohydrate counting on postprandial glucose excursions following a high fat and a high protein meal. Methods A randomized, crossover trial at two Paediatric Diabetes centres was conducted. On each day, particip...

Glycemic control in the young child with type 1 diabetes (T1D) has traditionally been challenging. Unpredictability in appetite and dietary intake has made the achievement of glycemic targets difficult. This study aimed to assess the nutritional quality and dietary behaviors of young children with T1D that attend a clinic that meets glycemic target...

Background: Young children with type 1 diabetes (T1D) present unique challenges for intensive diabetes management. We describe an intensive diabetes program adapted for young children and compare glycemic control, anthropometry, dietary practices and insulin regimens before and after implementation. Methods: Cross sectional data from children wi...

Aims: To determine the optimum combination bolus split to maintain postprandial glycaemia with a high-fat and high-protein meal in young people with Type 1 diabetes. Methods: A total of 19 young people (mean age 12.9 ± 6.7 years) participated in a randomized, repeated-measures trial comparing postprandial glycaemic control across six study condi...

Low carbohydrate diets for the management of type 1 diabetes have been popularised by social media. The promotion of a low carbohydrate diet in lay media is in contrast to published pediatric diabetes guidelines that endorse a balanced diet from a variety of foods for optimal growth and development in children with type 1 diabetes. This can be a so...

Aim: To determine the glycaemic impact of increasing protein quantities when consumed with consistent amounts of carbohydrate in individuals with Type 1 diabetes on intensive insulin therapy. Methods: Participants with Type 1 diabetes [aged 10-40 years, HbA1c ≤ 64 mmol/mol (8%), BMI ≤ 91(st) percentile] received a 30-g carbohydrate (negligible f...

Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive...