DugalDiabetes – A Decision Support App for Individualized Mealtime Insulin Dosing

8/8/18
WRITTEN BY: Michael Fox MS, RDN, LN
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Every two weeks, I meet up with a buddy of mine for dinner out. We always go to the same place, and I generally eat the same thing. You’d think I might remember what I dosed the last time, but I rarely do. Two weeks is a long time, and I’m focused on seeing my friend, not remembering some number. And since I don’t eat out much otherwise, I’m not all that good at guesstimating carb counts. So I take a shot in the dark and hope that I won’t be chasing the blood sugar for hours afterward. Sound familiar?

As a person living with Type 1 for almost 30 years and as a Registered Dietitian specializing in diabetes management, I believe the greatest challenge to blood sugar control is mealtime dosing. Even with the most current technologies available for T1D management, we still are the decision-makers when it comes to insulin dosage (1,2) – a decision largely based on guesswork (3).

Right now, figuring out how much to dose for meals is tough, to say the least. Food is not just carbs. Not all carbs impact the blood sugars the same (4). And protein, fat, and fiber play a role in blood sugar (5-9). Beyond the food we eat, there are numerous factors that impact blood sugars and insulin function like exercise, stress, and illness – to name a few (10,11). And what’s more, each of our bodies are different and have different insulin requirements (12-13). This leaves us with a mealtime insulin dosing strategy that is based largely on trial and error (3,14). If we don’t guess right, we end up with highs and lows which can be dangerous and exhausting – not exactly an ideal system. Enter DugalDiabetes.

I was diagnosed at age 12. At the time, I used Regular and NPH insulins, since there were no rapid acting insulins then. The size of the blood drop that was required for my first monitor would have covered half of some of the strips that are used now. The tiny logbooks I was given quickly turned into full size notebooks where I wrote everything down: blood sugars, insulin doses, activity, and all the food I ate. My mom was my teammate in this quest for blood sugar control. Visits to the doctor were spent pouring over the logbooks. But in spite of our efforts and being told we were doing a ‘great job’, my A1C was far above target, mealtime insulin dosing was a matter of best guesses, and management shifted toward being ready for the highs and lows afterward. While so much has changed in diabetes management from when I was first diagnosed, the guesswork required for mealtime insulin dosing really hasn’t. At this point in my life, I no longer find this acceptable – not with the technologies available nor with the growing scientific understanding of how foods and other factors influence blood glucose levels and insulin sensitivity.

I decided I couldn’t wait for the solution to happen. Mealtime insulin dosing is and has been integral to diabetes management and our quality of life but the problems associated with it have been normalized as just part of living with Type 1. So I turned my personal and professional experience into a burning passion to innovate – and DugalDiabetes is the result.

DugalDiabetes is a decision support app focused on mealtime insulin dosing that is customized to you and your experience. DugalDiabetes doesn’t tell you what to eat and it doesn’t tell you how much to dose; we all live our lives and manage our diabetes differently, and you are the master technician of your diabetes management. DugalDiabetes helps you figure out how much to dose for meals by allowing you to review similar meal experiences from your own history. Reviewing what has worked in the past makes it easier to figure out the right dose for the current meal. The more the app is used, the more specific the insight becomes.

DugalDiabetes is a tool for everyone living with Type 1, including parents of kids with Type 1 whose efforts to control their children’s blood sugars are monumental. We’re focused on making accurate mealtime insulin dosing possible, and we’d love you to try it out. Later this summer, we’ll have the first version of DugalDiabetes on the market for beta testing. If you want to be among the first to try this out or would like to learn more, please contact us here or follow us on twitter.


References

  1. Thabit, H. & Hovorka, R. (2016). Coming of age: the artificial pancreas for Type 1 diabetes. Diabetologia, 59 (9), 1795-1805.
  2. Gingras, V., Taleb, N., Roy-Fleming, A., Legault, L., & Rabasa-Lhoret, R. (2018). The challenges of achieving postprandial glucose control using closed-loop systems in patients with type 1 diabetes. Diabetes Obes Metab, 20 (2), 245-256.
  3. Brazeau, A.S., Mirescu, H., Desjardins, K., Leroux, C., Strychar, I., Ekoe, J.M., & Rabasa-Lhoret, R. (2013). Carbohydrate counting accuracy and blood glucose variability in adults with type 1 diabetes. Diabetes Research and Clinical Practice, 99 (1), 19-23.
  4. Brand-Miller, J.C., Stockman, K., Atkinson, F., Petocz, P., & Denyer, G. (2009). Glycemic index, postprandial glycemia, and the shape of the curve in healthy subjects: analysis of a database of more than 1000 foods. Am J Clin Nutr, 89 (1), 97-105.
  5. Bell, K.J., Smart, C.E., Steil, G.M., Brand-Miller J.C., King, B., & Wolpert, H.A. (2015) Impact of Fat, Protein, and Glycemic Index on Postprandial Glucose Control in Type 1 Diabetes: Implications for Intensive Diabetes Management in the Continuous Glucose Monitoring Era. Diabetes Care, 38 (6), 1008-1015. 
  6. Smart, E.M., Evans, M., O’Connell, S.M., McEldfuff, P., Lopez, P.E., Jones, T.W., Davis, E.A., & King, B.R. (2013). Both Dietary Protein and Fat Increase Postprandial Glucose Excursions in Children With Type 1 Diabetes, and the Effect is Additive. Diabetes Care, 36 (12), 3897-3902.
  7. Wolpert, H.A., Smith, S.A., Atakov-Castillo, A., & Steil, G.M. (2013). Dietary Fat Acutely Increases Glucose Concentrations and Insulin Requirements in Patients With Type 1 Diabetes. Diabetes Care, 36 (4), 810-816.
  8. Priebe, M.G., Wang, H., Weening, D., Schepers, M., Preston, T., & Vonk, R.J. (2010). Factors related to colonic fermentation of nondigestible carbohydrates of a previous meal increase tissue glucose uptake and moderate glucose-associated inflammation. Am J Clin Nutr, 91(1), 90-97.
  9. Nilsson, A.C., Ostman, E.M., Knudsen, K.E.B., Holst, J.J., & Bjork, I.M.E. (2010) A Cereal-Based Evening Meal Rich in Indigestible Carbohydrates Increases Plasma Butyrate the Next Morning. J Nutr., 140 (11), 1932-1936.
  10. American Diabetes Association [ADA]. Standards of Medical Care in Diabetes – 2018. Diabetes Care, 41 (Suppl 1).
  11. Riddell M.C., Gallen I.W., Smart C.E., Taplin C.E., Adolfsson P., Lumb A.N., …& Laffel L.M. (2017). Exercise Management in Type 1 Diabetes: A Consensus Statement. Lancet Diabetes Endocrinol., 5 (5), 377-390.
  12. Laguna, A.J., Rossetti, P., Ampudia-Blasco, F.J., Vehi, J., & Bondia, J. (2014). Identification of intra-patient variability in the postprandial response of patients with type 1 diabetes. Biomedical Signal Processing and Control, 12, 39-46.
  13. Ruan, Y., Thabit, H., Leelarantha, L., Hartnell, S., Willinska, M.E., Dellweg, S., Benesch, C., Mader, J.K., Holzer, M., Kojzar, H., Evans, M.L., Pieber, T.R., Arnolds, S., & Hovorka, R. (2016). Variability of Insulin Requirements Over 12 Weeks of Closed-Loop Insulin Delivery in Adults with Type 1 Diabetes. Diabetes Care, 39, 830-832.
  14. Bell, K.J., Barclay, A.W., Petocz, P., Colagiuri, S., & Brand-Miller, J.C. (2014). Efficacy of carbohydrate counting in type 1 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol, 2 (2), 133-140.


Michael Fox MS, RDN, LN

Michael Fox MS, RDN, LN is a PWT1D for nearly 30 years. He is a Registered Dietitian and CEO of DugalHealth, a tech startup leveraging technology to improve the lives of people with Type 1. He lives in Bozeman, MT with his two daughters.