Dr Carmel Smart: app goes beyond carb counting

Wednesday, 30 Jan 2019

Can you describe the aim of your project in less than 10 words?

To compare carb counting to insulin dosing for all macronutrients.

We’ve got a range of smartphone apps in diabetes. Why is this one different?

OptimAAPP is different from other smartphone apps as it enables dosing for all of the macronutrients (fat, protein and carbohydrate) in meals, not just carbohydrate alone. Diabetes guidelines state that insulin adjustment for fat and protein is necessary to prevent high blood glucose levels, particularly after foods such as pizza or a large steak. These calculations can be quite complicated so a smartphone app is the ideal tool to guide these insulin adjustments for foods of higher protein and fat amounts.

What have you already discovered in this area so far?

Our research has shown fat and protein cause delayed hyperglycaemia and they have an additive impact on blood glucose levels. We have also been investigating how much to adjust insulin for high protein and fat meals and have included the results of these studies in a mobile phone application. The app has been pilot-tested with diabetes clinicians in our service and consumers. Pilot data indicates that both families and health care professionals want to improve their knowledge of insulin needs for fat and protein and are willing to use the app. We have shown in this pilot decreased glycaemic variability with people using the app and now want to try it in a research study with both adult and paediatric populations. Pilot survey responses by health professionals working in diabetes in NSW found an app dosing for fat and protein would be highly useful and relevant to their practice. Additionally discussions at meetings overseas demonstrate an international interest in the app and the education package.

What aspect of this research excites you the most?

It is exciting to address questions people with type 1 diabetes would like answered about food. The part that excites me the most is trialing our new algorithm in a technology friendly form based on studies I commenced in 2002. Continuous glucose monitoring systems have made this research even more relevant. It is great to be able to answer questions posed by families and translate the findings directly into clinical practice.

Is carbohydrate counting outdated now? Or how long will it last?

Carbohydrate counting is not outdated as even with the newer hybrid closed loop pumps and other systems it is necessary to have a good understanding of carbohydrate amounts in food. However we know, even with the newest technology, that carbohydrate counting is a less than perfect system and people can still experience hypos and hyperglycaemia after meals. This means we need a better method that considers fat and protein in meal-time dosing and is individualised as people have different sensitivities to fat and protein amounts.

Are clinicians largely onboard with outsourcing complicated calculations to a phone app?

Both health professionals and people living with type 1 diabetes would like to understand how calculations are made to determine the meal-time insulin dose. Our mixed meal algorithm is complex and was developed with Process Control Engineers at the University of Newcastle based on over a decade of carefully controlled food studies. For this reason we have also developed a supporting, evidence-based fat and protein curriculum to enhance understanding of the insulin dose adjustments required for fat and protein in meals. Training will be provided to health professionals and people with diabetes on the use of the app and an instruction booklet and webinar provided to give the background on the insulin calculations it makes.

What’s your Holy Grail – the one thing you’d like to achieve in your research career?

One of the greatest parts of working with people with diabetes is that everyone is individual and there is a wide variation in sensitivities to different foods. My goal is to achieve an insulin dosing system for food that matches the individual’s needs and adapts over time as the child grows and new foods are eaten. My overall aim is to help to reduce the burden of living with diabetes by optimising meal-time insulin dosing and enabling people to have wide food choices.

What is your biggest research hurdle?

Food and unpredictable physical activity present the biggest challenges to closed loop systems. The more we understand about the glycaemic responses and insulin requirements for different types of food and exercise the better we can overcome these challenges.

Who has inspired you in work or life?

I am inspired everyday by the young people and families I work with. Their ‘can-do’ attitude towards achieving their goals and also their willingness to help others by participating in research is uplifting. Also the ability to admit when things are just too tough is admirable. I have been privileged to know several young people who have become youth ambassadors or overcome enormous social adversity to become a role model for others. I love hearing the stories of the children when they grow up and return to the paediatric clinic to say hi.

Can you describe a book that had a major influence on you?

I love reading “tramping” guide books of New Zealand. It is my favorite place to walk as the scenery is spectacular, but there are no snakes. On the walks there is no internet so lots of time just to spend with my family and good friends.

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