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Background Carbohydrate counting is a method used to calculate insulin doses to meals, in the treatment of diabetes type 1. Few studies are available with a clear consensus on its efficacy and effect on anthropometrics in children and adolescents. Aim To evaluate if carbohydrate counting as treatment method in diabetes type 1 improved glycemic control and anthropometrics compared to conventional treatment, one and two years after onset in children and adolescents at Astrid Lindgren children’s hospital. A secondary aim was to explore patients and caregivers perception of insulin dosage to meals with focus on efficacy, time consumption and adherence. Method A clinical prospective study was performed on data collected from the Swedish pediatric quality registry (Swediabkids). Children with diabetes onset between 2010 and 2014 registered at Astrid Lindgren Children’s hospital (n=371) were included and divided into two groups, carbohydrate counters and non-carbohydrate counters. Normal distribution was assumed and parametric tests were performed. The registry data was complemented with a web-based questionnaire providing information on perception of carbohydrate counting, answered by 78 subjects. Results Carbohydrate counting reduced insulin requirements (p<0.001) and eliminated differences between pump- and pen users (p<0.001) as well as differences between boys and girls. Glycemic control was not improved by carbohydrate counting one and two years after diabetes onset (p=0.233, p=0.295). An adverse effect was increased body mass index standard deviation score (BMI-sds) (p=0.044), especially amongst girls (p=0.038). Conclusion Carbohydrate counting lowers insulin requirements with maintained glycemic control. Contradictory, greater weight gain was found in the carbohydrate counting group, especially among girls. A plausible explanation is that carbohydrates have taken focus off protein- and fat intake in combination with a more liberal approach to energy dense foods, causing excess energy intake. The strength of carbohydrate counting does not lie in its ability to lower HbA1c-values but as a helpful tool, which patients are happy to use. / Bakgrund Kolhydraträkning är en metod som används för att beräkna insulindoser till måltider, i behandlingen av diabetes typ 1. Få studier finns för att ge en samlad konsensus gällande dess effekt på glykemisk kontroll och tillväxt hos barn och ungdomar. Syfte Att utvärdera om införandet av kolhydraträkning som behandlingsmetod vid diabetes typ 1 påverkat metabol kontroll och tillväxt i jämförelse med konventionell metod, ett och två år efter diabetesdebut. Ett andra syfte var att utforska patienters och vårdnadshavares uppfattning om insulindosering till måltider med fokus på effektivitet, tidskonsumtion och följsamhet. Metod En klinisk prospektiv studie utfördes med data inhämtad från Nationellt kvalitetsregister för barn och ungdomar med diabetes (Swediabkids). Barn och ungdomar som debuterade med diabetes typ 1 på Astrid Lindgrens barnsjukhus mellan 2010 och 2014 (n=371) inkluderades i studien och delades in i två grupper baserat på debutdatum; kolhydraträknare och icke-kolhydraträknare. Materialet bedömdes som normalfördelat och parametriska test utfördes. En tvärsnittsenkät administrerades till studiedeltagarna för att införskaffa fördjupad information om patienters och vårdnadshavares uppfattning om insulindosering till måltider. Den webbaserade enkäten besvarades av 78 deltagare. Resultat Kolhydraträkning reducerade insulinbehovet (p<0.001) och jämställde insulinbehovet mellan pump- och pennanvändare (p<0.001) liksom skillnader mellan pojkar och flickor inom gruppen. Glykemisk kontroll förändrades inte av kolhydraträkning ett och två år efter debut (p=0.233, p=0.295). En oönskad effekt av kolhydraträkningen var en ökning i BMI-sds (p=0.044), speciellt hos flickor (p=0.038). Slutsats Kolhydraträkning från diabetesdebut sänker insulinbehov med bibehållen glykemisk kontroll. Motsägelsefullt, så fanns en viktökning i gruppen som använde kolhydraträkning, speciellt hos flickor. En möjlig förklaring är att kolhydrater har tagit fokus från protein- och fettintag tillsammans med en mer frikostig syn på energität mat, vilket har orsakat ökat energiintag. Styrkan i kolhydraträkning ligger inte i dess förmåga att förbättra glykemisk kontroll men som ett användarvänligt verktyg som patienterna är nöjda med.

Abstract   Aims and objectives. To examine whether an intervention with carbohydrate- counting at onset of type 1 diabetes in children, has had any effect on metabolic indicators such as HbA1c , BMI-sds and total daily insulin / kg, 2 months and 1 year after onset by age and gender .Background. The pediatric department at the university hospital of Norrland in Umeå (NUS), has since several years a higher average HbA1c among children 0-17 years, compare with pediatric departments in the rest of Sweden.  Therefore, in autumn 2011, an intervention was made to teach children with diabetes and their parents to count carbohydrates from the onset of diabetes. Using this method they can regulate their insulin doses depending on the amount of carbohydrates they are eating. Design. This is an empirical registry study done on the basis of a quantitative method. It is retrospective controlled non- randomized with comparison group .Methods. The study included 46 children aged 0-17 years diagnosed with type 1 diabetes. Those who fell ill in 2009 (n=22) did not learn to use carbohydrate counting and served as a control group. The intervention group were diagnosed 2011-2012, (n=24), began using carbohydrate counting at the onset of diabetes.Results. The study shows with significant security that carbohydrate counting lowers HbA1c two months and one year after onset of type 1 diabetes. No significant difference was found in BMI-sds. The study shows no significant difference in HbA1c between the sexes.Conclusion.  Carbohydrate-counting from onset of diabetes gives a significant reduction of HbA1c without affecting BMI-sds significantly.Relevance to clinical practice. It is important that health professionals continue to teach and support families in carbohydrate counting from the onset of diabetes.Keywords. children, HbA1c, BMI- sds , type 1 diabetes , carbohydrate counting

Conselho Nacional de Desenvolvimento Científico e Tecnológico / Segundo a American Diabetes Association, é importante a ênfase no controle glicêmico com o objetivo de prevenir complicações microvasculares em diabéticos, e a adoção de um plano alimentar saudável é fundamental no tratamento destes pacientes. O método de contagem de carboidratos é uma estratégia nutricional, é um método usado por indivíduos diabéticos, que associa o total de carboidratos ingerido nas refeições com a dose de insulina utilizada, com o objetivo de manter a glicemia dentro dos limites convenientes. O objetivo desse estudo foi avaliar se a intervenção nutricional, utilizando o método de contagem de carboidratos, influencia o controle glicêmico de pacientes com diabetes mellitus tipo 1 (DM1). Foram avaliados 157 DM1, 96 constituíram o grupo intervenção com dieta prescrita e com o uso do método de contagem de carboidratos e 61 pacientes DM1 constituíram o grupo controle com dieta prescrita e sem contagem de carboidratos. Os diabéticos foram monitorados por um período de seis meses. Na primeira visita foram submetidos a um questionário de caracterização dos indivíduos, avaliação antropométrica, bioquímica, clínica e dietética. Houve diferença significativa entre o registro alimentar preenchido durante 3 dias e a dieta prescrita, nos gramas de proteína consumidos por dia 50,39 + 29,27 e 22,01 + 3,05 (p= 0,02), como também no índice glicêmico (IG) do almoço 43,00 + 24,89 e 7,83 + 1,88 (p=0,02), e do jantar 50,09 + 35,09 e 7,56 + 2,57 (p=0,00). Em relação a avaliação antropométrica houve aumento não significativo em ambos os grupos, no Índice de Massa Corporal calculado e nos parâmetros antropométricos (circunferência abdominal, circunferência de quadril e relação cintura-quadril). Na avaliação dos parâmetros bioquímicos, observa-se diminuição significativa, somente no grupo intervenção, da hemoglobina glicada (A1C) de 9,8 + 2,26 para 9,1 + 2,16 (p= 0,023) após 6 meses. As correlações entre os dados antropométricos e a A1C, e entre os diferentes tipos de ácidos graxos da dieta proposta e parâmetros bioquímicos colesterol, triglicerídeos, HDLc e LDLc plasmáticos foram consideradas de baixa intensidade. Diante dos resultados concluiu-se que a intervenção por meio do método de contagem de carboidratos proporcionou uma melhora significativa no controle glicêmico dos pacientes estudados. / According to the American Diabetes Association, is important to focus on glycemic control in order to prevent microvascular complications in patients with type 1 diabetes, and the adoption of a plan healthy food is crucial in treating these patients. The method of carbohydrate counting is a nutritional strategy, it is a method used by diabetic individuals, which combines the total carbohydrate intake at meals with the dose of insulin used, with the goal of maintaining blood glucose within the limits appropriate. The aim of this study was to assess whether the nutrition intervention, using the method of carbohydrate couting, influences the glycemic control of patients with diabetes mellitus type 1 (DM1). We evaluated 157 DM1, 96 constituted the intervention group with diet and the use of the method of carbohydrate counting and 61 DM1 patients formed the control group with diet and without the method of carbohydrate counting. The patients were monitored for six months. In the first visit were submitted to a questionnaire, anthropometric, biochemical, clinical and dietary evaluations. Significant difference between the food record completed for 3 days and prescribed diet, in grams of protein consumed per day 50.39 + 29.27 and 22.01 + 3.05 (p = 0.02), on the glycemic index (GI) of lunch 43.00 + 24.89 and 7.83 + 1.88 (p = 0.02), and dinner 50.09 + 35.09 and 7.56 + 2.57 (p = 0.00). For anthropometric assessment increase was not significant in both groups, the body mass index and anthropometric parameters (waist circumference, hip circumference and the waist-hip ratio). In the assessment of biochemical parameters, there is a significant decrease, only in the intervention group, the glycated hemoglobin (A1C) from 9.8 + 2.26 to 9,1 + 2.16 (p = 0.023) after 6 months. The correlations between the anthropometric data and A1C, and between different types of fatty acids in the diet proposal and biochemical parameters cholesterol, triglycerides, HDLc and LDLc plasma were of low intensity. The results concluded that intervention by the method of carbohydrate counting has provided a significant improvement in glycemic control of patients.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / Segundo a American Diabetes Association, é importante a ênfase no controle glicêmico com o objetivo de prevenir complicações microvasculares em diabéticos, e a adoção de um plano alimentar saudável é fundamental no tratamento destes pacientes. O método de contagem de carboidratos é uma estratégia nutricional, é um método usado por indivíduos diabéticos, que associa o total de carboidratos ingerido nas refeições com a dose de insulina utilizada, com o objetivo de manter a glicemia dentro dos limites convenientes. O objetivo desse estudo foi avaliar se a intervenção nutricional, utilizando o método de contagem de carboidratos, influencia o controle glicêmico de pacientes com diabetes mellitus tipo 1 (DM1). Foram avaliados 157 DM1, 96 constituíram o grupo intervenção com dieta prescrita e com o uso do método de contagem de carboidratos e 61 pacientes DM1 constituíram o grupo controle com dieta prescrita e sem contagem de carboidratos. Os diabéticos foram monitorados por um período de seis meses. Na primeira visita foram submetidos a um questionário de caracterização dos indivíduos, avaliação antropométrica, bioquímica, clínica e dietética. Houve diferença significativa entre o registro alimentar preenchido durante 3 dias e a dieta prescrita, nos gramas de proteína consumidos por dia 50,39 + 29,27 e 22,01 + 3,05 (p= 0,02), como também no índice glicêmico (IG) do almoço 43,00 + 24,89 e 7,83 + 1,88 (p=0,02), e do jantar 50,09 + 35,09 e 7,56 + 2,57 (p=0,00). Em relação a avaliação antropométrica houve aumento não significativo em ambos os grupos, no Índice de Massa Corporal calculado e nos parâmetros antropométricos (circunferência abdominal, circunferência de quadril e relação cintura-quadril). Na avaliação dos parâmetros bioquímicos, observa-se diminuição significativa, somente no grupo intervenção, da hemoglobina glicada (A1C) de 9,8 + 2,26 para 9,1 + 2,16 (p= 0,023) após 6 meses. As correlações entre os dados antropométricos e a A1C, e entre os diferentes tipos de ácidos graxos da dieta proposta e parâmetros bioquímicos colesterol, triglicerídeos, HDLc e LDLc plasmáticos foram consideradas de baixa intensidade. Diante dos resultados concluiu-se que a intervenção por meio do método de contagem de carboidratos proporcionou uma melhora significativa no controle glicêmico dos pacientes estudados. / According to the American Diabetes Association, is important to focus on glycemic control in order to prevent microvascular complications in patients with type 1 diabetes, and the adoption of a plan healthy food is crucial in treating these patients. The method of carbohydrate counting is a nutritional strategy, it is a method used by diabetic individuals, which combines the total carbohydrate intake at meals with the dose of insulin used, with the goal of maintaining blood glucose within the limits appropriate. The aim of this study was to assess whether the nutrition intervention, using the method of carbohydrate couting, influences the glycemic control of patients with diabetes mellitus type 1 (DM1). We evaluated 157 DM1, 96 constituted the intervention group with diet and the use of the method of carbohydrate counting and 61 DM1 patients formed the control group with diet and without the method of carbohydrate counting. The patients were monitored for six months. In the first visit were submitted to a questionnaire, anthropometric, biochemical, clinical and dietary evaluations. Significant difference between the food record completed for 3 days and prescribed diet, in grams of protein consumed per day 50.39 + 29.27 and 22.01 + 3.05 (p = 0.02), on the glycemic index (GI) of lunch 43.00 + 24.89 and 7.83 + 1.88 (p = 0.02), and dinner 50.09 + 35.09 and 7.56 + 2.57 (p = 0.00). For anthropometric assessment increase was not significant in both groups, the body mass index and anthropometric parameters (waist circumference, hip circumference and the waist-hip ratio). In the assessment of biochemical parameters, there is a significant decrease, only in the intervention group, the glycated hemoglobin (A1C) from 9.8 + 2.26 to 9,1 + 2.16 (p = 0.023) after 6 months. The correlations between the anthropometric data and A1C, and between different types of fatty acids in the diet proposal and biochemical parameters cholesterol, triglycerides, HDLc and LDLc plasma were of low intensity. The results concluded that intervention by the method of carbohydrate counting has provided a significant improvement in glycemic control of patients.

Type 1 diabetes (T1D) is an auto-immune disease characterized by insulin-deficiency. Insulin is a metabolic hormone that is involved in lowering blood glucose (BG) levels in order to control BG level to a tight range. In T1D this glycemic control is lost, causing chronic hyperglycemia (excess glucose in blood stream). Chronic hyperglycemia damages vital tissues. Therefore, glycemic control must be restored. A common therapy for restoring glycemic control is intensive insulin therapy, where the missing insulin is replaced with regular insulin injections. When dosing this compensatory insulin many factors that affect glucose metabolism must be considered. Linkura is a company that has developed tools for monitoring the most important factors, which are meals and exercise. In the Linkura meal and exercise tools, the nutrition content in meals and the calorie consumption during exercise are estimated. Another tool designed to aid control of BG is the bolus calculator. Bolus calculators use input of BG level, carbohydrate intake, and insulin history to estimate insulin need. The accuracy of these insulin bolus calculations suffer from two problems. First, errors occur when users inaccurately estimate the carbohydrate content in meals. Second, exercise is not included in bolus calculations. To reduce these problems, it was suggested that the Linkura web tools could be utilized in combination with a bolus calculator. For this purpose, a bolus calculator was developed. The bolus calculator was based on existing models that utilize clinical parameters to relate changes in BG levels to meals, insulin, and exercise stimulations. The bolus calculator was evaluated using data collected from Linkura's web tools. The collected data showed some inconsistencies which cannot be explained by any model.  The performance of the bolus calculator in predicting BG levels using general equations to derive the clinical parameters was inadequate. Performance was increased by adopting an update-algorithm where the clinical parameters were updated daily using previous data. Still, better model performance is prefered for use in a bolus calculator.   The results show potential in developing bolus calculator tools combined with the Linkura tools. For such bolus calculator, further evaluation on modeling long-term exercise and additional safety features minimizing risk of hypoglycemia are required.

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