High-protein meals require 30% additional insulin to prevent delayed postprandial hyperglycaemia.

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 g) breakfast drink over five consecutive days at home. A standard insulin dose (100%) was compared with additional doses of 115, 130, 145 and 160% for the protein, in randomized order. Doses were commenced 15-min pre-drink and delivered over 3 h using a combination bolus with 65% of the standard dose given up front. Postprandial glycaemia was assessed by 4 h of continuous glucose monitoring. RESULTS: The 100% dosing resulted in postprandial hyperglycaemia. From 120 min, ≥ 130% doses resulted in significantly lower postprandial glycaemic excursions compared with 100% (P < 0.05). A 130% dose produced a mean (sd) glycaemic excursion that was 4.69 (2.42) mmol/l lower than control, returning to baseline by 4 h (P < 0.001). From 120 min, there was a significant increase in the risk of hypoglycaemia compared with control for 145% [odds ratio (OR) 25.4, 95% confidence interval (CI) 5.5-206; P < 0.001) and 160% (OR 103, 95% CI 19.2-993; P < 0.001). Some 81% (n = 21) of participants experienced hypoglycaemia following a 160% dose, whereas 58% (n = 15) experienced hypoglycaemia following a 145% dose. There were no hypoglycaemic events reported with 130%. CONCLUSIONS: The addition of 30% more insulin to a standard dose for a high-protein meal, delivered using a combination bolus, improves postprandial glycaemia without increasing the risk of hypoglycaemia.

Impact of dietary protein on postprandial glycaemic control and insulin requirements in Type 1 diabetes: a systematic review.

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 the glycaemic impact of dietary protein and insulin requirements for individuals with Type 1 diabetes. METHODS: A systematic literature search of relevant biomedical databases was performed to identify research on the glycaemic impact of dietary protein when consumed alone, and in combination with other macronutrients in individuals with Type 1 diabetes. RESULTS: The review included 14 published studies dated from 1992 to 2018, and included studies that researched the impact of protein alone (n = 2) and protein in a mixed meal (n = 12). When protein was consumed alone a glycaemic effect was not seen until ≥ 75 g. In a carbohydrate-containing meal ≥ 12.5 g of protein impacted the postprandial glucose. Inclusion of fat in a high-protein meal enhanced the glycaemic response and further increased insulin requirements. The timing of the glycaemic effect from dietary protein ranged from 90 to 240 min. Studies indicate that the postprandial glycaemic response and insulin requirements for protein are different when protein is consumed alone or with carbohydrate and/or fat. CONCLUSIONS: This systematic review provides evidence that dietary protein contributes to postprandial glycaemic excursions and insulin requirements. These insights have important implications for the education of people with Type 1 diabetes and highlights the need for more effective insulin dosing strategies for mixed macronutrient meals.

Optimizing the combination insulin bolus split for a high-fat, high-protein meal in children and adolescents using insulin pump therapy.

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 conditions after a high-fat and high-protein meal. A standard bolus and five different combination boluses were delivered over 2 h in the following splits: 70/30 = 70% standard /30% extended bolus; 60/40=60% standard/40% extended bolus; 50/50=50% standard/50% extended bolus; 40/60=40% standard/60% extended bolus; and 30/70=30% standard/70% extended bolus. Insulin dose was determined using the participant's optimized insulin:carbohydrate ratio. Continuous glucose monitoring was used to assess glucose excursions for 6 h after the test meal. RESULTS: Standard bolus and combination boluses 70/30 and 60/40 controlled the glucose excursion up to 120 min. From 240 to 300 min after the meal, the glucose area under the curve was significantly lower for combination bolus 30/70 compared with standard bolus (P=0.004). CONCLUSIONS: High-fat and high-protein meals require a ≥60% insulin:carbohydrate ratio as a standard bolus to control the initial postprandial rise. Additional insulin at an insulin:carbohydrate ratio of up to 70% is needed in the extended bolus for a high fat and protein meal to prevent delayed hyperglycaemia.

Increasing the protein quantity in a meal results in dose-dependent effects on postprandial glucose levels in individuals with Type 1 diabetes mellitus.

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 ≤ 91st percentile] received a 30-g carbohydrate (negligible fat) test drink daily over 5 days in randomized order. Protein (whey isolate 0 g/kg carbohydrate, 0 g/kg lipid) was added in amounts of 0 (control), 12.5, 25, 50 and 75 g. A standardized dose of insulin was given for the carbohydrate. Postprandial glycaemia was assessed by 5 h of continuous glucose monitoring. RESULTS: Data were collected from 27 participants (15 male). A dose-response relationship was found with increasing amount of protein. A significant negative relationship between protein dose and mean excursion was seen at the 30- and 60-min time points (P = 0.007 and P = 0.002, respectively). No significant relationship was seen at the 90- and 120-min time points. Thereafter, the dose-response relationship inverted, such that there was a significant positive relationship for each of the 150-300-min time points (P < 0.004). Mean glycaemic excursions were significantly greater for all protein-added test drinks from 150 to 300 min (P < 0.005) with the 75-g protein load, resulting in a mean excursion that was 5 mmol/l higher when compared with the control test drink (P < 0.001). CONCLUSIONS: Increasing protein quantity in a low-fat meal containing consistent amounts of carbohydrate decreases glucose excursions in the early (0-60-min) postprandial period and then increases in the later postprandial period in a dose-dependent manner.

Influence of dietary protein on postprandial blood glucose levels in individuals with Type 1 diabetes mellitus using intensive insulin therapy.

AIM: To determine the effects of protein alone (independent of fat and carbohydrate) on postprandial glycaemia in individuals with Type 1 diabetes mellitus using intensive insulin therapy. METHODS: Participants with Type 1 diabetes mellitus aged 7-40 years consumed six 150 ml whey isolate protein drinks [0 g (control), 12.5, 25, 50, 75 and 100] and two 150 ml glucose drinks (10 and 20 g) without insulin, in randomized order over 8 days, 4 h after the evening meal. Continuous glucose monitoring was used to assess postprandial glycaemia. RESULTS: Data were collected from 27 participants. Protein loads of 12.5 and 50 g did not result in significant postprandial glycaemic excursions compared with control (water) throughout the 300 min study period (P > 0.05). Protein loads of 75 and 100 g resulted in lower glycaemic excursions than control in the 60-120 min postprandial interval, but higher excursions in the 180-300 min interval. In comparison with 20 g glucose, the large protein loads resulted in significantly delayed and sustained glucose excursions, commencing at 180 min and continuing to 5 h. CONCLUSIONS: Seventy-five grams or more of protein alone significantly increases postprandial glycaemia from 3 to 5 h in people with Type 1 diabetes mellitus using intensive insulin therapy. The glycaemic profiles resulting from high protein loads differ significantly from the excursion from glucose in terms of time to peak glucose and duration of the glycaemic excursion. This research supports recommendations for insulin dosing for large amounts of protein.

Electrochemical evidence for electronic interactions through the para-carborane skeleton in the novel tricluster [(Co2C2(SiMe3)(CO)4(dppm))2(mu-CB10H10C)].

The electrochemical properties of the title compound reveal electronic interactions between two dicobalt-dicarbon clusters via a 1,12-para-carborane cage.

Marketed sperm: use and regulation in the United States.

OBJECTIVE: To collate information relating to the current use of marketed semen for therapeutic donor insemination (DI) in the United States. DATA IDENTIFICATION: Literature was identified by Medline search and government document review. LITERATURE SELECTION: Materials selected for review included empirical studies, policy reviews, legal documents, and government surveys relating to use of donor sperm. RESULTS: Use of marketed (donor) sperm is associated with significant medical, genetic, and psychological risk. These risks directly affect the individuals involved in therapeutic DI. Also, the public's health is involved because these risks include transmission of infectious disease and genetic anomalies. Legal and social concerns associated with therapeutic DI include offspring's knowledge of genetic endowment, parental responsibility, and donor confidentiality. This analysis shows that policies currently in place regarding the use of marketed semen in therapeutic DI do not ensure consumer safety and do not protect society's interest. CONCLUSIONS: Current policies need to be improved to protect those directly involved in the therapeutic DI process and to address public health and societal concerns. Recommendations include: [1] programs to assure quality and safety of marketed sperm, [2] implementation of a central registry to collect information about the use and outcomes of therapeutic DI, and [3H] expansion of available therapeutic DI guidelines to address psychological and social support for persons involved in therapeutic DI.

Reproductive laboratory technology: an alternative career.

OBJECTIVES: Define the job description for reproductive laboratory technologist (RLT); describe the RLT laboratory setting; identify education level and certification of the respondents; establish level of job satisfaction and job security; determine if certification and position affect performance and job satisfaction; compare RLT job with any previous clinical laboratory position; and document education and training important for the position. SURVEY INSTRUMENT: A questionnaire was developed with questions targeted to answer objectives. SURVEY POPULATION: The questionnaire was mailed to a random sample of 300 non-physician members from the Reproductive Biology Professional Group and the Reproductive Laboratory Technology Group from membership lists provided by the American Society for Reproductive Medicine. STUDY POPULATION: 81 survey respondents. RESULTS: RLTs are mostly college-educated, certified and non-certified laboratory professionals, trained on the job for specialty work in andrology and assisted reproductive technology (ART). Position, but not certification, correlate with job performance and job satisfaction. Respondents describe the position of RLT as stressful, but very interesting, exciting, fulfilling, and secure. Respondents with previous clinical laboratory experience rated level of job satisfaction higher for the reproductive laboratory. The CLS curriculum is an excellent background for RLT. CONCLUSIONS: RLT is an exciting career alternative for CLSs. Newly formed laws and regulations, and the demand for more stringent regulation, will continue to increase the demand for certified CLSs for this position. Formal education and certification requirements are anticipated for RLT. The specialty is being incorporated in CLS training programs.

Managing risk in a changing health care system.

This article examines the information requirements and other strategies needed to manage business and financial risk in health care organizations. The business and financial risk of providers in the changing health care market is defined. The major factors that are increasing risk are outlined, and strategies for measuring and managing risk are discussed. The interaction of business and financial risk is described, and strategic goals that will minimize the effect of this interaction are presented.

Quality improvement--boon or boondoggle?

Is quality improvement (QI) reducing healthcare costs while improving patient care? Researchers find that QI has improved employee satisfaction and morale, but it was designed to do more. One solution is to use problem-solving techniques to help teams identify the level at which they want to address a problem, whether that be the subinstitutional, institutional, or system level. If QI is to fulfill its promise, skilled managers must create effective teams capable of defining and solving complex problems.

Client self-determination and professional intervention: striking a balance.

Social workers find themselves caught in the cross fire between two imperatives: (1) outcome-oriented and competency-based practice requisites and (2) the principle of client self-determination. In this context, the authors hypothesize that social workers use a wide range of gradations along a continuum of practice directiveness. Furthermore, there is ethical justification for this diverse role repertoire. Directiveness modalities are influenced by specific conditional factors that guide practitioner behavior. A study is described that empirically explores and amplifies these hypotheses.