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Insulin pump dosing strategies for meals varying in fat, protein or glycaemic index or grazing-style meals in type 1 diabetes: a systematic review

Metwally, Mariam, Cheung, Tin Oi, Smith, Roslyn, Bell, Kirstine J.·2021·Diabetes Research and Clinical Practice
DOI 10.1016/j.diabres.2020.108516
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Abstract

Background Nutritional composition and food patterns influence postprandial glycaemia in type 1 diabetes (T1D). For optimal glycaemic control, insulin dose and delivery pattern must be matched accordingly. This systematic review aimed to compare insulin dosing strategies for meals varying in fat, protein and glycaemic index (GI), and prolonged meals in T1D.Methods Studies in adults and/or children with T1D on insulin pump therapy comparing the glycaemic effects of different insulin pump bolus types for these meal types were identified from biomedical databases (MEDLINE, PREMEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials; March 1995-April 2020) and systematically reviewed.Results All eleven publications investigating high-fat meals (234 participants) and all seven studies investigating high-protein meals (129 participants) showed a dual-wave bolus was superior. Additional insulin further improved postprandial glycaemia, although increasing risk of hypoglycaemia in 5 of 14 studies. One study investigating GI found a dual-wave bolus reduced postprandial glycaemia and risk of hypoglycaemia. No studies were identified for grazing/degustation-style meals. Due to heterogeneity, meta-analysis was not possible.Conclusion Dual-wave boluses improve postprandial glycaemia in high-fat, high-protein and low-GI meals. Further research is needed to identify optimal bolus delivery split, duration and optimal total dose adjustment.

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  • Sensor‐augmented pump systems (SAP) enable adaptive insulin delivery, including dual‐wave or square‐wave boluses, which distribute insulin over several hours and better match the slow and prolonged glucose absorption typical of DGP, particularly in high‐fat or high‐protein meals.

    “Sensor‑augmented pump systems (SAP) enable adaptive insulin delivery, including dual‑wave or square‑wave boluses, which distribute insulin over several hours and better match the slow and prolonged glucose absorption typical of DGP [54, 112, 132, 148, 149], particularly in high‑fat or high‑protein meals [150–152].”

    From Diabetic gastroparesis: pathophysiology and impact on insulin timing choices (2026) · cites this paper as [150]

  • Checking glucose 3 h after eating may help to determine if additional insulin adjustments are required.

    “Checking glucose 3 h after eating may help to determine if additional insulin adjustments are required (i.e., increasing or stopping bolus) (185,192,193).”

    From 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:<i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [192]

  • If using an insulin pump, a split bolus feature may provide better insulin coverage for high-fat and/or high-protein mixed meals.

    “If using an insulin pump, a split bolus feature (part of the bolus delivered immediately, the remainder over a programmed duration of time) may provide better insulin coverage for high-fat and/or high-protein mixed meals (185,192).”

    From 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:<i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [192]

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Authors
Metwally, M., Cheung, T. O., Smith, R., & Bell, K. J.
Affiliations
  • The University of Sydney (AU)
  • Liverpool Hospital (AU)
Corresponding author
Bell, Kirstine J.
ORCID
Venue
Diabetes Research and Clinical Practice
Publisher
Elsevier BV
Published
2021-02
Volume
172
Pages
108516
ISSN
0168-8227 (ISSN-L)
DOI
10.1016/j.diabres.2020.108516
OpenAlex
W3093667457
Cited by
29
References
27
Citations by year
2026: 6 · 2025: 6 · 2024: 5 · 2023: 7 · 2022: 3 · 2021: 2
FWCI
0.46
Type
journal article
Language
en
Open access
closed
Licence
Locations
  • Diabetes Research and Clinical Practice (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Keywords
type 1 diabetes, insulin pump therapy, high-fat meal, protein-rich meals, glycemic index, postprandial glycaemia, hypoglycemia, meal composition
MeSH terms
Blood Glucose, Diabetes Mellitus, Type 1, Female, Humans, Insulin, Male, Proteins, Cross-Over Studies, CD36 Antigens, Glycemic Index, Meals

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