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What adult insulin pump users know and do - the role of nutrition and carbohydrate counting in diabetes… Malkin, Alison Amrit 2011

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What
Adult
Insulin
Pump
Users
Know
and
Do
–
The
Role
of
 Nutrition
and
Carbohydrate
Counting
in
Diabetes
Management
 by
 Alison
Amrit
Malkin
 B.Sc.,
The
University
of
British
Columbia,
1998
 A
THESIS
SUBMITTED
IN
PARTIAL
FULFILLMENT
OF
 THE
REQUIREMENTS
FOR
THE
DEGREE
OF
 MASTER
OF
SCIENCE
 in
 THE
FACULTY
OF
GRADUATE
STUDIES
 (Human
Nutrition)
 THE
UNIVERSITY
OF
BRITISH
COLUMBIA
 (Vancouver)
 
 
 May
2011
 ©
Alison
Amrit
Malkin,
2011
 ii
 ABSTRACT
 The
role
of
nutrition
in
diabetes
management
is
well
documented,
but
little
is
known
about
the
dietary
 practices
of
adult
insulin
pump
users.

This
cross‐sectional
quantitative
study
was
conducted
to
address
 this
gap.

An
electronic
survey
was
designed
with
the
assistance
of
a
national
advisory
group
of
diabetes
 health
 care
 (DHC)
 experts
 who
 identified
 nutrition
 domains
 relevant
 to
 flexible
 intensive
 insulin
 self‐ management.
 
The
survey
was
then
used
to
explore
the
nutrition
and
carbohydrate
counting
practices,
 satisfaction
with
and
sources
of
nutrition
support,
and
glycemic
control
of
adult
Medtronic
insulin
pump
 users.

Inter‐relationships
among
these
key
factors
were
also
explored.

Adult
pumpers
(n=297)
attained
 a
 nutrition
 knowledge
 scale
 score
 of
 70.8±16.9%
 and
 relied
 on
 label
 reading
 86.0±18.0%
 of
 the
 time.

 Gaps
in
nutrition
knowledge
included
carbohydrate
counting
for
low
carbohydrate
vegetables,
glycemic
 index,
 and
 label
 reading
 with
 sugar
 alcohols.
 
 Nutrition
 knowledge
 scores
 were
 higher
 among
 those
 without
severe
hypoglycemic
reactions
(73.1±16.2%
vs.
65.4±16.2%,
t=3.275,
p=0.001).

Higher
nutrition
 knowledge
scale
scores
were
also
correlated
with
more
favourable
glycated
hemoglobin
(A1c)
values
(r=‐ 0.171,
p=0.006).

Satisfaction
was
correlated
with
the
number
of
DHC
team
members
(r=0.412,
p=0.001;
 mean
 1.68±1.3).
 
 Dietitians
 (50.2%)
 and
 Diabetes
 Education
 Centres
 (DEC)
 (50.2%)
 were
 the
 most
 frequently
 reported
 sources
 of
 dietary
 support.
 
 “Self‐educators”
 received
 higher
 nutrition
 knowledge
 scale
 scores
 compared
 to
 “non
 self‐educators”
 (73.1±16.9%
 vs.
 67.7±16.2%,
 t=2.614,
p=0.004)
 but
 no
 difference
in
glycemic
control
was
found
between
the
two
groups
(7.2±1.0%
vs.
7.2±1.0%
A1c,
t=0.614,
 p=0.539).
 Results
 support
 the
 concept
 of
 a
 positive
 correlation
 between
 nutrition
 knowledge
 and
 glycemic
 control.
 
 Satisfaction
with
nutrition
 support
was
 linked
 to
 the
 size
and
 scope
of
 a
person’s
DHC
 team.

 Empowering
adult
pumpers
to
perceive
themselves
as
“self‐educators”
may
be
an
effective
strategy
to
 enhance
nutrition
knowledge
and
potentially
 improve
glycemic
control.
 
Although
this
sample
may
not
 be
 representative
 of
 all
 Canadian
 adult
 insulin
 pump
 users,
 they
 were
 motivated
 and
 well
 educated
 about
 nutrition
 and
 carbohydrate
 counting,
 flexible
 intensive
 insulin
 self‐management,
 and
 had
 good
 glycemic
control.
 iii
 PREFACE
 This
Master
 of
 Science
 thesis
 was
 prepared
 according
 to
 the
 requirements
 detailed
 by
 the
 Faculty
 of
 Graduate
Studies
at
the
University
of
British
Columbia.

For
Chapter
2,
I
conceived
the
study
design
and
 methods,
identified
the
study
objectives,
recruited
the
pilot
study
participants,
collected
and
managed
all
 data,
planned
and
conducted
the
data
analyses,
presented
findings
and
wrote
the
manuscript.

My
thesis
 advisor
(Dr.
Susan
Barr,
PhD,
RD)
was
the
Principal
 Investigator
for
the
study
and
contributed
patiently
 and
continuously
to
all
aspects
of
the
study
in
addition
to
offering
key
editorial
support.

My
committee
 members
(Karol
Traviss,
MSc,
RD
and
Dr.
Clarissa
Wallace,
MD,
FRCPC)
made
significant
contributions
by
 suggesting
varying
approaches
and
providing
useful
examples
pertaining
to
methodological
choices,
stat‐ istical
analyses
as
well
as
editorial
 input.
 
Sharon
Zeiler,
RD
from
the
Canadian
Diabetes
Association
as‐ sisted
with
the
recruitment
of
diabetes
health
care
experts
to
make
up
the
national
advisory
group
that
 helped
identify
fundamental
nutrition
domains
relevant
to
intensive
insulin
therapy,
nutrition
and
carbo‐ hydrate
counting
for
adult
insulin
pump
users
and
provided
feedback
on
the
preliminary
survey
design.

 David
Calhoun
leads
an
adult
insulin
pump
support
group
and
circulated
the
pilot
survey
to
group
mem‐ bers.

Medtronic
of
Canada
Ltd.
gave
valuable
assistance
in
recruiting
the
final
national
sample
to
com‐ plete
the
survey
and
sponsored
the
research
initiative.
 Ethics
approval
to
conduct
this
research
was
obtained
by
the
University
of
British
Columbia
–
Behav‐ ioural
Research
Ethics
Board
 (BREB)
on
 June
9,
2008
 (UBC
BREB
number:
H07‐01240).
 
Ethics
approval
 was
terminated
on
February
14,
2009.
 iv
 CONTENTS

 ABSTRACT
..................................................................................................................................................... ii
 PREFACE
 .......................................................................................................................................................iii
 CONTENTS
 ....................................................................................................................................................iv
 LIST
OF
TABLES.............................................................................................................................................vii
 LIST
OF
FIGURES .............................................................................................................................................x
 LIST
OF
ABBREVIATIONS................................................................................................................................xi
 ACKNOWLEDGEMENTS ................................................................................................................................xii
 CHAPTER
1:
 
INTRODUCTION...................................................................................................................... 1
 1.1
 Background ................................................................................................................................. 1
 1.2
 Literature
review......................................................................................................................... 2
 1.2.1
 Overview......................................................................................................................... 2
 1.2.2
 Etiology
of
diabetes ........................................................................................................ 2
 1.2.3
 Glycemic
control............................................................................................................. 3
 1.2.4
 Flexible
intensive
insulin
self‐management ................................................................... 4
 1.2.5
 Nutrition
therapy
and
carbohydrate
counting ............................................................... 6
 1.2.6
 Self‐management
education
(SME)
and
the
diabetes
health
care
(DHC)
team ............. 9
 1.2.7
 Insulin
pump
therapy
and
the
bolus
calculator .............................................................. 9
 1.2.8
 Satisfaction
with
nutrition
support .............................................................................. 11
 1.3
 Limits
to
current
knowledge ..................................................................................................... 12
 1.4
 Rationale ................................................................................................................................... 12
 1.4.1
 Research
objectives ...................................................................................................... 12
 1.5
 References ................................................................................................................................ 14
 v
 CHAPTER
2:
 WHAT
ADULT
INSULIN
PUMP
USERS
KNOW
AND
DO
–
THE
ROLE
OF
NUTRITION
AND
 CARBOHYDRATE
COUNTING
IN
DIABETES
MANAGEMENT................................................... 20
 2.1
 Introduction .............................................................................................................................. 20
 2.2
 Methods.................................................................................................................................... 22
 2.2.1
 Study
design ................................................................................................................. 22
 2.2.2
 Survey
development..................................................................................................... 22
 2.2.3
 Survey
description ........................................................................................................ 22
 2.2.4
 Participant
selection..................................................................................................... 23
 2.2.5
 Survey
administration .................................................................................................. 23
 2.2.6
 Statistical
analysis......................................................................................................... 24
 2.2.7
 Scale
construction ........................................................................................................ 24
 2.3
 Results....................................................................................................................................... 25
 2.3.1
 Overall
subject
characteristics...................................................................................... 25
 2.3.2
 Level
of
satisfaction ...................................................................................................... 25
 2.3.3
 Sources
of
diabetes
education ..................................................................................... 25
 2.3.4
 Nutrition
knowledge..................................................................................................... 26
 2.3.5
 Glycemic
outcome........................................................................................................ 27
 2.3.6
 Relationships ................................................................................................................ 27
 2.3.7
 Topics
of
future
interest
and
comments ...................................................................... 29
 2.4
 Discussion.................................................................................................................................. 29
 2.5
 Summary
and
conclusion .......................................................................................................... 33
 2.6
 Tables ........................................................................................................................................ 35
 2.7
 Figures....................................................................................................................................... 41
 2.8
 Acknowledgments..................................................................................................................... 42
 2.9
 References ................................................................................................................................ 43
 CHAPTER
3:
 
CONCLUSION........................................................................................................................ 48
 3.1
 General
discussion
and

summary
of
current
state
of
knowledge............................................ 48
 3.2
 General
conclusions .................................................................................................................. 49
 3.3
 Strengths
and
limitations .......................................................................................................... 52
 3.4
 Applications............................................................................................................................... 53
 3.5
 Future
directions....................................................................................................................... 54
 3.7
 References ................................................................................................................................ 62
 
 vi
 APPENDICES
 
 APPENDIX
1:
 Methodologies
of
survey
development
with
the
national
expert
advisory
 committee
and
pilot
study
group ........................................................................... 66
 Appendix
2:
 Copy
of
pilot
study........................................................................................................ 73
 Appendix
3:


Results
of
pilot
survey
–
section
F ................................................................................ 99
 Appendix
4:
 Copy
of
final
survey .................................................................................................... 107
 Appendix
5:
 Copy
of
consent
letter ................................................................................................ 132
 Appendix
6:
 Copy
of
survey
invitations .......................................................................................... 134
 Appendix
7:
 Results
of
final
survey................................................................................................. 137
 7.1
Univariate
responses ............................................................................................ 137
 7.2
Multivariate
responses......................................................................................... 159
 7.3
Response
comments ............................................................................................ 162
 
 
 vii
 List
of
Tables
 Table
1:

 Demographic
and
anthropometric
data
of
participants ............................................................ 35
 Table
2:

 Relationships
among
survey
variables ....................................................................................... 36
 Table
3:

 Characteristics
of
respondents
by
use
of
the
Bolus
Wizard™
calculator ................................... 37
 Table
4:

 Characteristics
of
respondents
by
experience
of
severe
hypoglycemia .................................... 38
 Table
5:

 Characteristics
of
self‐educators
and
non‐self‐educators.......................................................... 39
 Table
6:
 Nutrition
knowledge
and
glycemic
control
of
respondents
by
number
of
DHC
team
members
 and
frequency
of
contact
with
DEC ........................................................................................... 40
 Table
7:

 Summary
of
specific
study
objectives
and
key
research
findings .............................................. 56
 Table
8:

 Identification
of
nutrition
domains
relevant
to
adult
insulin
pump
users ................................. 70
 Table
9:

 Pilot
survey
question
45
–
How
would
you
rate
the
following
survey? ................................... 100
 Table
10:

Pilot
survey
question
46
–
Do
you
feel
your
nutrition
knowledge
regarding

 your
diabetes
management
was
assessed
appropriately? ...................................................... 101
 Table
11:

Pilot
survey
question
46
–
Comments...................................................................................... 102
 Table
12:

Pilot
survey
question
47
–
Did
you
find
any
questions
unclear?.............................................. 103
 Table
13:

Pilot
survey
question
47
–
Comments...................................................................................... 103
 Table
14:
 
Pilot
survey
question
48
–
Is
there
anything
you
would
change,
add
or
delete

 from
this
survey? ..................................................................................................................... 104
 Table
15:
 Pilot
survey
question
48
–
Comments...................................................................................... 104
 Table
16:

Pilot
survey
question
49
–
Please
add
any
comments
about
this
survey
that
you

 have
not
yet
addressed............................................................................................................ 105
 Table
17:

Pilot
survey
question
50
–
How
long
did
it
take
you
to
complete
the
survey? ........................ 105
 Table
18:

Pilot
survey
question
50
–
Comments...................................................................................... 106
 Table
19:

 Survey
question
2A
–
I
am
very
satisfied
with
the
nutrition
support
I
receive ........................ 137
 Table
20:

 Survey
question
2B
–
The
nutrition
support
I
have
received
in
the
last
few
years

 is
just
about
perfect ................................................................................................................. 137
 viii
 Table
21:

 Survey
question
2C
–
There
are
things
about
the
nutrition
support
I
receive
that

 could
be
better ........................................................................................................................ 137
 Table
22:

 Survey
question
3
–
Who
currently
provides
the
nutrition
support
for
your
diabetes
 management?
(Please
check
all
that
apply) ............................................................................ 138
 Table
23:

 Survey
question
4
–
How
do
you
find
the
nutrition
support
provided
by
the

following

 members
of
your
diabetes
health
care
team?......................................................................... 138
 Table
24:

 Survey
question
5
–
When
was
your
last
visit
to
a
Diabetes
Education
Centre? ..................... 139
 Table
25:

 Survey
question
6
–
When
was
your
last
visit
with
a
dietitian?............................................... 139
 Table
26:

 Survey
question
7
–
How
many
times
have
you
seen
a
dietitian
to
learn
about
how

 insulin
matches
food
(carbohydrate
counting)? ...................................................................... 140
 Table
27:

 Survey
question
8
–
How
do
you
decide
how
much
insulin
to
give
yourself
when

 eating
a
meal/snack? ............................................................................................................... 140
 Table
28:

 Survey
question
9
–
How
often
do
you
USE
THE
LABEL
TO
COUNT
the
number
of

 carbohydrates
in
your
meal/snack
versus
ESTIMATING? ........................................................ 141
 Table
29:

 Survey
question
10
–
Do
you
have
a
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at

 MEALS
and
SNACKS?................................................................................................................ 141
 Table
30:

 Survey
question
11
–
What
is
the
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at
MEALS? ..... 142
 Table
31:

 Survey
question
11
–
What
is
the
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at
SNACKS? ... 142
 Table
32:

 Survey
question
12
–
Do
you
know
your
CARBOHYDRATE
TO
INSULIN
RATIO
for
your

 first
meal
of
the
day? ............................................................................................................... 143
 Table
33:

 Survey
question
13
–
What
is
your
CARBOHYDRATE
TO
INSULIN
RATIO
for
your

 first
meal
of
the
day? ............................................................................................................... 143
 Table
34:

 Survey
question
14
–
Do
you
know
your
CORRECTIVE/INSULIN
SENSITIVITY
FACTOR

 is
for
your
first
meal
of
the
day?.............................................................................................. 144
 Table
35:

 Survey
question
15
–
What
is
your
CORRECTIVE/INSULIN
SENSITIVITY
FACTOR
for

 your
first
meal
of
the
day?....................................................................................................... 144
 Table
36:

 Survey
question
16
–
If
eaten
on
its
own,
which
nutrient
is
fully
converted
to
sugar

 2
hours
after
eating?................................................................................................................ 145
 Table
37:

 Survey
question
17
–
Which
of
the
food
groups
below
DO
NOT
contain
CARBOHYDRATES:
 (Please
check
all
that
apply)..................................................................................................... 145
 Table
38:

 Survey
question
18
–
How
do
fats,
protein,
and
fibre
affect
the
digestion
of

 carbohydrates
when
included
in
the
same
meal? ................................................................... 146
 Table
39:

 Survey
question
19
–
Are
you
familiar
with
the
concept
of
glycemic
index?........................... 146
 Table
40:

 Survey
question
20
–
What
food
in
the
list
below
has
the
HIGHEST
glycemic
index? ............. 147
 Table
41:
 Survey
question
21
–
If
your
blood
glucose
drops
on
its
own
overnight
or
if
you

 skip
a
meal,
what
insulin
would
you
reduce? .......................................................................... 147
 ix
 Table
42:
 Survey
question
22
–
When
reading
food
labels,
the
gram
count
for
“carbohydrates”

 is
more
important
than
the
gram
count
for
“sugar”................................................................ 148
 Table
43:

 Survey
question
23
–
What
is
the
serving
size
for
this
bread?................................................. 149
 Table
44:

 Survey
question
24
–
How
many
grams
of
available
carbohydrate
should
be
counted

 for
1
serving? ........................................................................................................................... 149
 Table
45:
 Survey
question
25
–
How
many
grams
of
available
carbohydrate
should
be
counted
if

 you
eat
only
1
slice
of
bread? .................................................................................................. 150
 Table
46:

Survey
question
26
–
How
many
grams
of
available
carbohydrate
should
be
counted

 for
1
serving? ........................................................................................................................... 151
 Table
47:
 Survey
question
27
–
When
a
label
states
“No
Added
Sugar”
that
means
it
will
NOT

 raise
blood
glucose
at
all.......................................................................................................... 151
 Table
48:

 Survey
question
28
–
What
do
you
USUALLY
do
if
you
have
a
low
blood
glucose?................. 152
 Table
49:

 Survey
question
29
–
How
many
times
in
the
LAST
6
MONTHS
have
you
had
a
SEVERE

 low
blood
glucose
reaction
(i.e.
resulting
in
passing
out
or
needing
someone
else’s
help)? .. 152
 Table
50:

 Survey
question
30
–
When
was
the
last
time
you
had
an
A1c
test
done
(a
test
that

 measures
your
average
blood
glucose
level
over
the
past
2‐3
months)?................................ 153
 Table
51:

 Survey
question
31
–
Do
you
know
the
result
of
your
MOST
RECENT
A1c
test? ..................... 153
 Table
52:

 Survey
question
32
–
What
was
the
result
of
your
MOST
RECENT
A1c
test? .......................... 154
 Table
53:

 Survey
questions
33
–
43
inclusive:
Characteristics
of
survey
respondents ............................ 154
 Table
54:

Diabetes
health
care
team
member
scale
score ...................................................................... 159
 Table
55:

Nutrition
knowledge
scale
score.............................................................................................. 161
 Table
56:

Glycemic
outcome
score .......................................................................................................... 161
 Table
57:

 Survey
response
comments
–
Question
3................................................................................ 162
 Table
58:

 Survey
response
comments
–
Question
8................................................................................ 164
 Table
59:

 Survey
response
comments
–
Question
28.............................................................................. 165
 Table
60:

 Survey
response
comments
–
Question
44.............................................................................. 167
 Table
61:

 Survey
response
comments
–
Question
45.............................................................................. 169
 Table
62:

 Survey
response
comments
–
Question
46.............................................................................. 176
 x
 List
of
Figures
 Figure
1:
Subject
selection
for
study........................................................................................................... 41
 Figure
2:
Survey
question
23
to
25
–
Nutrition
Facts
label
#1 .................................................................. 148
 Figure
3:
Survey
question
26
–
Nutrition
Facts
label
#2............................................................................ 150
 
 xi
 LIST
OF
ABBREVIATIONS
 A1c
 glycated
hemoglobin
 ADA
 American
Diabetes
Association
 BMI
 body
mass
index
(kg/m2)
 BREB
 Behavioural
Research
Ethics
Board
 CDA
 Canadian
Diabetes
Association
 CF
 correction
factor
 CIR
 carbohydrate
to
insulin
ratio
 DAFNE
 Dose
Adjustment
For
Normal
Eating
 DCCT
 Diabetes
Control
and
Complications
Trial
 DEC
 diabetes
education
centre
 DHC
 diabetes
health
care
 GI
 glycemic
index
 ISF
 insulin
sensitivity
factor
 Kg
 kilogram
 m
 meter
 mmol/L
 millimole
per
litre
 SME
 Self‐management
education
 SPSS
 Statistical
Package
for
Social
Sciences
 UBC
 University
of
British
Columbia
 UKPDS
 United
Kingdom
Prospective
Diabetes
Study
 vs.
 versus
 xii
 ACKNOWLEDGEMENTS
 I
would
like
to
acknowledge
the
support
and
guidance
of
many
individuals,
without
whom
this
graduate
 degree
would
not
have
been
possible.
 First
and
foremost,
 I
would
like
to
thank
my
supervisor
Dr.
Susan
Barr,
PhD,
RD
for
providing
such
 valuable
insight
and
direction
regarding
the
development,
evolution
and
completion
of
this
research
in‐ itiative.

Susan,
your
endless
patience
and
encouragement
were
greatly
appreciated
and
have
facilitated
 my
development
as
a
researcher,
educator
and
dietitian.

It
has
been
a
true
pleasure
and
honour
to
work
 with
and
learn
from
you.

Your
passion
and
commitment
to
research
and
to
your
students
is
truly
inspir‐ ing!
 To
my
committee
members,
Karol
Traviss,
MSc,
RD
and
Dr.
Clarissa
Wallace,
MD,
FRCPC,
thank
you
 for
sharing
your
enthusiasm
and
expertise
throughout
this
research
process.
 
Your
feedback
on
how
to
 improve
the
study
and
your
thought‐provoking
questions
were
indispensible.
 Thank
you
to
Bill
Mercer,
PhD,
Director
of
G.W.
Mercer
Consulting
Inc.,
for
playing
an
instrumental
 role
in
directing
the
initial
development
of
the
statistical
analysis
used
in
this
study.

The
opportunity
to
 review
and
discuss
my
analysis
with
you
was
most
helpful.
 I
also
want
to
acknowledge
Medtronic
of
Canada
Ltd.
for
funding
and
facilitating
this
project
by
dis‐ tributing
the
survey
to
their
customers.
 
A
special
thank
you
to
Suleen
Mak
for
seeing
the
value
of
this
 research
and
to
Adrian
Ongpin
for
his
technical
support.
 I
also
want
to
recognize
the
important
contributions
of
the
members
of
my
national
advisory
com‐ mittee,
pilot
group
and
survey
participants
whose
interest,
time,
energy
and
feedback
formed
the
back‐ bone
of
this
study.
 Lastly,
I
want
to
thank
my
parents,
Ezra
and
Anita
Beinhaker,
and
sister
Karen
for
their
unwavering
 support,
unconditional
 love,
and
 for
always
believing
 in
me.
 
 I
 feel
 incredibly
 fortunate
 to
have
such
a
 wonderful
 family
 and
 group
 of
 fabulous
 friends
 who
 provided
 much
 encouragement
 and
 excitement
 about
the
completion
of
this
project.

A
special
thank
you
to
my
husband
and
soul
mate
Steven
for
edit‐ ing
suggestions,
ongoing
support
and
for
always
bringing
a
smile
to
my
face.
 1
 CHAPTER
1:
INTRODUCTION
 1.1
 BACKGROUND
 Diabetes
 Mellitus
 is
 a
 chronic
 condition
 that
 results
 from
 the
 body’s
 inability
 to
 sufficiently
 produce
 and/or
use
 insulin
 resulting
 in
elevated
blood
glucose
 levels.
 
The
 long‐term
consequences
of
diabetes
 can
often
be
severe
and
life
altering,
resulting
in
the
dysfunction
and
failure
of
various
organs
such
as
the
 kidneys,
eyes,
heart,
nerves
and
blood
vessels
and
can
result
 in
premature
death
(1).
 
According
to
the
 most
recent
National
Diabetes
Surveillance
Survey
data
from
2006
–
2007,
approximately
2
million
Ca‐ nadians
or
about
1
 in
16
people
have
been
diagnosed
with
diabetes
 resulting
 in
a
prevalence
of
6.2%.

 Projections
indicate
that
by
2012
almost
2.8
million
Canadians
will
be
living
with
diagnosed
diabetes
re‐ sulting
in
an
overall
increase
of
about
25%
from
2007
(2).

The
primary
goal
of
diabetes
management
is
to
 achieve
 blood
 glucose
 levels
 as
 close
 to
 normal
 as
 possible
 in
 an
 effort
 to
 prevent
 or
 delay
 diabetes‐ related
complications
or
co‐morbidities
(1,3,4).
 Unfortunately,
the
many
factors
that
affect
the
degree
of
blood
glucose
variability
(i.e.,
 food
choi‐ ces,
 activity,
medications,
 stress,
hormones,
 etc.)
make
 the
pursuit
of
near‐normoglycemia
challenging
 and
complex.

In
cases
where
insulin
therapy
is
required,
the
use
of
continuous
subcutaneous
insulin
in‐ fusion
or
an
insulin
pump
is
widely
accepted
as
the
gold
standard
of
insulin
delivery.

Accordingly,
insulin
 pump
use
has
markedly
increased
since
its
launch
in
the
1970s
(5).

Successful
pump
therapy
use
requires
 an
 understanding
 of
 the
 principles
 involved
 in
 intensive
 insulin
 therapy
 as
 well
 as
 appropriate
 self‐ management
problem
solving
skills
regarding
insulin
adjustment
(6‐9).

These
skills
help
promote
optimal
 glycemic
control
with
a
greater
degree
of
flexibility
and
a
better
quality
of
life
(10,11).

In
addition
to
hav‐ ing
the
support
of
a
multi‐
and
interdisciplinary
diabetes
health
care
(DHC)
team,
knowledge
of
nutrition
 and
carbohydrate
counting
(1,12‐20)
are
key
factors
in
effective
diabetes
management
(1,21‐24).
 While
much
 is
known
about
the
fundamental
roles
of
nutrition
and
carbohydrate
counting,
a
sup‐ portive
DHC
team,
and
optimal
glycemic
control,
 there
 is
 limited
research
that
 looks
specifically
at
 the
 nutrition‐related
 diabetes
 management
 practices
 of
 adult
 insulin
 pump
 users.
 
 Furthermore,
 little
 is
 known
about
how
each
of
these
aspects
of
care
relate
to
each
other
and
to
the
level
of
satisfaction
of
the
 adult
insulin
pump
user
with
their
nutrition
support
team.
 2
 1.2
 LITERATURE
REVIEW
 1.2.1
 Overview
 This
review
of
the
current
research
regarding
what
adult
insulin
pump
users
know
and
do
regarding
the
 role
of
nutrition
and
carbohydrate
counting
in
diabetes
management
begins
by
providing
basic
informa‐ tion
on
the
etiology
of
diabetes
and
relevant
research
supporting
the
targeting
of
near‐normoglycemia.

 A
 brief
 history
 of
 insulin
 treatment
 and
 the
 uptake
 of
 flexible
 intensive
 insulin
 self‐management
 into
 mainstream
practice
follows.

The
vital
role
of
nutrition
therapy
and
the
popularization
of
carbohydrate
 counting
 as
 the
 preferred
 dietary
 approach
 for
 insulin
 dose
 adjustment
 is
 then
 presented
 along
with
 other
 relevant
 nutrition‐related
 concepts
 such
 as
 glycemic
 index
 and
 label
 reading.
 
 The
 role
 of
 self‐ management
education
and
an
integrated
diabetes
health
care
team
is
also
discussed
in
addition
to
the
 mechanics
and
benefits
of
insulin
pump
therapy.

The
lack
of
reliable
and
validated
questionnaires
that
 examine
the
level
of
satisfaction
people
with
diabetes
have
regarding
their
nutrition
support
or
sources
 of
nutrition
information
is
also
explored.
 1.2.2
 Etiology
of
diabetes
 Diabetes
 is
 a
 serious
and
growing
public
health
problem
both
 in
Canada
 (1)
 and
globally
 and
 is
 antici‐ pated
to
be
one
of
the
most
challenging
chronic
diseases
of
the
21st
century
(25).

Diabetes
is
a
metabolic
 disorder
characterized
by
the
presence
of
hyperglycemia
due
to
faulty
insulin
secretion,
imperfect
insulin
 action,
or
a
combination
of
the
two.

Insulin
is
a
hormone
secreted
by
the
beta
cells
in
the
pancreas
and
 is
responsible
for
facilitating
the
uptake
of
glucose
from
the
bloodstream
into
the
cells
of
the
body,
pri‐ marily
in
muscle,
fat
and
liver
tissue,
where
it
is
converted
into
energy
(1,26).
 Three
classes
of
diabetes
predominate,
that
is
type
1
diabetes,
type
2
diabetes,
and
gestational
dia‐ betes:
 • Type
1
diabetes,
historically
known
as
 insulin‐dependent
diabetes
mellitus
or
 juvenile
diabe‐ tes,
typically
onsets
in
childhood
or
early
adolescence
and
is
characterized
by
pancreatic
beta
 cell
destruction
resulting
 in
the
need
for
multiple
daily
 injections
of
 insulin
for
survival.
 
The
 cause
of
type
1
diabetes
is
not
fully
understood
but
it
is
believed
that
a
combination
of
genetic
 and
environmental
 factors,
such
as
viruses,
 trigger
the
body’s
 immune
system
to
attack
and
 destroy
 its
 own
 insulin
 producing
 beta
 cells.
 
 Latent
 autoimmune
 diabetes
 in
 adults
 is
 also
 classified
under
type
1
diabetes
and
is
used
to
describe
a
group
of
adult
onset
patients
with
 immune‐mediated
 loss
 of
 pancreatic
 beta
 cells
whose
 presentation
 initially
 suggests
 type
 2
 diabetes,
but
who
quickly
evolve
to
require
insulin
(1,
26).
 3
 • Type
2
diabetes,
previously
known
as
non
insulin‐dependent
diabetes
mellitus
or
adult
onset
 diabetes,
is
the
most
common
form
of
diabetes
and
typically
onsets
after
the
age
of
40.

How‐ ever,
with
the
increasing
prevalence
of
pediatric
and
adolescent
obesity,
type
2
diabetes
is
no
 longer
seen
only
in
adults.

The
pathophysiology
of
type
2
diabetes
progresses
gradually
over
 time
and
ranges
from
predominant
insulin
resistance
with
relative
insulin
deficiency
to
a
pre‐ dominant
 secretory
 defect
with
 less
 severe
 insulin
 resistance.
 
 Typically,
 by
making
 healthy
 lifestyle
choices
including
eating
a
balanced
diet,
losing
weight
(if
overweight,
a
5–10%
reduc‐ tion
 in
 total
 body
weight),
 exercising
 regularly,
 or
 by
 taking
 oral
 antihyperglycemic
medica‐ tions,
the
majority
of
people
with
type
2
diabetes
can
overcome
their
resistance
to
insulin
at
 the
cellular
level
and
maintain
normoglycemia;
however,
some
individuals
may
require
insulin
 injections
(1,26).
 People
with
type
2
diabetes
account
for
approximately
90–95%
of
the
total
diabetic
popula‐ tion
 compared
 to
 about
 5–10%
of
 people
with
 type
 1
 diabetes
 (2).
 
 The
 life
 expectancy
 of
 adults
diagnosed
with
type
2
diabetes
is
found
to
be
shortened
by
5–10
years
while
the
con‐ sequences
of
having
 type
1
diabetes
have
been
 found
 to
be
more
 severe
 resulting
 in
more
 significant
 impact
on
a
person’s
quality
of
 life
and
an
approximate
15
year
 reduction
of
 life
 (26).
 • Gestational
diabetes
mellitus
 is
a
 form
of
diabetes
 involving
glucose
 intolerance
 that
occurs
 during
pregnancy
and
 typically
disappears
after
delivery.
 
Gestational
diabetes
occurs
 in
ap‐ proximately
4%
of
all
pregnancies,
and
increases
a
woman’s
risk
of
developing
type
2
diabetes
 later
in
life
(1,26).
 1.2.3
 Glycemic
control
 Evidence
supporting
the
targeting
of
near‐normoglycemia
in
an
effort
to
minimize
the
risk
of
developing
 microvascular
 complications
 (i.e.,
 diabetic
 retinopathy,
 nephropathy,
 and
 neuropathy)
 is
 provided
 by
 large
scale
randomized
controlled
clinical
trials
involving
people
with
both
type
1
(3)
and
2
diabetes
(4).

 A
reduction
in
cardiovascular
disease
has
also
been
convincingly
demonstrated
in
people
with
type
1
dia‐ betes
who
 achieve
 good
 glycemic
 control
 (27);
 however,
 the
 same
macrovasular
 benefits
 of
 tight
 gly‐ cemic
control
have
not
been
seen
in
people
with
type
2
diabetes
(28,29).
 Glycated
hemoglobin
(A1c)
is
a
laboratory
test
that
is
globally
recognized
as
being
a
valuable
indica‐ tor
of
the
effectiveness
of
diabetes
treatment
and
management.

A1c
is
the
product
of
a
non‐enzymatic
 reaction
called
glycosylation
between
glucose
and
free‐amino
groups
of
hemoglobin
in
erythrocytes
(30).

 A1c
 is
 accepted
 as
 a
 dependable
 estimate
 of
mean
 plasma
 glucose
 levels
 over
 the
 past
 three
 to
 four
 months
(31)
and
has
been
found
to
be
closely
correlated
with
the
development
of
 long‐term
diabetes‐ related
complications
(4,32).

An
A1c
target
of
≤7.0%
is
recommended
for
adults
with
type
1
and
2
diabe‐ 4
 tes;
 however,
 it
 is
 recognized
 that
 clinical
 judgment
 be
 used
 pertaining
 to
 which
 people
 can
 safely
 achieve
this
target
while
limiting
their
risk
of
hypoglycemia
(1).
 According
 to
 the
 Canadian
Diabetes
 Association
 (CDA)
 guidelines,
 A1c
 should
 be
measured
 every
 three
months
when
glycemic
targets
are
not
being
met
and
when
diabetes
therapy
is
being
adjusted
(1).

 However,
the
most
comprehensive
way
to
assess
glycemic
control
results
from
regular
self‐monitoring
of
 blood
glucose
combined
with
A1c
(1,33).

The
majority
of
research
studies
use
only
the
A1c
value
to
as‐ sess
diabetes
treatment
effectiveness.

The
diabetes
management
goal
to
achieve
an
A1c
value
≤7.0%
is
 referred
to
as
intensive
diabetes
treatment.
 1.2.4
 Flexible
intensive
insulin
self‐management
 Insulin
treatment
for
diabetes
management
has
progressed
significantly
over
the
past
40
years.
 
 In
the
 early
1970s,
people
were
injecting
fixed
doses
of
animal
 insulin,
relying
on
urinary
glucose
excretion
to
 guide
 insulin
adjustments,
and
were
encouraged
to
follow
strict
dietary
guidelines.
 
Toward
the
end
of
 the
decade,
 the
development
of
home
blood
glucose
monitoring
devices,
A1c
assays,
more
stable
and
 faster
acting
purified
insulin
preparations
and
the
development
of
the
first
 insulin
pump
revolutionized
 diabetes
treatment
and
supported
the
implementation
of
intensive
insulin
therapy
(34).
 Conventional
 insulin
 therapy
was
usually
 limited
 to
 two
daily
 injections
of
mixed
 short
 and
 inter‐ mediate
acting
insulins.

Intensive
insulin
therapy
is
based
on
a
basal‐bolus
insulin
regime.

“Basal”
insulin
 refers
to
the
background
insulin
used
to
cover
 insulin
needs
between
meals
and
overnight
and
“bolus”
 insulin
is
a
faster
acting
insulin
used
to
cover
insulin
needs
when
eating
carbohydrates
and
to
correct
for
 hyperglycemia.

Basal‐bolus
insulin
regimes
require
more
frequent
self‐monitoring
of
blood
glucose
lev‐ els
 (i.e.,
 a
minimum
of
 four
 times
per
day,
usually
before
all
meals
 and
at
bedtime)
 and
 the
ability
 to
 problem
solve
and
make
appropriate
 insulin
dose
adjustments
based
on
 individual
blood
glucose
read‐ ings
and
targets.

Intensive
insulin
therapy
involving
multiple
daily
injections
of
insulin
or
an
insulin
pump
 have
both
been
shown
to
mimic
normal
pancreatic
insulin
secretion
more
closely
than
conventional
insu‐ lin
 therapy
 (6‐9).
 
 Intensive
 insulin
 therapy
 is
also
known
as
 flexible
 intensive
 insulin
 self‐management
 therapy:
“Flexible”
because
of
the
increased
amount
of
freedom
each
individual
has
with
regard
to
their
 food
intake
and
lifestyle
choices,
and
“intensive
insulin
self‐management”
because
of
the
greater
amount
 of
blood
glucose
 testing
and
self‐management
problem
solving
 skills
 that
are
 required
 for
optimal
gly‐ cemic
control
(35).
 When
using
a
basal‐bolus
insulin
regime,
an
individual’s
ability
to
calculate
an
accurate
bolus
dose
of
 rapid
acting
meal
time
insulin
to
optimize
post‐prandial
glycemia
requires
consideration
of
the
following
 components:
(1)
target
blood
glucose,
(2)
current
blood
glucose,
(3)
carbohydrate
to
 insulin
ratio
(CIR),
 (4)
total
grams
of
carbohydrate
in
a
meal
or
snack,
(5)
correction
factor
(CF)
or
insulin
sensitivity
factor
 (ISF),
 (6)
 the
 timing
 and
 size
 of
 the
 previous
 bolus,
 and
 (7)
 any
 special
 considerations
 (i.e.,
 exercise,
 stress,
illness,
macronutrient
composition
of
meal,
etc.)
(7,12,13,17,36,37).

A
CIR
is
the
number
of
grams
 5
 of
carbohydrate
 that
would
be
covered
by
one
unit
of
 insulin.
 
For
example,
 if
a
person
was
eating
60
 grams
of
carbohydrate
and
their
CIR
was
one
unit
of
rapid
acting
insulin
for
every
10
grams
of
carbohyd‐ rate,
they
would
bolus
six
units
for
that
meal
(i.e.,
60
gram
carbohydrate
meal/10
grams
=
6
units
of
insu‐ lin).
 
 A
 CF/ISF
 is
 a
 ratio
 used
 to
 calculate
 how
much
 one
 unit
 of
 insulin
will
 lower
 an
 elevated
 blood
 glucose
value.

For
example,
if
a
person’s
CF/ISF
was
2mmol/L,
their
blood
glucose
target
was
6mmol/L
 and
their
blood
glucose
reading
before
the
meal
was
10mmol/L,
they
would
need
an
additional
two
units
 of
rapid
insulin
(i.e.,
10mmol/L
–
6mmol/L
=
4mmol/L
above
target/2mmol/L
=
2
units
of
extra
insulin).

 Building
on
the
above
example,
this
individual
would
need
six
units
of
rapid
acting
insulin
to
cover
the
60
 grams
of
carbohydrate
eaten
at
the
meal
in
addition
to
two
extra
units
of
rapid
acting
insulin
to
accom‐ modate
for
the
elevated
blood
glucose
reading
of
10
mmol/L
prior
to
eating.

This
results
in
a
total
meal
 and
correction
bolus
equal
to
eight
units
of
rapid
acting
insulin.
 In
 the
past,
 people
 taking
 insulin
were
advised
 to
not
make
any
 insulin
 adjustments
without
 first
 contacting
 their
physician.
 
 The
 concept
of
 insulin
 self‐management,
 combined
with
a
 liberalized
meal
 plan,
was
seen
as
a
radical
notion
that
was
much
too
complicated
for
the
average
person
with
diabetes.

 Muhlhauser
et
al.
changed
this
way
of
thinking
and
conducted
a
research
study
at
two
university
hospi‐ tals
in
Dusseldorf,
Germany
(1978)
and
Vienna,
Austria
(1981)
that
looked
at
the
possible
benefits
associ‐ ated
with
 the
development
 of
 a
 structured
 training
 program
 supporting
 the
 self‐adjustment
 of
 insulin
 doses
(38).

The
group‐based
program
included
six
to
12
insulin‐dependent
people
and
was
run
as
a
five‐ day
 in‐hospital
program
 led
by
a
diabetes
 trained
nurse,
dietitian
and
 laboratory
 technician
under
 the
 guidance
of
medical
staff.
 
The
primary
goal
of
the
program
was
for
participants
to
attempt
to
achieve
 near‐normoglycemia
using
 flexible
 intensive
 insulin
self‐management
 therapy
and
to
handle
minor
gly‐ cemic
corrections
without
the
assistance
of
a
doctor.

All
participants
were
trained
to
self‐manage
their
 insulin
regardless
of
 their
educational
status
and
were
encouraged
to
explore
the
possibility
of
a
more
 flexible
lifestyle
with
respect
to
their
exercise
and
dietary
regime.

Participants
were
required
to
monitor
 their
urine
or
blood
glucose
at
least
three
to
four
times
per
day
and
make
appropriate
glycemic
correc‐ tions
using
multiple
daily
injections
of
regular
insulin
if
blood
glucose
was
not
within
target.

This
study
 demonstrated
that
flexible
intensive
insulin
self‐management
therapy,
combined
with
a
more
liberalized
 dietary
 approach,
 is
 able
 to
 achieve
 significant
 glycemic
 improvements,
 reductions
 in
 A1c,
 and
 fewer
 hospitalizations
without
 an
 increased
 risk
 of
 hypoglycemia
 for
 at
 least
 22
months
 post
 initial
 training.

 This
study
instigated
the
development
of
what
is
presently
known
as
The
Dusseldorf
Diabetes
Treatment
 and
Teaching
Programme,
which
is
the
standard
treatment
approach
for
individuals
with
type
1
diabetes
 in
Germany.

It
also
made
a
notable
global
impact
in
the
diabetes
community
and
fuelled
much
additional
 research
in
the
area
of
flexible
intensive
insulin
self‐management
and
dietary
freedom.
 The
 landmark
 United
 States‐based
 study
 entitled
 The
 Diabetes
 Control
 and
 Complications
 Trial
 (DCCT)
built
on
the
successes
of
European
studies.

The
DCCT
randomly
assigned
people
with
type
1
dia‐ betes
to
an
intensive
or
conventional
insulin
therapy
group
and
treated
them
for
a
mean
of
six
and
a
half
 years
between
1983
and
1993.

The
intensive
insulin
therapy
group
included
people
using
multiple
daily
 6
 injections
or
an
insulin
pump.

Participants
in
the
intensive
insulin
therapy
group
were
closely
monitored
 by
 study
 staff
and
were
 required
 to
attend
monthly
 follow
up
appointments
 in
addition
 to
having
 fre‐ quent
phone
contact
to
review
and
adjust
their
insulin
and
dietary
regimes.

Carbohydrate
counting
was
 one
of
 four
meal
planning
strategies
used
 in
the
DCCT
for
the
 intensive
therapy
group
(18).
 
The
DCCT
 was
the
first
study
to
demonstrate
that
flexible
intensive
insulin
self‐management
therapy
can
be
used
as
 an
effective
strategy
for
achieving
near‐normoglycemia
and
reducing
long‐term
microvascular
complica‐ tions
associated
with
diabetes
without
negatively
impacting
participants’
quality
of
life
(3).

However,
the
 combination
of
the
time‐consuming
and
costly
nature
of
the
insulin
dose
adjustment
strategy
used
in
the
 DCCT,
 together
with
a
 three‐fold
 increase
 in
 the
occurrence
of
severe
hypoglycemia,
 slowed
the
wide‐ spread
uptake
of
flexible
intensive
insulin
self‐management
methods
into
mainstream
diabetes
practice.
 Another
 randomized
 controlled
 study,
 the
 Dose
 Adjustment
 For
 Normal
 Eating
 (DAFNE)
 study,
 based
in
the
United
Kingdom,
followed
the
DCCT
and
evaluated
whether
a
course
teaching
flexible
inten‐ sive
 insulin
 self‐management
combined
with
dietary
 freedom
based
on
carbohydrate
counting
can
 im‐ prove
 both
 glycemic
 control
 and
 quality
 of
 life
 in
 type
 1
 diabetes
 (35).
 
 The
 five‐day
 course
 was
 conducted
in
an
outpatient
setting
and
was
closely
based
on
the
structured
diabetes
teaching
and
train‐ ing
model
used
by
Muhlhauser
et
al.
in
Germany
(38).

The
course
focused
on
building
participants’
sense
 of
 autonomy
 and
 confidence
 using
 adult
 self‐management
 education
 principles.
 
 Participants
 were
 taught
to
self‐adjust
their
insulin
doses
to
fit
their
lifestyle
rather
than
modify
their
lifestyle
to
accommo‐ date
their
diabetes.

Once
again,
findings
from
the
DAFNE
study
strengthened
the
growing
evidence
sup‐ porting
 improved
glycemic
 control
without
 an
 increased
 risk
of
 severe
hypoglycemia
 and
 celebrated
a
 measurably
better
quality
of
life
associated
with
a
more
liberalized
diet
and
lifestyle.
 Over
the
past
 four
decades,
an
abundance
of
studies
 from
around
the
world
have
successfully
re‐ inforced
 the
 glycemic
 and
 quality
 of
 life
 advantages
 associated
 with
 flexible
 intensive
 insulin
 self‐ management
combined
with
dietary
freedom
based
on
carbohydrate
counting
(18,35,38‐57).
 
Although
 these
programs
vary
widely
in
design,
duration
and
setting,
similar
carbohydrate
counting
nutrition
prin‐ ciples
are
present.
 1.2.5
 Nutrition
therapy
and
carbohydrate
counting
 Nutrition
 therapy
 is
widely
 recognized
 as
 being
 a
 fundamental
 component
 of
 effective
 diabetes
 treat‐ ment
and
patient
self‐management.

Research
findings
indicate
nutrition
therapy
supports
a
favourable
 1.0
to
2.0%
reduction
in
A1c
and
has
the
potential
for
further
clinical
and
metabolic
benefits
when
com‐ bined
other
aspects
of
diabetes
care
(1,15,58).

The
goals
of
nutrition
therapy
are
to
maintain
or
improve
 quality
of
 life
and
nutritional
and
physiological
health,
and
to
prevent
and
treat
acute
complications
of
 diabetes,
associated
co‐morbid
conditions
and
concomitant
disorders.

Because
each
person’s
needs
are
 individual
 and
 dynamic,
 it
 is
 recognized
 that
 nutrition
 therapy
 should
 be
 regularly
 evaluated
 and
 pro‐ 7
 moted
in
order
to
achieve
sustained
metabolic
control,
improved
lifestyle,
and
positive
behavioural
out‐ comes
(1,15,18,22‐24,59).
 The
principles
of
nutrition
therapy
for
people
with
diabetes
are
the
same
as
for
the
general
popula‐ tion
and
are
based
on
Canada’s
Food
Guide
(60).

Consistency
in
carbohydrate
intake,
spacing
and
regu‐ larity
in
meal
consumption
(1,59,61)
has
been
shown
to
improve
glycemic
control
for
some
people
and
 may
continue
to
be
the
best
option
for
them.

However,
the
CDA
guidelines
encourage
the
use
of
flexible
 intensive
insulin
self‐management
regimes
based
on
carbohydrate
intake
when
possible
(1).
 Carbohydrate
counting
is
a
meal
planning
approach
that
supports
a
more
desirable
quality
of
life
by
 permitting
a
greater
degree
of
choice
and
flexibility
compared
to
rigid
conventional
insulin
regimes
with
 fixed
carbohydrate
loads
and
established
meal
timing.

Carbohydrate
counting
focuses
on
carbohydrate
 as
 being
 the
 dominant
 macronutrient
 affecting
 postprandial
 glycemia
 and
 remains
 a
 key
 strategy
 in
 achieving
 optimal
 glycemic
 control
 for
 people
 using
 intensive
 insulin
 therapy
 (1,12‐18,20,35,38‐ 40,43,46,47,49‐57,62‐64).

Mastery
of
carbohydrate
counting
requires
the
ability
to
recognize
sources
of
 dietary
carbohydrate,
as
well
as
a
readiness
to
assess
quantities
of
these
foods,
interpret
nutrition
labels
 and
perform
simple
mathematical
calculations.

An
understanding
of
the
relationships
among
food,
phys‐ ical
activity,
carbohydrate
to
 insulin
ratios,
and
pattern
management
of
blood
glucose
 levels
 is
also
ne‐ cessary
for
optimal
glycemic
control
(7,12‐14,17).
 Carbohydrate
counting
gained
renewed
popularity
in
North
America
during
the
DCCT
study
in
which
 it
was
one
of
four
meal
planning
approaches
(18,41).

Carbohydrate
counting
was
later
reinforced
by
the
 DAFNE
 study
 (35),
which
was
 based
 on
 the
 established
 liberalized
 dietary
 approach
 used
 in
 Germany
 since
the
early
1980s
(38).
 Carbohydrate
counting
focuses
on
the
total
amount
(in
grams)
of
available
carbohydrate
as
a
means
 of
encouraging
choice
and
flexibility.

There
are
two
approaches
to
carbohydrate
counting
that
differ
in
 their
complexity.

The
more
basic
approach
consists
of
15
gram
carbohydrate
choices
where
each
food
is
 assigned
a
serving
size
of
approximately
15
grams
of
carbohydrate.

The
amount
of
insulin
to
be
used
is
 determined
 by
 the
 number
 of
 carbohydrate
 choices
 (e.g.,
 two
 vs.
 three
 carbohydrate
 choices)
 rather
 than
the
actual
food
choice
(e.g.,
a
small
apple
vs.
a
slice
of
bread
vs.
a
cup
of
milk)
(12,13,17).

Carbo‐ hydrate
rich
foods
are
separated
into
specific
categories
such
as
grains
and
starches,
fruits,
milk
and
al‐ ternatives,
and
other
choices
(sweets).
The
meal
planning
teaching
tool
developed
by
the
CDA
illustrating
 this
 technique
 is
 called
Beyond
 the
Basics:
Meal
 Planning
 for
Healthy
 Eating,
Diabetes
 Prevention
 and
 Management
(65).

In
this
resource,
protein
(i.e.,
meat
and
alternatives),
fats
as
well
as
most
vegetables
 are
not
found
to
affect
glycemic
control
and
are
not
“counted”
when
eaten
in
moderate
amounts.

Only
 corn,
 potatoes,
 parsnips,
 peas,
 rutabagas
 (turnips),
 and
 squash
 are
 considered
 to
provide
 a
 significant
 amount
of
carbohydrate
(i.e.,
at
least
15
grams
of
carbohydrate)
when
more
than
125ml
(½
cup)
is
eaten.

 Therefore,
regardless
of
whether
the
food
in
question
is
a
small
apple,
slice
of
bread
or
glass
of
milk,
the
 same
amount
of
insulin
will
be
used.
 8
 The
more
advanced
carbohydrate
counting
approach
builds
on
the
concepts
used
 in
 the
basic
ap‐ proach
but
supports
 the
adjustment
of
 insulin
doses
based
on
varying
meal/snack
carbohydrate
 loads,
 and
 is
 reliant
 on
 label
 reading,
 using
measuring
 cups
 and
 spoons,
 food
 scales,
 carbohydrate
 counters,
 educated
“guesstimating”,
etc.

Advanced
carbohydrate
counting
combined
with
flexible
intensive
insulin
 self‐management
supports
the
use
of
a
CIR
(i.e.,
the
quantity
of
carbohydrate
to
be
covered
by
1
unit
of
 insulin)
 and
 a
 CF/ISF
 (i.e.,
 a
 ratio
 used
 to
 calculate
 how
much
 1
 unit
 of
 insulin
will
 lower
 an
 elevated
 blood
glucose
value)
(6,7,12‐14,17).
 Central
to
the
advanced
carbohydrate
counting
approach
is
an
understanding
of
 label
reading
and
 appropriate
adjustments
for
fibre
and
sugar
alcohols.

The
grams
of
total
carbohydrate
on
food
labels
is
 calculated
by
 the
“subtraction
of
 the
sum
of
crude
protein,
 total
 fat,
moisture,
and
ash
 from
the
 total
 weight
 of
 the
 food”
 (20).
 
 Other
 carbohydrate
 variables
 are
 obtained
 from
 direct
 chemical
 analysis.

 Natural
as
well
as
added
sugars
are
listed
as
a
subcomponent
of
total
carbohydrate
as
chemical
analysis
 cannot
distinguish
between
the
two.
 
Assessing
the
nature
of
the
food
and
 ingredient
 list
 (which
 is
ex‐ pressed
in
descending
order
from
heaviest
to
lightest
constituent)
provides
an
indication
of
the
presence
 of
added
sugars.

The
amount
of
“sugar”
does
not
affect
the
total
amount
of
carbohydrate.

According
to
 the
CDA
Nutrition
Committee,
the
total
grams
of
fibre
is
subtracted
from
the
total
amount
of
available
 carbohydrate
(1).

Only
half
of
the
sugar
alcohols
are
to
be
subtracted
from
the
total
amount
of
available
 carbohydrate
(65).

Interestingly,
this
contrasts
with
the
American
Diabetes
Association
(ADA)
guidelines
 that
 promote
 only
 subtracting
 the
 total
 amount
 of
 fibre
 and
 half
 the
 sugar
 alcohols
 from
 the
 total
 amount
of
available
carbohydrate
when
the
amount
is
≥5
grams
per
serving
(20).
 Comprehensive
diabetes
nutrition
education
also
 involves
an
understanding
of
how
the
quality
of
 carbohydrate
in
food
defined
by
glycemic
index
(GI)
affects
post‐prandial
glycemia
(1,14,17,20,63).

The
 GI
 is
a
scale
 that
 ranks
 individual
carbohydrate
rich
 foods
by
how
much
they
raise
post‐prandial
blood
 glucose
and
insulin
demand
compared
to
a
standard
food.

The
standard
food
is
usually
50
grams
of
glu‐ cose
or
white
bread.

A
high
GI
food
would
indicate
that
the
majority
of
carbohydrate
is
quickly
absorbed
 into
the
bloodstream
creating
a
more
significant
and
rapid
rise
in
post‐prandial
blood
glucose.

A
low
GI
 food
indicates
a
slower,
partial
digestion
of
carbohydrate
resulting
in
a
comparatively
more
gradual
post‐ prandial
blood
glucose
rise
and
hence,
may
require
a
smaller
prandial
 insulin
dose.
 
Research
supports
 encouraging
people
with
 insulin
dependent
diabetes
 to
 choose
 lower
GI
 foods
 in
an
effort
 to
 improve
 glycemic
control
(66‐70).

Foods
rich
in
soluble
fibre
(i.e.,
barley,
legumes,
oats,
psyllium,
etc.)
are
exam‐ ples
of
foods
with
a
low
GI
as
they
delay
gastric
emptying.

There
are
numerous
factors,
such
as
degree
of
 food
 ripeness,
 starch
 gelatinization
 caused
 by
 cooking,
 amount
 of
 fibre,
 fructose,
 lactose
 and
 fat
 in
 a
 meal,
etc.,
that
need
to
be
considered
to
properly
understand
and
benefit
from
using
the
GI
as
a
nutri‐ tion
 tool
 to
promote
optimal
glycemia
 (14).
 
 There
has
been
much
debate
and
 research
 regarding
 the
 value
of
GI
as
a
diabetes
teaching
tool.

Carbohydrate
quantity
determined
by
carbohydrate
counting
is
 thought
 to
have
a
more
substantial
 impact
on
post‐prandial
glycemia
than
carbohydrate
quality
deter‐ mined
by
GI
(19,20,63).
 9
 Restriction
of
carbohydrate
load
at
meals
is
another
concept
used
to
help
control
post‐prandial
gly‐ cemia.

Although
food
habits
and
daily
schedules
differ
greatly
from
person
to
person,
the
general
guide‐ line
 of
 eating
 a
maximum
 of
 45–60
 grams
 of
 carbohydrate
 per
meal
 for
women
 and
 45–75
 grams
 of
 carbohydrate
 for
active
women
or
men
 is
widely
encouraged.
 
 In
addition,
while
 snacking
 is
no
 longer
 advocated
as
being
an
essential
component
of
a
person’s
diet,
keeping
the
carbohydrate
load
of
snacks
 within
15–30
grams
is
recommended
(13,14).
 1.2.6
 Self‐management
education
(SME)
and
the
diabetes
health
care
(DHC)
team
 Self‐management
education
(SME)
is
a
key
component
of
nutrition
therapy
and
plays
an
essential
role
in
 intensified
insulin
teaching
programs.

SME
focuses
on
nurturing
a
feeling
of
self‐efficacy
and
empower‐ ment
enabling
the
person
with
diabetes
to
play
a
more
participatory
and
active
role
 in
their
care
plan.

 SME
focuses
on
skills
development,
coping
strategies
and
problem
solving
to
reinforce
the
importance
of
 self‐care
and
behaviour
change.

Research
supports
SME
as
a
means
of
nurturing
a
greater
sense
of
satis‐ faction
for
the
person
regarding
their
diabetes
care,
improving
glycemic
control
and
encouraging
the
de‐ velopment
of
a
more
effective
relationship
with
their
DHC
team
(1,21,22,59).
 The
 daily
 and
 continued
 commitment
 of
 the
 person
with
 diabetes
 to
 self‐management
 practices
 combined
with
the
ongoing
support
of
an
integrated
DHC
team
that
is
multi‐
and
interdisciplinary
in
na‐ ture
 is
thought
to
support
optimal
diabetes
outcomes.
 
The
person
with
diabetes
and
his
or
her
family
 are
recognized
as
being
central
members
of
the
DHC
team
in
addition
to
the
family
physician
and/or
dia‐ betes
specialist,
and
diabetes
educators
(nurse
and
dietitian).

Psychological
support
has
also
been
found
 to
play
a
key
part
of
usual
diabetes
care
supporting
 improved
glycemic
control.
 
While
 it
 is
 recognized
 that
all
DHC
 team
members
 should
 share
a
 comprehensive
plan
of
 care,
 the
dietitian
has
been
 recog‐ nized
as
playing
the
most
effective
role
in
providing
nutrition
support
(1,15,23,24,32,41,71‐73).
 The
central
roles
of
nutrition,
SME
and
a
multi‐
and
interdisciplinary
DHC
team
have
a
synergistic
ef‐ fect
 that
 works
 to
 support
 the
 successes
 that
 have
 been
 seen
 in
 flexible
 intensive
 insulin
 self‐ management
teaching
programs
and
diabetes
care.
 1.2.7
 Insulin
pump
therapy
and
the
bolus
calculator
 An
insulin
pump
is
a
small
mechanical
device
similar
in
size
to
a
deck
of
cards
or
pager.

The
pump
con‐ tains
a
syringe‐like
reservoir
of
insulin
that
holds
up
to
200‐300
units
of
insulin,
which
will
last
a
person
 anywhere
from
one
to
six
days
depending
on
their
individual
insulin
requirements.
 
The
insulin
is
deliv‐ ered
from
the
reservoir
via
a
thin,
disposable
piece
of
plastic
tubing
that
is
attached
to
a
flexible
rubber
 cannula,
which
is
inserted
under
a
person’s
skin
with
the
help
of
a
steel
inducer
needle
that
is
then
re‐ moved.

The
cannula
is
held
in
place
with
an
adhesive
patch.

While
the
reservoir
and
tubing
can
be
used
 up
to
six
days,
the
cannula
needs
to
be
replaced
every
two
to
three
days
to
minimize
the
chance
of
infec‐ 10
 tion.

A
small
battery
in
the
pump
provides
power
to
a
computer
chip
that
controls
how
much
basal
insu‐ lin
the
pump
delivers
throughout
the
day
via
a
continuous
drip
according
to
a
pre‐programmed
schedule
 of
delivery.

Buttons
on
the
pump
allow
the
user
to
deliver
flexible
bolus
doses
of
insulin
depending
on
 the
amount
of
 carbohydrate
 they
are
eating
or
 to
 correct
 for
an
elevated
blood
glucose
 level.
 
 Insulin
 pumps
most
commonly
use
rapid
acting
insulin
to
cover
both
basal
and
bolus
needs
(6‐9,14).

The
onset
 time
of
rapid
acting
insulin
is
10
to
15
minutes,
one
to
two
hours
to
peak
and
three
to
five
hours
of
dur‐ ation.
 
An
understanding
of
the
action
profile
of
the
 insulin(s)
a
person
is
using
 is
helpful
 in
supporting
 optimal
glycemic
control.

 There
are
numerous
functional
advantages
to
using
an
insulin
pump
compared
to
other
insulin
de‐ livery
devices.
 
Most
notably,
pump
therapy
eliminates
 the
need
 for
multiple
daily
 injections
of
 insulin
 using
a
syringe
or
pen.
 
Pump
therapy
 is
also
able
to
offer
smaller
 increments
of
basal
 (0.025
units
vs.
 fixed
whole
unit
doses)
and
bolus
insulin
(0.05
units
versus
only
0.5
to
whole
units)
facilitating
more
pre‐ cise
insulin
delivery
with
less
blood
glucose
variability
(6,7,74‐76).

Pump
therapy
thereby
supports
simi‐ lar
or
enhanced
glycemic
 control
with
 less
or
comparable
 risk
of
hypoglycemia
when
compared
 to
 the
 best
of
flexible
multiple
daily
dosing
regimens,
even
since
the
advent
of
improved
long‐acting
basal
insu‐ lin
analogues
(77‐81).

Pump
users
also
claim
a
greater
degree
of
freedom
facilitating
a
better
quality
of
 life
and
greater
treatment
satisfaction
(10,11).
 Basal
 delivery
 advantages
when
using
 a
 pump
 include
 the
 ability
 to
 program
multiple
 basal
 rates
 throughout
 the
 day
 to
more
 closely
mimic
 natural
 pancreatic
 insulin
 secretion.
 
 This
 feature
 helps
 to
 minimize
the
risk
of
nocturnal
hypoglycemia
as
well
to
control
the
glucose
increment
associated
with
the
 dawn
phenomenon
(i.e.,
a
common
rise
in
blood
glucose
readings
during
the
early
morning
hours
due
to
 the
 release
of
 counter
 regulatory
hormones
 and
 a
 greater
 degree
of
 insulin
 resistance).
 
 The
use
of
 a
 temporary
basal
rate
is
another
unique
insulin
pump
feature.

A
temporary
basal
rate
accommodates
for
 fluctuating
 basal
 needs
 during
 the
 day
 due
 to
 exercise/activity,
 schedule
 changes,
 illness,
 hormonal
 changes,
etc.
versus
being
limited
to
a
set
basal
insulin
profile
on
multiple
daily
injections.

There
are
also
 notable
bolus
delivery
advantages
with
pump
therapy.
These
include
the
use
of
multiple
meal
bolus
de‐ livery
options
to
better
accommodate
meals
of
varying
macronutrient
composition,
carbohydrate
quality
 and
quantity
(6,7).
 
 In
addition,
the
presence
of
a
bolus
calculator
on
“smart
pumps”
helps
to
calculate
 bolus
insulin
doses
based
on
input
from
the
pumper
to
support
optimal
glycemic
control.

The
bolus
cal‐ culator
on
the
Medtronic
insulin
pump
is
called
the
Bolus
Wizard™.

To
use
the
Bolus
Wizard™
the
pump
 user
 is
required
to
enter
the
number
of
carbohydrate
grams
they
are
planning
to
eat
and
their
current
 blood
glucose
reading.

The
Bolus
Wizard™
calculator
then
combines
this
information
with
the
pumper’s
 individualized
target
blood
glucose
level,
CIR,
CF/ISF,
and
duration
of
insulin
action
(i.e.,
amount
of
insu‐ lin
on
board
from
the
previous
bolus)
to
make
a
bolus
suggestion.

The
pumper
then
proceeds
to
decide
 whether
or
not
they
agree
with
the
bolus
prediction
and
enters
the
bolus
amount
they
would
like
to
re‐ ceive.
 
 The
 use
 of
 “smart
 pump”
 bolus
 calculators
 (i.e.,
 the
 Bolus
Wizard™
 on
Medtronic
 pumps)
 has
 been
found
to
support
optimal
post‐prandial
control
by
reducing
the
number
of
correction
boluses
re‐ 11
 quired
to
adjust
for
hyperglycemia
and
decrease
the
amount
of
carbohydrate
required
to
treat
hypogly‐ cemia
when
compared
to
standard
bolus
techniques
(36,37).

“Smart
pump”
bolus
calculators
have
also
 been
found
to
be
easy
to
use
and
are
associated
with
a
high
degree
of
user
satisfaction
(82).

Although
it
 is
clear
“smart
pump”
bolus
calculators
can
simplify
required
mathematical
calculations,
not
all
pumpers
 choose
to
use
them.

For
those
pumpers
who
do
rely
on
their
bolus
calculator,
an
understanding
of
how
 their
bolus
calculator
works
in
order
to
avoid
hyper‐
and
hypoglycemia
remains
important
and
reinforces
 the
fundamental
value
of
SME
and
ongoing
support
from
a
DHC
team.
 1.2.8
 Satisfaction
with
nutrition
support
 There
are
currently
no
reliable
and
validated
questionnaires
that
examine
the
level
of
satisfaction
people
 with
diabetes
have
regarding
their
nutrition
support
or
sources
of
nutrition
information.

The
question‐ naire
closest
in
design
to
exploring
aspects
of
satisfaction
and
diabetes
care
were
found
in
the
diabetes
 history
survey
 (83)
designed
by
 the
Michigan
Diabetes
Research
and
Training
Centre.
 
Section
 three
of
 this
survey
focuses
on
the
person’s
perceived
level
of
satisfaction
regarding
their
general
diabetes
care
as
 well
as
their
main
sources
of
diabetes
care
(i.e.,
generalist,
specialist,
other).
 The
measurement
 tools
used
 in
 the
 literature
 to
assess
quality
of
 life
of
people
with
diabetes
are
 broad
and
diverse
in
nature.

Studies
examining
flexible
intensive
insulin
self‐management
and
quality
of
 life
often
 focus
on
 the
potentially
 greater
amount
of
dietary
 freedom
associated
with
 insulin
dose
ad‐ justment
versus
the
level
of
satisfaction
people
have
regarding
their
nutrition
support
or
sources
of
diet‐ ary
education.
 
 In
the
DAFNE
study
(35),
the
Audit
of
Diabetes‐Dependent
Quality
of
Life
questionnaire
 was
one
of
 three
questionnaires
used
 to
measure
 impact
of
diabetes
on
quality
of
 life
and
provided
a
 weighted
impact
of
diabetes
score
based
on
responses
to
the
comment
“freedom
to
eat
as
I
wish”(84).

 The
Diabetes
Treatment
and
Satisfaction
Questionnaire
(85)
and
12‐item
Well‐Being
Questionnaire
(86)
 were
also
used
to
assess
general
 treatment
satisfaction
and
wellbeing.
 
A
different
but
similarly
varied
 combination
 of
 quality
 of
 life
 measurement
 tools
 was
 used
 by
 the
 Italian
 based
 EQuality1
 Study
 Group(10).
They
included
the
Diabetes
Specific
Quality
of
Life
Scale
(87,88)
which
was
designed
to
assess
 six
main
 components
 of
 quality
 of
 life
 including
 social
 relations,
 leisure
 time
 flexibility,
 physical
 com‐ plaints,
worries
about
future,
diet
restrictions,
daily
hassles
and
fears
about
hypoglycemia.

The
Diabetes
 Treatment
Satisfaction
Questionnaire
(85)
as
well
as
the
SF‐36
Health
Survey
(89)
were
also
used
to
as‐ sess
 the
 satisfaction
of
people
with
diabetes
using
different
 treatment
 regimes
 (i.e.,
pump
 therapy
vs.
 multiple
daily
injections)
and
general
health
status.
 The
lack
of
available
resources
assessing
the
level
of
satisfaction
people
with
diabetes
have
regard‐ ing
their
nutrition
support
or
sources
of
nutrition
information
substantiates
the
development
of
such
a
 tool
to
fill
this
gap
in
the
literature.
 12
 1.3
 LIMITS
TO
CURRENT
KNOWLEDGE
 Nutrition
 therapy
 is
widely
 accepted
 as
 a
 vital
 component
 of
 diabetes
management
 and
 supports
 im‐ proved
glycemic
 control.
 
 The
pursuit
 of
 near‐normoglycemia
 in
diabetes
 treatment
 is
 associated
with
 the
postponement
and
prevention
of
diabetes‐related
complications
and
co‐morbidities.

The
principles
 of
nutrition
therapy
for
people
with
diabetes
are
similar
to
those
used
with
the
general
population
and
 are
based
on
Canada’s
Food
Guide.

For
people
using
flexible
intensive
insulin
self‐management
therapy,
 education
regarding
both
the
quantity
(i.e.,
grams)
and
quality
(i.e.,
glycemic
index)
of
carbohydrate,
are
 important
aspects
of
managing
post‐prandial
glycemia.
 
The
greater
degree
of
precision,
 flexibility
and
 complexity
associated
with
adult
insulin
pump
users’
choice
of
insulin
delivery
differentiates
this
group
of
 insulin
dependent
people
from
those
using
multiple
daily
injections.

Although
there
is
an
abundance
of
 nutrition
and
carbohydrate
counting
education
materials
available,
no
data
could
be
located
that
specifi‐ cally
address
what
adult
insulin
pump
users
know
and
do
with
respect
to
the
role
of
nutrition
and
carbo‐ hydrate
 counting
 in
 diabetes
management.
 
 In
 addition,
 little
 is
 known
about
 how
adult
 insulin
 pump
 users’
nutrition
knowledge
relates
to
the
amount
of
nutrition
support
they
receive
from
their
DHC
team,
 their
 perceived
 level
 of
 satisfaction
 with
 their
 nutrition
 support,
 diabetes
 self‐management
 problem
 solving
skills
and
glycemic
control.
 1.4
 RATIONALE
 People
with
diabetes
using
an
insulin
pump
are
a
unique
group
of
individuals
in
the
sense
that
they
are
 using
an
advanced
electronic
device
to
deliver
their
insulin
and
require
a
solid
understanding
of
the
vari‐ ous
 aspects
 of
 flexible
 intensive
 insulin
 self‐management
 and
 diabetes‐related
 problem
 solving
 skills.

 Identifying
 and
 exploring
 relevant
 aspects
 of
 nutrition
 education
 for
 this
 population
 group,
 combined
 with
a
broader
examination
of
how
nutrition
knowledge
and
carbohydrate
counting
are
related
to
pump
 users’
 level
of
 satisfaction
with
 their
nutrition
support
and
glycemic
control,
has
 the
potential
 to
mold
 and
direct
future
nutrition‐related
educational
efforts
in
a
positive
way.
 1.4.1
 Research
objectives
 The
primary
purpose
of
this
study
was
to
explore
the
nutrition
and
carbohydrate
counting
knowledge
of
 adult
insulin
pump
users
and
to
identify
potential
gaps
in
understanding
of
nutrition
concepts
that
may
 be
preventing
optimal
 glycemic
 control.
 
 In
 addition,
 potential
 correlates
of
 nutrition
 knowledge
were
 explored,
including
satisfaction
with
nutrition
support,
sources
of
nutrition
education,
and
glycemic
con‐ trol.

To
accomplish
this
a
national
advisory
group
of
DHC
experts
were
consulted
to
identify
fundamental
 nutrition
domains
relevant
to
adult
insulin
pump
users
and
flexible
intensive
insulin
management.

A
sur‐ 13
 vey
was
then
designed
exploring
the
nutrition
domains
identified.

As
this
study
was
designed
to
be
ex‐ ploratory
 in
nature,
specific
hypotheses
were
not
established.
 
Rather,
specific
objectives
were
used
to
 guide
the
study
and
data
analysis.
 Study
objectives
included:
 1.
 Characterize
pump
users’:
 a.
 Level
of
satisfaction
with
nutrition
support
 b.
 Sources
of
nutrition
education
 c.
 Nutrition
knowledge
including
carbohydrate
counting
and
label
reading
skills
 d.
 Glycemic
control
 2.
 Assess
whether
relationships
exist
among
adult
insulin
pump
users’
understanding
of
nutri‐ tion,
satisfaction
with
nutrition
support,
involvement
with
their
DHC
team
as
sources
of
nu‐ trition
education,
and
their
glycemic
control.
 14
 1.5
 REFERENCES
 (1)
Canadian
Diabetes
Association
Clinical
Practice
Guidelines
Expert
Committee.
Canadian
Diabetes
 Association
2008
clinical
practice
guidelines
for
the
prevention
and
management
of
diabetes
in
 Canada.
Can
J
Diabetes
2008;32
(Suppl
1):S1‐S201.
 (2)
Public
Health
Agency
of
Canada.
Report
from
the
National
Diabetes
Surveillance
System:
Diabetes
in
 Canada,
2009.
http://www.ndss.gc.ca.
Accessed
October
19th,
2010.
 (3)
Diabetes
Control
and
Complications
Trial
(DCCT)
Research
Group.
The
effect
of
intensive
treatment
of
 diabetes
on
the
development
and
progression
of
long‐term
complications
in
insulin‐dependent
 diabetes
mellitus.
New
Engl
J
Med
1993;329:977‐986.
 (4)
UK
Prospective
Diabetes
Study
(UKPDS)
Group.
Intensive
blood‐glucose
control
with
sulphonylureas
 or
insulin
compared
with
conventional
treatment
and
Risk
of
complications
in
patients
with
type
 2
diabetes
(UKPDS
33).
Lancet
1998;352:837‐853.
 (5)
Pickup
JC,
Keen
H,
Parsons
JA,
et
al.
Continuous
subcutaneous
insulin
infusion:
an
approach
to
 achieving
normoglycaemia.
BMJ
1978:1:204‐207.
 (6)
Scheiner
G,
Sobel
RJ,
Smith
DE,
et
al.
Successful
outcomes
with
insulin
pump
therapy.
Diabetes
Educ
 2009;35(Suppl.
2):S29‐S41.
 (7)
Walsh
J,
Roberts
R.
Pumping
insulin:
everything
you
need
for
success
on
a
smart
insulin
pump.
4th
ed.
 San
Diego:
Torrey
Pines
Press;
2006.
 (8)
Pickup
JC,
Keen
H.
Continuous
subcutaneous
insulin
infusion
at
25
years.
Diabetes
Care
 2002;25(3):593‐598.
 (9)
Bode
BW,
Tamborlane
WV,
Davidson
PC.
Insulin
pump
therapy
in
the
21st
century.
Postgrad
Med
 2002;111(5):69‐77.
 (10)
Nicolucci
A,
Maione
A,
Franciosi
M,
et
al.
Quality
of
life
and
treatment
satisfaction
in
adults
with
type
 1
diabetes:
a
comparison
between
continuous
subcutaneous
insulin
infusion
and
multiple
daily
 injections:
The
Equality
1
Study
Group.
Diabetes
Med
2008;25:213‐220.
 (11)
Hammond
P,
Liebel
A,
Grunder
S.
International
survey
of
insulin
pump
users:
impact
of
continuous
 subcutaneous
insulin
infusion
therapy
on
glucose
control
and
quality
of
life.
Prim
Care
Diabetes
 2007;1(3):143‐146.
 (12)
Gillespie
SJ,
Kulkarni
KD,
Daly
AE.
Using
carbohydrate
counting
in
diabetes
clinical
practice.
J
Am
Diet
 Assoc
1998;98(8):897‐905.
 (13)
Kulkarni
K.
Carbohydrate
counting:
a
practical
meal‐planning
option
for
people
with
diabetes.
Clin
 Diabetes
2005;23(3):120‐124.
 15
 (14)
Warshaw
HS,
Bolderman
KM.
Practical
carbohydrate
counting:
a
how‐to
teach
guide
for
health
 professionals.
2nd
ed.
Alexandria:
American
Diabetes
Association,
Inc.;
2008.
 (15)
Franz
MJ,
Boucher
JL,
Green‐Pastors
J,
Powers
MA.
Evidence‐based
nutrition
practice
guidelines
for
 diabetes
and
scope
and
standards
of
practice.
J
Am
Diet
Assoc
2008;108:S52‐S58.
 (16)
Jenkins
E.
Carbohydrate
counting:
successful
dietary
management
of
type
1
diabetes.
J
Diabetes
 Nursing
2006;10(4):150‐154.
 (17)
Pytka
E.
Nutritional
strategies
in
type
1
diabetes:
calories
are
important,
but
carbohydrates
count!
 Can
Diabetes
2009;22(2):3‐6.
 (18)
Anderson
EJ,
Delahanty
L,
Richardson
M,
et
al.
Nutrition
interventions
for
intensive
therapy
in
the
 diabetes
control
and
complications
trial.
The
Diabetes
Control
and
Complications
Trial
(DCCT).
J
 Am
Diet
Assoc
1993;93(7):768‐772.
 (19)
Franz
MJ.
Carbohydrate
and
diabetes:
is
the
source
or
the
amount
of
more
importance?
Curr
 Diabetes
Rep
2001;1:177‐186.
 (20)
Wheeler
ML,
Pi‐Sunyer
FX.
Carbohydrate
Issues:
type
and
amount.
J
Am
Diet
Assoc
2008;108:S34‐ S39.
 (21)
Franz
MJ,
Warshaw
H,
Daly
AE,
et
al.
Evolution
of
diabetes
medical
nutrition
therapy.
Postgrad
Med
J
 2003;79:30‐35.
 (22)
Clark
M.
Diabetes
self‐management
education.
A
review
of
published
studies.
Prim
Care
Diabetes
 2008;2:113‐120.
 (23)
Kulkarni
K,
Castle
G,
Gregory
R,
et
al
for
the
Diabetes
Care
and
Education
Dietetic
Practice
Group.
 Nutrition
practice
guidelines
for
type
1
diabetes
mellitus
positively
affect
dietitian
practices
and
 patient
outcomes.
J
Am
Diet
Assoc.
1998;98:62‐70.
 (24)
Delahanty
LM.
Clinical
significance
of
medical
nutrition
therapy
in
achieving
diabetes
outcomes
and
 the
importance
of
the
process.
J
Am
Diet
Assoc
1998;98(1):28‐30.
 (25)
International
Diabetes
Federation.
Diabetes
Atlas,
4th
ed.
 http://www.diabetesatlas.org/content/executive‐summary
.
Accessed
Oct.
18th,
2010.
 (26)
Health
Canada.
Diabetes
in
Canada
–
2nd
ed.,
2002.
http://www.phac‐aspc.gc.ca/publicat/dic‐ dac2/pdf/dic‐dac2_en.pdf.

Accessed
October
26th,
2010.
 (27)
Nathan
DM,
Cleary
PA,
Backlund
JY,
et
al.
Intensive
diabetes
treatment
and
cardiovascular
disease
in
 patients
with
type
1
diabetes.
New
Eng
J
Med
2005(353):2643‐2653.
 (28)
The
ADVANCE
Collaborative
Group.
Intensive
blood
glucose
control
and
vascular
outcomes
in
 patients
with
type
2
diabetes.
New
Eng
J
Med
2008;358:2560‐2572.
 (29)
The
Action
to
Control
Cardiovascular
Risk
in
Diabetes
(ACCORD)
Study
Group.
Effects
of
intensive
 glucose
lowering
in
type
2
diabetes.
New
Eng
J
Med
2008;358:2545‐2559.
 (30)
Calisti
L,
Tognetti
S.
Measure
of
glycosylated
hemoglobin.
Acta
Biomed
2005;76;Suppl.3:59‐62.
 16
 (31)
McCarter
RJ,
Hempe
JM,
Chalew
SA.
Mean
blood
glucose
and
biological
variation
have
greater
 influence
on
HbA1c
levels
than
glucose
instability:
an
analysis
of
data
from
The
Diabetes
Control
 and
Complications
Trial.
Diabetes
Care
2006;29:352‐355.
 (32)
DCCT
Research
Group.
Expanded
role
of
the
dietitian
in
the
Diabetes
Control
and
Complications
 Trial:
implications
for
clinical
practice.
J
Am
Diet
Assoc
1993;93:758‐764.
 (33)
American
Diabetes
Association.
Standards
of
medical
care
in
diabetes
–
2007.
Diabetes
Care
2007;30
 (suppl
1):S4‐S41.
 (34)
Sherr
J,
Tamborlane
WV.
Past,
present,
and
future
of
insulin
pump
therapy:
better
shot
at
diabetes
 control.
Mt
Sinai
J
Med
2008;75:352‐361.
 (35)
DAFNE
Study
Group.
Training
in
flexible,
intensive
insulin
management
to
enable
dietary
freedom
in
 people
with
type
1
diabetes:
dose
adjustment
for
normal
eating
(DAFNE)
randomised
controlled
 trial.
BMJ
2003;325:746.
 (36)
Gross
T,
Kayne
D,
King
A,
et
al.
A
bolus
calculator
is
an
effective
means
of
controlling
postprandial
 glycemia
in
patients
on
insulin
pump
therapy.
Diabetes
Tech
Therap
2003;5:365‐369.
 (37)
Zisser
H,
Robinson
L,
Bevier
W,
et
al.
Bolus
calculator:
a
review
of
four
“smart”
insulin
pumps.
 Diabetes
Tech
Therap
2008;10(6):441‐444.
 (38)
Muhlhauser
I,
Jorgens
V,
Berger
M,
et
al.
Bicentric
evaluation
of
a
teaching
and
treatment
 programme
for
type
1
(insulin
dependent)
diabetic
patients:
improvement
of
metabolic
control
 and
other
measures
of
diabetes
care
for
up
to
22
months.
Diabetologia
1983;25:470‐476.
 (39)
Muhlhauser
I,
Bruckner
I,
Berger
M,
et
al.
Evaluation
of
an
intensified
insulin
treatment
and
teaching
 programme
as
routine
management
of
type
1
(insulin
dependent)
diabetes:
The
Bucharest‐ Dusseldorf
Study.
Diabetologia
1987;30:681‐690.
 (40)
Muhlhauser
I,
Bott
U,
Overmann
H,
et
al.
Liberalized
diet
in
patients
with
type
1
diabetes.
J
Intern
 Med
1995;237(6):591‐597.
 (41)
Delahanty
LM,
Halford
BN.
The
role
of
diet
behaviors
in
achieving
improved
glycemic
control
in
 intensively
treated
patients
in
the
Diabetes
Control
and
Complications
Trial.
Diabetes
Care
 1993;16(11):1453‐1458.
 (42)
Jorgens
V,
Gruber
M,
Bott
U,
et
al.
Effective
and
safe
translation
of
intensified
insulin
therapy
to
 general
internal
medicine
departments.
Diabetologia
1993;36:99‐105.
 (43)
Plank
J,
Kohler
G,
Rakovac
I,
et
al.
Long‐term
evaluation
of
a
structured
outpatient
education
 programme
for
intensified
insulin
therapy
in
patients
with
type
1
diabetes:
a
12‐year
follow‐up.
 Diabetologia
2004;47:1370‐1375.
 (44)
Pieber
TR,
Brunner
GA,
Schnedl
WJ,
et
al.
Evaluation
of
a
structured
outpatient
group
education
 program
for
intensive
insulin
therapy.
Diabetes
Care
1995;18:625‐630.
 (45)
Muller
U,
Femerling
M,
Berger
M.
et
al.
Intensified
treatment
and
education
of
Type
1
diabetes
as
 clinical
routine.
Diabetes
Care
1999;22(Suppl.
2):B29‐33.
 17
 (46)
Lowe
J,
Linjawi
S,
Mensch
M,
et
al.
Flexible
eating
and
flexible
insulin
dosing
in
patients
with
 diabetes:
results
of
an
intensive
self‐management
course.
Diabetes
Res
Clin
Prac
2008
;80:439‐ 443.
 (47)
Sumner
J,
Dyson
P,
Allan
S.
Local
application
of
CHO
counting
and
insulin
dose
adjustment.
J
 Diabetes
Nursing
2003;7(2):59‐61.
 (48)
Kinch
A,
Ruddy
L,
Oswald
G.
Local
implementation
of
a
carbohydrate
counting
system.
J
Diabetes
 Nursing
2004;8(1):28‐30.
 (49)
Everett
J,
Jenkins
E,
Kerr
D,
Cavan
DA.
Implementation
of
an
effective
outpatient
intensive
education
 programme
for
patients
with
type
1
diabetes.
Practical
Diabetes
Int
2003;20(2):51‐55.
 (50)
Voevodin
M,
Steele
C,
Pierce
K,
Colman
P.
Eating
and
pumping:
evaluating
the
nutrition
service
of
 the
insulin
pump
clinic
at
the
Royal
Melbourne
Hospital.
Nutr
Diet
2003;60(2):122‐125.
 (51)
Oswald
G,
Kinch
A,
Ruddy
E.
Transfer
to
a
patient
centred,
carbohydrate
counting
and
insulin
 matching
programme
in
a
shortened
time
frame:
a
structured
education
programme
for
type
1
 diabetes
incorporating
intensified
conventional
therapy
and
CSII.
Practical
Diabetes
Int
 2004;21(9):334‐338.
 (52)
Samann
A,
Muhlhauser
I,
Bender
R,
et
al.
Glycaemic
control
and
severe
hypoglycemia
following
 training
in
flexible
intensive
insulin
therapy
to
enable
dietary
freedom
in
people
with
type
1
 diabetes:
a
prospective
implementation
study.
Diabetologia
2005;48:1965‐1970.
 (53)
Trento
M,
Trinetta
A,
Borgo
E,
et
al.
Carbohydrate
counting
improves
coping
ability
and
metabolic
 control
in
patients
with
type
1
diabetes
managed
by
Group
Care.
J
Endocrinol
Invest.
2010
May
3
 [Epub
ahead
of
print].
 (54)
Almazadeh
R,
Berhe
T,
Wyatt
DT.
Flexible
insulin
therapy
with
glargine
insulin
improved
glycemic
 control
and
reduced
severe
hypoglycemia
among
preschool‐aged
children
with
type
1
diabetes
 mellitus.
Pediatrics
2005;115:1320‐1324.
 (55)
Waller
H,
Eiser
C,
Knowles
J,
et
al.
Pilot
study
of
a
novel
educational
programme
for
11‐16
year
olds
 with
type
1
diabetes:
the
KICK‐OFF
course.
Arch
Dis
Child
2008;93:927‐931.
 (56)
Mehta
SN,
Quinn
N,
Volkening
LK,
et
al.
Impact
of
carbohydrate
counting
on
glycemic
control
in
 children
with
type
1
diabetes.
Diabetes
Care
2009;32(6):1014‐1016.
 (57)
Starostina
EG,
Antisferov
M,
Galstyan
GR,
et
al.
Effectiveness
and
cost‐benefit

analysis
of
intensive
 treatment
and
teaching
programmes
for
type
1
diabetes
in
Moscow.
Diabetologia
1994;37:170‐ 176.
 (58)
Pastors
JG,
Warshaw
H,
Daly
A,
et
al.
The
evidence
for
the
effectiveness
of
medical
nutrition
therapy
 in
diabetes
management.
Diabetes
Care
2002;25:608‐613.
 (59)
Vallis
TM,
Higgins‐Browser
I,
Edwards
L,
et
al.
The
role
of
diabetes
education
in
maintaining
lifestyle
 changes.
Can
J
Diabetes
2005;29:193‐202.
 (60)
Health
Canada.
Eating
Well
with
Canada’s
Food
Guide.
Ottawa,
ON:
Health
Products
and
Food
 Branch,
Office
of
Nutrition
and
Promotion;
2007.
Publication
H39‐166/1990E.
 18
 (61)
Wolever
TM,
Hamad
S,
Chiasson
JL,
et
al.
Day‐to‐day
consistency
in
amount
and
source
of
 carbohydrate
associated
with
improved
glycemic
control
in
type
1
diabetes.
J
Am
Coll
Nutr
 1999(18):242‐247.
 (62)
Rabasa‐Lhoret
R,
Garon
J,
Langelier
H,
et
al.
Effects
of
meal
carbohydrate
content
on
insulin
 requirements
in
type
1
diabetic
patients
treated
intensively
with
basal‐bolus
(ultralente‐regular)
 insulin
regimen.
Diabetes
Care
1999;22(5):667‐673.
 (63)
Kelley
D.
Sugars
and
starch
in
the
nutritional
management
of
diabetes
mellitus.
Am
J
Clin
Nutr
 2003;78(suppl):858S‐864.
 (64)
Chiesa
G,
Piscopo
MA,
Rigamonti
A,
et
al.
Insulin
therapy
and
carbohydrate
counting.
Acta
Biomed
 2005;76;Suppl.3:44‐48.
 (65)
Canadian
Diabetes
Association.
Beyond
The
Basics:
Meal
Planning
for
Healthy
Eating,
Diabetes
 Prevention
and
Management.
http://www.diabetes.ca/for‐ professionals/resources/nutrition/beyond‐basics/.

Accessed
Oct.
20th,
2010.
 (66)
Brand‐Miller
J,
Hayne
S,
Petocz
P,
et
al.
Low
glycemic
index
diets
in
the
management
of
diabetes:
a
 meta‐analysis
of
randomized
controlled
trials.
Diabetes
Care
2003;26:2261‐2267.
 (67)
Opperman
Am,
Venter
CS,
Oosthuizen
W,
et
al.
Meta‐analysis
of
the
health
effects
of
using
the
 glycaemic
index
in
meal
planning.
Br
J
Nutr
2004;92:367‐381.
 (68)
Nansel
T,
Gellar
L,
McGill
A.
Effect
of
varying
glycemic
index
meals
on
blood
glucose
assessed
with
 continuous
glucose
monitoring
in
youth
with
type
1
diabetes
on
basal‐bolus
insulin
regimens.
 Diabetes
Care
2008;31;4:695‐697.
 (69)
Giacco
R,
Pirillo
M,
Rivellese
AA,
et
al.
Long‐term
dietary
treatment
with
increased
amounts
of
fibre‐ rich
low
glycemic
index
natural
foods
improves
blood
glucose
control
and
reduces
number
of
 hypoglycemic
events
in
type
1
diabetic
patients.
Diabetes
Care
2000;23:1461‐1466.
 (70)
Rovner
AJ,
Nansel
TR,
Gellar
L.
The
effect
of
a
low‐glycemic
diet
vs.
a
standard
diet
on
blood
glucose
 levels
and
macronutrient
intake
in
children
with
type
1
diabetes.
J
Am
Diet
Assoc
 2009;109(2):303‐7.
 (71)
Wilson
C,
Acton
K,
Brown
T,
et
al.
Effects
of
clinical
nutrition
education
and
educator
discipline
on
 glycemic
control
outcomes
in
the
Indian
Health
Service.
Diabetes
Care
2003;26(9):2500‐2504.
 (72)
Willaing
I,
Ladelund
S,
Jorgensen
T,
et
al.
Nutritional
counseling
in
primary
health
care:
a
randomized
 comparison
of
an
intervention
by
general
practitioner
or
dietician.
Eur
J
Cardiovasc
Prev
Rehabil
 2004;11:513‐520.
 (73)
Pickup
JC,
Kidd
J,
Burmiston
S,
Yemane
N.
Determinants
of
glycaemic
control
in
type
1
diabetes
 during
intensified
therapy
with
multiple
daily
insulin
injections
or
continuous
subcutaneous
 insulin
infusion:
importance
of
blood
glucose
variability.
Diabetes
Metab
Res
Rev
2006;22:232‐ 237.
 (74)
Lauritzen
T,
Pramming
S,
Deckert
T,
Binder
C.
Pharmacokinetics
of
continuous
subcutaneous
insulin
 infusion.
Diabetologia
1983;24:326‐329.
 19
 (75)
Pickup
JC,
Renard
E.
Long‐acting
insulin
analogs
versus
insulin
pump
therapy
for
the
treatment
of
 type
1
and
type
2
diabetes.
Diabetes
Care
2008;31(Suppl.
2):S140‐S145.
 (76)
Fatourechi
MM,
Kudva
YC,
Murad
MH,
et
al.
Hypoglycemia
with
intensive
insulin
therapy:
A
 systematic
review
and
meta‐analyses
of
randomized
trials
of
continuous
subcutaneous
insulin
 infusion
versus
multiple
daily
injections.
J
Clin
Endocrinol
Metab
2009;94(3):729‐740.
 (78)
Pickup
JC,
Sutton
AJ.
Severe
hypoglycaemia
and
glycaemic
control
in
type
1
diabetes:
meta‐analysis
 of
multiple
daily
insulin
injections
compared
with
continuous
subcutaneous
insulin
infusion.
 Diabetic
Med
2008;25:765‐774.
 (79)
Pickup
JC,
Mattock
M,
Kerry
S.
Glycaemic
control
with
continuous
subcutaneous
insulin
infusion
 compared
with
intensive
insulin
injection
in
patients
with
type
1
diabetes:
meta‐analysis
of
 randomised
controlled
trials.
BMJ
2002;324:705‐708.
 (80)
Jeitler
K,
Horvath
K,
Berghold
A,
et
al.
Continuous
subcutaneous
insulin
infusion
versus
multiple
daily
 insulin
injections
in
patients
with
diabetes
mellitus:
systematic
review
and
meta‐analysis.
 Diabetologia
2008;51:941‐951.
 (81)
Bolli
GB,
Kerr
D,
Reena
T,
et
al.
Comparison
of
multiple
daily
insulin
injection
regimen
(basal
once‐ daily
glargine
plus
mealtime
lispro)
and
continuous
subcutaneous
insulin
infusion
(lispro)
in
type
 1
diabetes.
Diabetes
Care
2009;32(7):1170‐1176.
 (82)
Shashaj
B,
Busetto
E,
Sulli
N.
Benefits
of
a
bolus
calculator
in
pre‐
and
postprandial
glycaemic
control
 and
meal
flexibility
of
paediatric
patients
using
continuous
subcutaneous
insulin
infusion
(CSII).
 Diabetic
Med
2008;25:1036‐1042.
 (83)
Diabetes
History
(2.0).
Michigan
Diabetes
Research
and
Training
Center,
1998.
 http://www.med.umich.edu/mdrtc/profs/survey.html#dmh
.
Accessed
October
26th,
2010.
 (84)
Bradley
C,
Todd
C,
Gorton
T,
et
al.
The
development
of
an
individualized
questionnaire
measure
of
 perceived
impact
of
diabetes
on
quality
of
life:
the
ADDQoL.
Qual
Life
Res
1999;8:79‐91.
 (85)
Bradley
C.
The
diabetes
treatment
satisfaction
questionnaire:
DTSQ.
In:
Bradley
C,
ed.
Handbook
of
 psychology
and
diabetes.
Chur,
Switzerland:
Harwood
Academic
publishers,
1994:
111‐132.
 (86)
Bradley
C.
The
12‐item
well‐being
questionnaire:
origins,
current
stage
of
development,
and
 availablity.
Diabetes
Care
2000;23:875.
 (87)
Bott
U,
Muhlhauser
I,
Overmann
H,
et
al.
Validation
of
a
diabetes‐specific
quality‐of‐life
scale
for
 patients
with
type
1
diabetes.
Diabetes
Care
1998;21:757‐769.
 (88)
Bott
U,
Ebrahim
S.
Further
development
of
a
quality‐of‐life
measure
for
IDDM
patients.
Diabetologia
 1998;41:
A74
(Abstract).
 (89)
Ware
JE
Jr,
Sherbourne
CD.
The
MOS
36‐item
short‐form
health
survey
(SF‐36).
I.
Conceptual
 framework
and
item
selection.
Med
Care
1994;30:473‐483.
 20
 CHAPTER
2:
What
Adult
Insulin
Pump
Users
 Know
and
Do
–
The
Role
of
Nutrition
and
 Carbohydrate
Counting
in
Diabetes
Management
 2.1
 INTRODUCTION
 Diabetes
mellitus
 is
a
metabolic
disorder
characterized
by
hyperglycemia
resulting
from
the
body’s
 ina‐ bility
to
properly
produce
and/or
use
insulin.

The
long‐term
consequences
of
diabetes
are
often
severe
 and
life
altering.
 
Diabetes
has
been
found
to
be
the
leading
cause
of
blindness,
end‐stage
renal
failure
 and
non‐traumatic
amputation
in
Canadian
adults
and
has
lead
to
a
two‐
to
four‐fold
increase
in
cardio‐ vascular
disease
(1).
 
In
addition,
diabetes
is
associated
with
a
shortened
life
expectancy
by
as
much
as
 15
years
 for
people
with
type
1
diabetes
and
five
to
10
years
 for
people
with
type
2
diabetes
(2).
 
Ap‐ proximately
5–10%
of
 all
 cases
of
diabetes
 are
 type
1.
 
According
 to
2006‐2007
Census
data,
 approxi‐ mately
2
million
Canadians,
or
about
1
in
16
people,
have
diagnosed
diabetes
resulting
in
a
prevalence
of
 6.2%.

Projections
indicate
that
by
2012
almost
2.8
million
Canadians
will
be
living
with
diagnosed
diabe‐ tes
resulting
in
an
overall
increase
of
about
25%
from
2007
(3).
 Large‐scale
studies
 including
the
Diabetes
Clinical
Control
and
Complications
Trial
(DCCT)
(4,5)
and
 the
United
Kingdom
Prospective
Diabetes
Study
(UKPDS)
(6),
have
clearly
shown
the
importance
of
keep‐ ing
glycemic
levels
as
close
to
normal
as
possible
in
delaying
and
preventing
diabetes‐related
complica‐ tions.

The
use
of
continuous
subcutaneous
insulin
infusion,
or
an
insulin
pump,
is
widely
accepted
as
the
 gold
standard
of
 insulin
delivery
and
has
been
gaining
widespread
popularity
since
 its
 initial
use
 in
 the
 late
1970s
(7).

An
insulin
pump
mimics
the
body’s
physiological
production
of
insulin
with
greater
preci‐ sion
and
 flexibility
 than
other
 insulin
delivery
devices
 such
as
 syringes
and
pens
 (8‐11).
 
 Insulin
pumps
 have
been
found
to
reduce
blood
glucose
variability
(12,13)
and
to
improve
blood
glucose
predictability
 when
 “smart
 pump”
 bolus
 calculator
 features
 are
 used
 (14,15).
 
 In
 addition,
 pump
 therapy
 has
 been
 found
 to
 support
 similar
 or
 enhanced
 glycemic
 control
 with
 less
 or
 comparable
 risk
 of
 hypoglycemia
 (8,16‐21),
a
better
quality
of
life
and
greater
treatment
satisfaction
when
compared
with
multiple
daily
 insulin
injections
(22,23).

An
insulin
pump
uses
a
continuous
basal
or
background
amount
of
rapid
acting
 insulin
at
one
or
multiple
predetermined
rates
throughout
the
day.

The
pump
user
provides
a
meal
bolus
 21
 by
matching
the
amount
of
 insulin
to
the
amount
of
carbohydrate
eaten,
or
alternately
provides
a
cor‐ rection
bolus
to
lower
an
elevated
blood
glucose
(8‐11).

This
insulin
regime
is
referred
to
as
flexible
in‐ tensive
insulin
self‐management:
“Flexible”
because
of
the
increased
amount
of
freedom
each
individual
 has
with
 regard
 to
 their
 food
 intake
and
 lifestyle
choices,
and
“intensive
 insulin
 self‐management”
be‐ cause
of
 the
greater
amount
of
blood
glucose
 testing
and
self‐management
problem
solving
skills
 that
 are
required
for
optimal
glycemic
control.
 Nutrition
therapy
is
widely
acknowledged
as
a
fundamental
component
of
diabetes
treatment
and
 patient
self‐management.
Because
each
person’s
needs
are
individual
and
dynamic,
it
is
recognized
that
 nutrition
 therapy
should
be
regularly
evaluated
and
promoted
 in
order
 to
achieve
sustained
metabolic
 control,
improved
lifestyle,
and
positive
behavioural
outcomes
(1,24‐28).

Nutrition
therapy
delivered
by
 a
dietitian
as
part
of
an
inter‐
and
multi‐disciplinary
team
that
shares
a
comprehensive
plan
of
care
has
 been
shown
to
achieve
superior
health‐related
outcomes
(24,25,27,29‐33).

Over
the
past
30
years,
nu‐ merous
studies
have
explored
and
illustrated
the
benefits
of
teaching
 insulin
dose
adjustment
and
car‐ bohydrate
 counting
 to
 patients
 encouraging
 a
 more
 liberalized
 approach
 to
 nutrition
 and
 lifestyle
 compared
 to
conventional
 fixed‐dose
 insulin
 regimens
 (28,32,34‐53).
 
Carbohydrate
counting
 is
a
meal
 planning
 approach
 that
 focuses
 on
 carbohydrate
 as
 being
 the
 dominant
macronutrient
 affecting
 post‐ prandial
glycemia
and
remains
a
key
strategy
in
achieving
glycemic
control
for
people
using
intensive
in‐ sulin
therapy
(1,24,54‐61).
 
Mastery
of
carbohydrate
counting
 includes
understanding
the
relationships
 among
food,
physical
activity,
carbohydrate
to
insulin
ratios,
and
pattern
management
of
blood
glucose
 levels
(9,54‐57).

Though
practitioners
recognize
that
intensive
insulin
self‐management
education
(SME)
 is
the
cornerstone
of
treatment
for
people
with
diabetes,
there
is
currently
limited
evidence‐based
data
 regarding
what
current
adult
 insulin
pump
users
know
and
do
with
respect
to
the
role
of
nutrition
and
 carbohydrate
 counting
 in
 diabetes
 management.
 Furthermore,
 the
 relationship
 between
 adult
 insulin
 pump
users’
understanding
of
nutrition,
satisfaction
with
nutrition
support,
 involvement
with
their
dia‐ betes
health
 care
 (DHC)
 team
as
 sources
of
nutrition
education,
and
 their
 glycemic
 control
 is
not
 fully
 understood.
Accordingly,
we
designed
a
questionnaire
with
 the
collaboration
of
diabetes
experts
 from
 across
Canada,
and
surveyed
Canadian
adult
insulin
pump
users.

Specific
objectives
were
to:
 1. Characterize
pump
users’:
 a.
 Level
of
satisfaction
with
nutrition
support
 b.
 Sources
of
diabetes
nutrition
education
 c.
 Nutrition
knowledge
including
carbohydrate
counting
and
label
reading
skills
 d.
 Glycemic
control
 2. Assess
whether
relationships
exist
among
adult
pump
users’
understanding
of
nutrition,
satis‐ faction
with
nutrition
support,
involvement
with
their
DHC
team
as
sources
of
diabetes
nutri‐ tion
education,
and
their
glycemic
control.
 22
 2.2
 METHODS
 2.2.1
 Study
design
 This
was
a
cross‐sectional
quantitative
study
exploring
what
adult
 insulin
pump
users
know
and
do
re‐ garding
the
role
of
nutrition
and
carbohydrate
counting
in
diabetes
management.

Pump
users’
level
of
 satisfaction
with
their
nutrition
support,
involvement
with
their
DHC
team
as
sources
of
nutrition
support
 and
 their
 glycemic
 control
were
also
assessed
 to
gain
a
better
understanding
of
how
 these
aspects
of
 care
relate
to
a
person’s
understanding
of
nutrition
and
carbohydrate
counting
in
diabetes
management.
 2.2.2
 Survey
development
 In
collaboration
with
the
Canadian
Diabetes
Association
(CDA),
a
national
advisory
committee
consisting
 of
DHC
experts
 (n=11)
was
 recruited
 to
 help
 identify
 the
nutrition
domains
 relevant
 to
 diabetes
man‐ agement.

The
framework
for
the
nutrition
knowledge
aspect
of
the
survey
was
based
on
Canadian
dia‐ betes
 education
 standards
 versus
 those
 of
 other
 countries.
 
 Committee
members’
 feedback
was
 then
 incorporated
 into
 the
 design
 of
 an
 electronic
 survey
 draft,
which
 they
were
 asked
 to
 review
 and
 edit
 (n=9).

Comments
on
the
appropriateness
of
the
questions
as
well
as
the
overall
impression
of
the
survey
 and/or
other
suggestions
were
encouraged
(Appendix
1).
 The
survey
was
then
pilot‐tested
with
current
pump
users
who
were
previously
known
to
the
inves‐ tigative
team
(n=11)
and
an
insulin
pump
support
group
(n=65)
resulting
in
anonymous
feedback
(n=26).

 The
pilot
survey
included
an
additional
section
with
a
combination
of
closed
and
open‐ended
questions
 on
the
study
design,
relevance
and
completion
time
(Appendix
2).

This
feedback
was
incorporated
into
 the
final
survey
design
(Appendix
3).
 2.2.3
 Survey
description
 The
final
survey
consisted
of
five
distinct
sections
(Appendix
4).

Section
I
gathered
data
on
participants’
 level
of
 satisfaction
with
 their
nutrition
 support,
 sources
of
 diabetes‐related
nutrition
 information
and
 involvement
with
their
DHC
team.

There
are
currently
no
reliable
and
validated
questionnaires
looking
 specifically
at
the
level
of
satisfaction
people
with
diabetes
have
with
their
nutrition
support.

Although
 this
was
not
a
primary
objective
in
the
study,
it
was
felt
that
it
would
be
an
interesting
aspect
of
diabetes
 management
to
consider
in
an
attempt
to
gain
a
broader
scope
of
the
numerous
factors
that
affect
adult
 insulin
pump
users’
nutrition
knowledge
and
glycemic
control.

The
satisfaction‐related
questions
used
in
 the
 survey
 were
 adapted
 from
 similar
 questions
 used
 in
 the
 Diabetes
 History
 questionnaire,
 Section
 three
–
Satisfaction
developed
by
 the
Michigan
Diabetes
Training
and
Research
Centre
 (62).
 
Section
 II
 23
 focused
on
areas
of
nutrition
knowledge
 identified
by
 the
advisory
committee
and
 included
carbohyd‐ rate‐rich
foods,
glycemic
 index
(GI),
carbohydrate
counting,
 label
reading,
understanding
and
use
of
 in‐ tensive
 insulin
 self‐management
 principles,
 and
 use
 of
 the
 bolus
 calculator
 (i.e.,
 Bolus
Wizard™).
 
 The
 Bolus
Wizard™
 calculates
 and
 suggests
 bolus
 doses
 of
 insulin
 for
meals
 and
blood
 glucose
 corrections
 using
a
pump
user’s
current
blood
glucose
reading,
personal
carbohydrate
to
insulin
(CIR)
ratio,
correc‐ tion
factor
(CF)
or
 insulin
sensitivity
factor
(ISF),
amount
of
 insulin
on
board,
and
blood
glucose
targets
 (14,15).

Several
basic
nutrition
and
label
reading
questions
that
were
used
in
the
carbohydrate
counting
 assessment
 test
 from
 the
 Sensor‐Augmented
 Pump
 Therapy
 for
 A1c
 Reduction
 3
 study
 (63)
 were
 in‐ corporated
into
the
design
of
the
final
survey
due
to
a
lack
of
reliable
and
validated
questionnaires
that
 are
relevant
to
insulin
pump
users
or
people
with
diabetes
practicing
insulin‐dose
adjustment.

Section
III
 assessed
blood
glucose
control
and
treatment
for
hypoglycemia.
Section
IV
collected
demographic
data
 and
self‐reported
height
and
weight,
which
were
used
to
calculate
Body
Mass
Index
(BMI,
kg/m2).

Lastly,
 section
V
explored
participants’
interest
in
receiving
additional
education/information
on
selected
topics,
 and
also
contained
open‐ended
comment
boxes
where
respondents
could
express
their
thoughts
regard‐ ing
 the
 role
of
nutrition
and
carbohydrate
 counting,
 and
 the
 survey
 in
general.
 The
majority
of
 survey
 questions
were
multiple
choice
with
occasional
opportunities
to
add
comments
if
needed.

Responses
to
 all
questions
were
optional.
 2.2.4
 Participant
selection
 Subject
 inclusion
 criteria
 included
 Canadian
 adults
 (>18
 years
 of
 age)
 using
 a
Medtronic
 insulin
 pump
 who
agreed
(at
an
earlier
date)
to
be
contacted
in
English
via
email
from
Medtronic
of
Canada
Ltd.

Ex‐ clusion
criteria
included
those
whose
preferred
language
of
contact
was
not
English.

Informed
consent
 was
provided
by
all
potential
participants
prior
 to
commencing
 the
survey
 (Appendix
5).
 
The
research
 protocol
was
approved
by
the
Human
Research
Ethics
Board
of
The
University
of
British
Columbia.
 2.2.5
 Survey
administration
 Medtronic
distributed
a
 total
of
 three
email
 invitations
 to
all
of
 its
pump
users
who
met
 the
 inclusion
 criteria
for
the
study
(Appendix
6).

The
emails
contained
a
direct
link
for
pump
users
to
access
the
ques‐ tionnaire
using
Survey
Monkey®
technology.

In
an
attempt
to
encourage
survey
participation,
Medtronic
 distributed
 the
 survey
on
 three
occasions
approximately
one
week
apart
over
a
period
of
one
month.

 The
first
email
invitation
was
sent
out
on
July
9,
2008
(n=891)
and
the
survey
was
closed
on
August
11,
 2008.

As
an
added
incentive
all
participants
who
received
the
emails
were
entered
into
a
draw
with
an
 opportunity
to
win
one
of
three
$100
gift
certificate
to
Medtronic’s
on‐line
store
(chances
1/300).
 The
link
to
the
study
information
and
consent
letter
was
stored
on
a
server
at
The
University
of
Brit‐ ish
Columbia
 (UBC).
 
Access
 to
 the
survey
 results
was
available
only
 through
the
researcher’s
personal
 24
 Survey
Monkey®
account
and
all
potential
Medtronic
subjects
remained
completely
anonymous
to
UBC
 researchers.
 2.2.6
 Statistical
analysis
 Data
assessment
included
a
combination
of
descriptive
statistics,
bi‐variate
Pearson
correlation
analysis
 and
group
comparisons
of
means
by
t
test
or
Mann‐Whitney
U
test,
as
appropriate.

The
Mann‐Whitney
 U
 test
was
used
as
a
non‐parametric
equivalent
of
 the
 independent
 samples
 t
 test
when
 the
Levene’s
 test
 for
 equality
 of
 variances
 (test
 statistic
 F)
was
 significant.
 
 In
 several
 cases,
 ordinal
 variables
were
 used
as
continuous
variables
for
the
purpose
of
analyses
[i.e.,
satisfaction
(table
19),
frequency
of
con‐ tact
with
DEC
(table
24),
frequency
of
carbohydrate
counting
(table
26),
frequency
of
label
reading
(table
 28)].

All
data
were
inspected
for
outliers
and
extreme
scores
and
none
were
found.

Statistical
analyses
 were
completed
using
SPSS
version
17.0,
with
p<0.05
considered
statistically
significant.
 2.2.7
 Scale
construction
 A
nutrition‐related
DHC
team
member
scale
score
was
calculated
 to
 reflect
 the
number
of
health
care
 practitioners
pump
users
refer
to
for
their
nutrition
support
regarding
their
diabetes
management.
 
All
 health
 care
 practitioners
 were
 assessed
 as
 discrete
 variables
 and
 participants
 had
 an
 opportunity
 to
 check
all
health
care
practitioners
that
applied.

Participants
received
a
score
of
“1”
for
each
health
care
 practitioner
 they
 selected.
 
 Otherwise
 they
 received
 a
 score
 of
 “0”.
 
 The
 health
 care
 practitioners
 in‐ cluded
 medical
 generalist,
 medical
 specialist,
 nurse,
 dietitian
 and
 Diabetes
 Education
 Centre
 (DEC).
 Scores
on
the
scale
can
range
from
0
to
5
(Appendix
7.2.1).

In
addition,
the
response
“I
educate
myself”
 was
evaluated
as
an
independent
variable.
 A
nutrition
knowledge
scale
score
was
calculated
to
explore
participants’
understanding
of
 funda‐ mental
nutrition
and
label
reading
principles
involved
in
diabetes
management.

Appropriate
treatment
 of
 low
blood
glucose
was
also
included
in
this
scale.
 
Each
question
was
recoded
based
on
a
correct
or
 incorrect
answer.
 
Participants
received
a
score
of
“1”
when
they
answered
the
question
correctly.
 
All
 other
answers
 including
“I
do
not
know”
were
given
a
score
of
“0”.
 
 If
a
participant
skipped
a
question
 the
assumption
was
made
that
they
did
not
know
the
answer
and
they
received
a
score
of
“0”.

For
the
 label
 reading
questions,
participants
were
asked
to
 refer
 to
 two
examples
of
 labels
and
determine
the
 appropriate
 portion
 size
 and
 available
 carbohydrate
 with
 the
 presence
 of
 fibre
 and
 sugar
 alcohols.

 Scores
on
the
knowledge
scale
can
range
from
0
to
13
(Appendix
7.2.2).
 A
 glycemic
outcome
 score
was
 calculated
 to
 assess
participants’
 diabetes
management
outcomes
 based
on
their
glycemic
control.

The
score
was
developed
by
asking
participants
their
most
recent
A1c
 test
result
and
recoding
their
answers
based
on
the
most
recent
CDA
Clinical
Practice
Guidelines
(1).

Par‐ ticipants
with
an
optimal
A1c
test
result
of
≤7%
received
a
score
of
“1”
and
those
with
test
results

>7%
 25
 received
a
score
of
“0”.

If
a
participant
“did
not
know”
their
most
recent
A1c
test
result
or
skipped
the
 question
(i.e.
“missing”),
they
were
not
given
a
glycemic
score
and
were
not
included
in
any
analysis
re‐ lated
to
glycemic
control
(Appendix
7.2.3).
 2.3
 RESULTS
 2.3.1
 Overall
subject
characteristics
 A
total
of
891
adult
Medtronic
insulin
pump
users
were
initially
contacted
by
Medtronic
of
Canada
Ltd.
 via
 email.
 
 Thirty‐two
emails
were
 returned
as
 invalid
 addresses,
 four
pump
users
 stated
 they
did
not
 meet
the
eligibility
criteria,
and
an
additional
31
survey
respondents
were
excluded
from
the
data
analy‐ sis
due
to
insufficient
demographic
and/or
nutrition
knowledge
data.

The
response
rate
(i.e.,
usable
re‐ sponses
out
of
those
who
received
and
completed
the
survey)
from
859
Medtronic
pump
users
was
297
 (34.6%).

Unless
otherwise
indicated,
n=297.

Refer
to
Figure
1.

Any
exclusion
of
missing
data
was
spe‐ cifically
noted.

For
raw
data
on
responses
to
all
survey
items,
see
Appendix
7.
 Table
1
presents
demographic
and
anthropometric
characteristics
of
adult
insulin
pump
users.
 
On
 average,
respondents
were
middle‐aged,
well‐educated
and
moderately
overweight.

Almost
all
had
type
 1
 diabetes,
 but
 length
 of
 time
 using
 an
 insulin
 pump
 varied
 widely.
 Respondents
 were
 from
 across
 Canada,
with
the
largest
representation
from
Ontario
(43.8%).

Overall,
there
were
no
significant
differ‐ ences
between
men
and
women,
although
the
majority
of
respondents
were
women
(65%).
 2.3.2
 Level
of
satisfaction
 Participants
(n=290)
responded
to
the
statement
“I
am
very
satisfied
with
the
nutrition
support
I
receive”
 using
a
five‐point
Likert‐type
scale
where
1
=
strongly
agree
and
5
=
strongly
disagree.

The
mean
score
 was
3.7±1.0.
 2.3.3
 Sources
of
diabetes
education
 The
number
of
DHC
professionals
who
provide
insulin
pump
users
with
nutrition
support
for
their
diabe‐ tes
management
ranged
from
0
to
5.
The
mean
DHC
team
member
score
was
1.7±1.3.
 
Dietitians
were
 respondents
 most
 frequently
 reported
 source
 of
 nutrition
 information
 (50.2%)
 in
 addition
 to
 DEC
 (50.2%),
followed
by
specialists
(30.3%),
nurses
(19.9%)
and
general
practitioners
(17.8%).
 
A
 large
pro‐ portion
of
 respondents
 (62.0%)
 indicated
 that
 they
 educate
 themselves.
 
 The
majority
 of
 respondents
 26
 (59.5%)
 indicated
they
had
visited
a
DEC
 in
the
previous
12
months,
and
an
additional
16.3%
indicated
 they
had
visited
a
DEC
in
the
past
one
to
two
years
(n=289).
 More
than
half
of
respondents
(58.5%)
indicated
they
had
seen
a
dietitian
to
learn
about
carbohyd‐ rate
counting
at
least
three
times,
and
an
additional
20.2%
indicated
they
had
been
taught
carbohydrate
 counting
at
least
twice
(n=282).
 2.3.4
 Nutrition
knowledge
 The
 overall
mean
 nutrition
 scale
 score
 for
 respondents
was
 70.8±16.9%
 (or
 9.2±2.2
 out
 of
 a
 possible
 score
of
13).
 
Almost
all
participants
 (89.9%)
 identified
carbohydrate
as
 the
macronutrient
 that
 is
 fully
 converted
to
sugar
two
hours
after
eating,
if
eaten
on
its
own.

When
asked
about
the
carbohydrate
con‐ tent
of
the
different
food
groups,
the
majority
of
respondents
correctly
 indicated
that
fats
(72.4%)
and
 protein
(88.9%)
do
not
contain
carbohydrates.

Although
all
participants
agreed
that
starchy
vegetables
 (potatoes,
peas,
 corn,
winter
 squash,
beans)
 contain
 carbohydrates,
37.4%
of
 respondents
 falsely
 indi‐ cated
that
vegetables
(broccoli,
tomatoes,
green
beans
and
cauliflower)
do
not
have
carbohydrates.

Ad‐ ditionally,
most
respondents
(83.2%)
correctly
indicated
that
the
addition
of
fats,
protein
and
fibre
slows
 down
the
digestion
of
carbohydrate
when
included
in
the
same
meal.

When
questioned
about
glycemic
 index,
over
three‐quarters
of
respondents
(76.4%)
stated
they
were
familiar
with
the
concept.

However,
 of
 those
 respondents,
 only
 approximately
 two‐thirds
 (70.5%)
 correctly
 chose
 the
 food
 item
 with
 the
 highest
 glycemic
 index
 from
 the
 food
 list
provided.
 
 The
majority
of
 respondents
 (89.9%)
 indicated
an
 appropriate
answer
when
questioned
about
how
they
usually
treat
a
low
blood
glucose.
 Responses
to
the
question
“how
often
do
you
use
the
label
to
count
the
number
of
carbohydrates
in
 your
meal/snack
versus
estimating?”
ranged
from
1
to
5
using
a
Likert‐type
scale
with
1
=
almost
never
 and
5
=
almost
always,
resulting
in
a
mean
score
of
4.3±0.9
(n=295).

The
majority
of
respondents
(84.4%)
 correctly
indicated
that
when
reading
food
labels,
the
gram
count
for
“carbohydrate”
is
more
important
 than
the
gram
count
for
“sugar”
(n=294).

Similarly,
99.0%
of
respondents
correctly
indicated
that
foods
 with
the
label
claim
“no
added
sugar”
will
NOT
raise
blood
glucose
at
all
was
false.

When
label
reading
 skills
were
evaluated,
98%
of
respondents
accurately
identified
the
correct
serving
size
and
93.9%
of
re‐ spondents
properly
adjusted
 the
available
 carbohydrate
 for
a
half
 serving.
 
However,
 in
 the
 two
cases
 presented,
only
59.1%
(n=296)
and
59.6%
of
people
properly
 identified
the
amount
of
available
carbo‐ hydrate
by
subtracting
all
of
the
fibre
from
the
total
amount
of
carbohydrate.

Furthermore,
only
6.4%
of
 respondents
correctly
subtracted
half
of
the
sugar
alcohols
and
the
fibre
to
identify
the
total
amount
of
 available
carbohydrate
(n=295).
 In
response
to
the
question
“how
do
you
decide
how
much
 insulin
to
give
yourself
when
eating
a
 meal
or
a
snack”,
67.3%
of
respondents
stated
they
use
the
Bolus
Wizard™
calculator.

A
fifth
(20.2%)
of
 respondents
 stated
 they
 calculate
 their
own
 insulin
dose
using
 their
personal
CIR
and
CF/ISF,
 and
 less
 than
a
tenth
(7.1%)
indicated
they
use
a
sliding
scale
based
on
their
pre‐meal/snack
blood
glucose
levels.
 27
 When
 respondents
 were
 asked
 about
 their
 understanding
 of
 flexible
 intensive
 insulin
 self‐ management
principles,
64.6%
indicated
they
had
a
range
of
carbohydrates
they
tried
to
stay
within
at
 meals
 and
 snacks.
 
 The
mean
 upper
 range
 of
 carbohydrates
 females
 indicated
 they
 eat
 at
meals
was
 59.8±24.0
 grams
 (n=117)
 and
25.8±12.2
 grams
at
 snacks
 (n=112).
 
 For
men,
 the
mean
upper
 range
of
 carbohydrates
they
eat
at
meals
was
86.6±26.6
grams
(n=64)
and
34.8±14.3
grams
at
snacks
(n=60).

The
 majority
of
respondents
(86.2%)
indicated
they
knew
their
CIR
and
CF/ISF
(69.9%)
for
their
first
meal
of
 the
day
 (n=296).
 
The
 females’
mean
CIR
was
11.1±4.5
grams
(n=160)
vs.
9.6±3.6
grams
(n=95)
 for
 the
 men.

For
the
CF/ISF,
the
females
indicated
using
2.6±1.4
mmol/L
(n=130)
vs.
2.2±1.6
mmol/L
(n=77)
for
 the
men.
 
 In
addition,
82.5%
of
respondents
correctly
 indicated
they
would
reduce
their
basal
 insulin
if
 their
blood
glucose
dropped
overnight
or
if
they
skipped
a
meal,
 illustrating
an
understanding
of
inten‐ sive
insulin
therapy
and
basal/bolus
insulin
adjustment.
 2.3.5
 Glycemic
outcome
 Of
the
297
respondents,
64%
indicated
having
an
A1c
test
within
the
last
three
months,
and
an
additional
 26.9%
 of
 respondents
 indicated
 having
 it
 within
 the
 past
 six
 months.
 
 The
 majority
 of
 respondents
 (84.8%)
indicated
that
they
knew
the
result
of
their
most
recent
A1c
test.
The
mean
A1c
test
result
was
 7.2±1.0%
and
ranged
from
5.1
to
11.1%.

Of
the
respondents
who
knew
their
last
A1c
test
(n=252),
47.6%
 received
an
optimal
glycemic
outcome
score
 indicating
 their
 latest
A1c
 test
 result
was
≤7.0%.
Approxi‐ mately
 three‐quarters
of
 respondents
 (76.3%)
denied
experiencing
any
 severe
 low
blood
glucose
 reac‐ tions
 (i.e.,
 resulting
 in
 passing
 out
 or
 needing
 someone
 else’s
 help)
 in
 the
 last
 six
 months
 (n=296).

 Although
nearly
a
fifth
of
respondents
(19.6%)
reported
having
three
or
fewer
severe
low
blood
glucose
 reactions
over
the
past
six
months,
only
4.1%
of
respondents
experienced
having
four
or
more
(n=296).

 Overall,
23.7%
of
respondents
experienced
having
one
or
more
severe
hypoglycemic
reactions
(n=296).
 2.3.6
 Relationships
 Table
2
presents
data
from
a
pair‐wise
bi‐variate
correlation
matrix
used
to
identify
possible
relationships
 between
respondents’
degree
of
satisfaction
with
their
nutrition
support,
number
of
DHC
team
members
 who
provide
nutrition
 support,
 frequency
of
 contact
with
 a
DEC,
 nutrition
 knowledge
 scale
 score,
 fre‐ quency
of
label
reading,
frequency
of
being
taught
carbohydrate
counting
and
glycemic
control
using
the
 absolute
value
of
respondents’
last
self‐reported
A1c
test
result.
 Satisfaction
with
nutrition
support
was
found
to
be
positively
correlated
with
number
of
DHC
team
 members,
 frequency
of
 contact
with
 a
DEC,
 frequency
of
 label
 reading
 and
 frequency
of
 being
 taught
 carbohydrate
counting.
 28
 The
number
of
DHC
team
members
who
provide
nutrition
support
was
found
to
be
positively
corre‐ lated
with
frequency
of
visits
to
a
DEC,
frequency
of
label
reading
and
frequency
of
being
taught
carbo‐ hydrate
counting.
 Visits
 to
 a
 DEC
was
 positively
 correlated
with
 frequency
 of
 label
 reading
 and
 frequency
 of
 being
 taught
carbohydrate
counting.
 A
small
positive
correlation
was
found
between
nutrition
knowledge
and
frequency
of
label
reading.

 In
addition,
a
small
negative
correlation
existed
between
nutrition
knowledge
and
glycemic
control
indi‐ cating
that
those
with
higher
knowledge
scores
had
lower,
more
desirable
A1c
test
values.
 Respondents
who
indicated
they
rely
on
the
Bolus
Wizard™
calculator
to
determine
how
much
insu‐ lin
to
give
when
eating
a
meal/snack
were
compared
to
respondents
who
do
not
use
the
Bolus
Wizard™
 (Table
3).

Respondents
who
used
the
Bolus
Wizard™
had
significantly
higher
nutrition
knowledge
scale
 scores
and
used
labels
to
count
the
number
of
carbohydrates
in
their
meals/snacks
more
frequently.

No
 significant
differences
were
found
for
satisfaction,
number
of
DHC
team
members
who
provide
nutrition
 support,
 frequency
of
DEC
visits,
 frequency
of
being
taught
carbohydrate
counting,
or
glycemic
control
 based
on
respondents’
last
A1c
test.

Similarly,
no
significant
differences
were
seen
between
respondents
 who
indicated
they
use
the
Bolus
Wizard™
calculator
when
compared
to
those
who
do
not,
and
occur‐ rences
of
severe
hypoglycemia
(x2=0.055,
p=0.814).
 Respondents
who
indicated
they
had
not
experienced
any
severe
low
blood
glucose
reactions
in
the
 past
six
months
were
compared
to
respondents
who
had
at
 least
one
 (Table
4).
 
Respondents
without
 any
occurrences
of
 severe
hypoglycemia
had
significantly
higher
nutrition
knowledge
scale
 scores.
 
No
 significant
differences
were
found
for
satisfaction,
number
of
DHC
team
members
who
provide
nutrition
 support,
 frequency
 of
 DEC
 visits,
 frequency
 of
 label
 reading,
 frequency
 of
 being
 taught
 carbohydrate
 counting,
or
glycemic
control
based
on
respondents’
last
A1c
test.
 Respondents
 who
 classified
 themselves
 as
 being
 self‐educators
 were
 compared
 to
 non‐self‐ educators
 (Table
 5).
 
 Self‐educators
 scored
 significantly
 higher
 on
 the
 nutrition
 knowledge
 scale,
 and
 non‐self‐educators
 visited
a
DEC
more
 frequently
and
were
 taught
 carbohydrate
 counting
more
often.
 No
significant
differences
were
found
for
satisfaction,
number
of
DHC
team
members
who
provide
nutri‐ tion
support,
frequency
of
label
reading,
or
glycemic
control
based
on
respondents’
last
A1c
test.

Use
of
 the
 Bolus
Wizard™
 calculator
 (x2=0.078,
 p=0.780)
 and
 occurrences
 of
 severe
 hypoglycemia
 (x2=0.076,
 p=0.782)
were
also
not
significantly
different
between
self‐educators
and
non‐self‐educators.
 Respondents
were
divided
into
dichotomous
groups
based
on
an
approximate
50:50
group
split
for
 number
of
DHC
team
members
who
provide
nutrition
support
(0–1
vs.
≥2),
last
DEC
visit
(≤1
year
vs.
>1
 year),
and
nutrition
knowledge
(high
vs.
low).

No
differences
in
nutrition
knowledge
or
glycemic
control
 were
observed
between
the
two
DHC
team
member
groups,
or
between
the
two
DEC
groups
(Table
6).
 Respondents
 with
 a
 higher
 nutrition
 knowledge
 score
 (n=122)
 had
 better
 glycemic
 control
 com‐ pared
to
respondents
(n=130)
with
lower
scores
(7.0±0.9%
vs
7.3±1.0%
A1c;
t=‐2.341,
p=0.020).
 29
 2.3.7
 Topics
of
future
interest
and
comments
 When
 questioned
 about
 potential
 topics
 of
 further
 interest
 related
 to
 pump
 use,
 a
 large
 number
 of
 adults
(63.0%)
expressed
a
desire
to
 learn
more
about
when
to
use
various
bolus
delivery
options
(i.e.,
 normal,
 square
 wave,
 dual
 wave)
 based
 on
 different
 meal
 choices.
 
 Appropriate
 insulin
 adjustments
 when
 eating
 out
 (e.g.
 restaurants,
 vacation,
 other
 people’s
 homes)
 (54.9%)
 and
 exercising
 (55.7%),
 as
 well
as
nutrition
for
weight
management
(49.8%)
were
other
popular
topics
of
 interest.
To
a
 lesser
ex‐ tent,
participants
wanted
additional
information
on
how
to
make
appropriate
insulin
adjustments
based
 on
food
choices
and
carbohydrate
counting
(33.7%)
as
well
as
blood
glucose
values
(26.6%),
and
general
 guidelines
for
healthy
eating
(29.3%).
 Ninety‐seven
pump
users
 (32.7%)
 responded
 to
an
open‐ended
 item
asking
 for
 comments
on
 the
 role
of
nutrition
or
carbohydrate
counting
 in
diabetes
management.
 
The
most
frequent
comment
was
 that
carbohydrate
counting
plays
a
critical
role
in
their
diabetes
management
(48.5%).
 
Another
shared
 comment
(18.6%)
was
related
to
the
importance
of
proper
nutrition
and
sensible
eating.

Additionally,
a
 number
of
adults
 (13.4%)
expressed
appreciation
of
 their
pump
as
a
preferred
 form
of
 insulin
delivery
 and
commented
on
the
importance
of
support
from
their
diabetes
health
care
team
(6%).
 2.4
 DISCUSSION
 This
survey
of
Canadian
adult
insulin
pump
users
revealed
the
role
of
nutrition
and
carbohydrate
count‐ ing
 in
diabetes
management
and
explored
potential
 relationships
between
 respondents’
 level
of
nutri‐ tion
knowledge,
sources
of
nutrition
education,
satisfaction
with
nutrition
support,
and
glycemic
control.
 Study
respondents
were
found
to
be
of
similar
age
to
volunteers
in
the
DAFNE
study
(47)
and
older
 than
participants
in
the
intensive
arm
of
the
DCCT
(4).

In
addition,
this
study’s
participants
were
heavier
 than
those
 in
both
above‐mentioned
studies,
which
were
conducted
 in
the
1980s
and
early
1990s.
 
Al‐ though
those
with
type
1
diabetes
are
often
characterized
as
being
of
normal
weight,
the
mean
BMI
for
 both
women
and
men
was
above
25
kg/m2,
the
World
Health
Organization
cut‐point
for
overweight
(64).

 Interestingly,
 these
 findings
 are
 consistent
 with
 current
 data
 from
 the
 2007–2009
 Canadian
 Health
 Measures
Survey
which
found
the
mean
BMI
of
Canadian
adults
aged
20
to
39
years
to
be
26.3
kg/m2
and
 27.7
kg/m2
for
adults
aged
40
to
59
years
(65).
 
These
findings
 indicate
that
study
participants
had
the
 same
BMI
as
 their
non‐diabetic
peers.
 
The
 increasing
prevalence
of
overweight
and
obese
adults
 is
of
 particular
importance
due
to
the
many
associated
negative
health
risks
and
may
illustrate
a
need
to
ad‐ dress
growing
 rates
of
overweight
and
obesity
 in
not
 just
 the
general
population
but
also
people
with
 type
 1
 diabetes.
 
 Fittingly,
 half
 of
 survey
 respondents
 indicated
 they
would
 be
 interested
 in
 receiving
 more
 information
 about
 nutrition
 for
weight
management
 demonstrating
 the
 relevance
 and
 need
 for
 increased
support
and
resources
in
this
area.
 30
 Approximately
half
the
sample
of
adult
pump
users
relied
upon
two
or
more
DHC
team
members
to
 provide
them
with
nutrition
education.

Although
dietitians
in
particular
were
most
frequently
reported
 as
 being
 the
DHC
professional
 to
 provide
nutrition
 support,
 other
DHC
 resources
 including
DECs
were
 clearly
important.

This
finding
is
in
alignment
with
current
diabetes
practice
guidelines
where
the
diet‐ itian
is
recognized
as
playing
a
central
role
as
part
of
the
DHC
team
and
an
expert
in
providing
nutrition
 therapy
(24,25,27,29‐33).

Pump
users’
involvement
with
dietitians
is
further
emphasized
by
the
numer‐ ous
 times
adults
were
taught
carbohydrate
counting
and
the
 large
number
of
 times
 respondents
com‐ mented
on
the
vital
role
of
carbohydrate
counting
in
diabetes
management.

The
regular
reinforcement
 and
 evaluation
 of
 carbohydrate
 counting
 has
 been
 shown
 to
 support
 desired
 education
 practice
 out‐ comes
(1,8,9,24‐28,54‐57,59).
 Respondents
demonstrated
a
good
understanding
of
fundamental
nutrition
principles
and
appropri‐ ate
treatment
of
hypoglycemia.
 Interestingly,
over
a
third
of
respondents
did
not
 identify
 lower
carbo‐ hydrate
vegetables
(broccoli,
tomatoes,
green
beans
and
cauliflower)
as
having
carbohydrate.

A
possible
 explanation
for
this
may
be
due
to
a
“carry
over”
effect
of
a
basic
nutrition
message
used
in
novice
car‐ bohydrate
counting
classes
for
individuals
with
type
2
diabetes
or
using
fixed
doses
of
insulin
which
indi‐ cate
that
most
vegetables
contain
insignificant
amounts
of
carbohydrate
and
should
not
be
counted
(66).

 Depending
 on
 the
 portion
 of
 lower
 carbohydrate
 vegetables
 consumed
 at
 one
 time,
 not
 bolusing
 for
 them
may
prove
to
be
of
significance
and
could
be
linked
to
suboptimal
post‐prandial
blood
glucose
con‐ trol.
 Glycemic
 index
 was
 another
 nutrition
 education
 concept
 that
 participants
 did
 not
 fully
 grasp
 (57,60,61,67).
Participants’
 inability
to
 implement
their
perceived
understanding
of
glycemic
 index
may
 be
due
to
a
lack
of
opportunity
to
test
and
challenge
their
knowledge
in
the
marketplace.

For
example,
if
 the
glycemic
index
of
different
foods
was
clearly
visible
on
food
labels
(possibly
alongside
the
macronut‐ rients),
it
may
help
to
encourage
a
more
comprehensive
understanding
of
the
nutrition
principle.
 The
 importance
 of
 nutrition
 information
 on
 food
 labels
 is
 clearly
 evident
 by
 the
 majority
 of
 re‐ spondents
who
 indicated
 they
 relied
on
 label
 reading
“most”
or
 “almost
all”
of
 the
 time
 to
determine
 their
 insulin
boluses.
 
 Although
over
half
 of
 respondents
 correctly
 subtracted
 all
 of
 the
 fibre
 from
 the
 total
amount
of
carbohydrate,
only
slightly
more
than
five
percent
of
respondents
knew
to
subtract
half
 of
the
sugar
alcohols
to
obtain
the
total
amount
of
available
carbohydrate
in
the
labels
presented,
indi‐ cating
that
sugar
alcohols
are
another
apparent
gap
in
nutrition
knowledge
(54,55,60).
 
Although
foods
 containing
sugar
alcohols
are
not
promoted
by
the
Canadian
Diabetes
Association,
they
are
recognized
as
 being
a
viable
option
for
people
with
diabetes
(1,66).

The
potentially
small
percentage
of
foods
that
re‐ spondents
are
eating
with
sugar
alcohols
in
addition
to
the
emphasis
on
following
the
same
healthy
eat‐ ing
 principles
 as
 the
 general
 population
 based
 on
 Eating
Well
with
 Canada’s
 Food
Guide
may
 help
 to
 explain
respondents’
 lack
of
understanding
of
how
to
account
for
them
(68).
 
 In
addition,
diverse
mes‐ sages
being
promoted
 in
research
and
practice
guidelines
around
the
world
regarding
appropriate
ma‐ nipulation
of
sugar
alcohols
on
food
labels
may
also
add
to
respondents’
confusion.

Commendably,
the
 31
 finding
that
half
of
respondents
properly
accommodated
for
fibre
is
of
far
greater
significance
based
on
 its
more
prevalent
 place
 in
 a
 healthy
diabetic
 diet,
 and
 its
 associated
health
 and
 glycemic
 advantages
 (1,60,61,67)
 The
majority
of
adult
pump
users
in
this
sample
appeared
to
have
a
solid
understanding
of
intensive
 insulin
 self‐management
 principles
 illustrated
 by
 their
 knowledge
 of
 personal
 carbohydrate
 to
 insulin
 ratios,
 insulin
 sensitivity
 factors,
 appropriate
 basal‐bolus
 insulin
 adjustment,
 and
 use
 of
 a
 reasonable
 maximum
carbohydrate
load
range
at
meals
and
snacks
to
support
optimal
post‐prandial
blood
glucose
 control.

“Smart
pump”
bolus
features
such
as
the
Bolus
Wizard™
calculator
were
incorporated
into
insu‐ lin
 pump
 technology
with
 the
 intention
 of
 facilitating
 and
 improving
 blood
 glucose
 control
 (14,15,69).

 When
using
the
Bolus
Wizard™,
the
pump
user
remains
responsible
for
indicating
how
many
carbohyd‐ rates
they
are
eating,
which
helps
to
explain
the
significant
outcome
indicating
that
respondents
who
use
 the
Bolus
Wizard™
also
 read
 labels
more
 frequently.
 
Although
 two‐thirds
of
 respondents
were
 taking
 advantage
of
this
technology,
a
fifth
indicated
that
though
they
were
using
intensive
insulin
therapy
prin‐ ciples
 (carbohydrate
 to
 insulin
 ratio,
 insulin
 sensitivity
 factor)
 they
were
 still
 doing
 the
math
 on
 their
 own.

A
small
percentage
of
participants
even
indicated
they
were
using
a
sliding
scale.
 
Using
a
sliding
 scale
 insulin
 regime
 requires
 following
 a
 relatively
 rigid
 dietary
 regime
with
 a
 fixed
 carbohydrate
 load
 combined
 with
 using
 a
 predetermined
 sliding
 dose
 of
 additional
 bolus
 insulin
 based
 on
 pre‐prandial
 blood
glucose
readings.

Further
investigation
of
possible
barriers
adult
pumpers
have
for
not
using
the
 Bolus
Wizard™
calculator
may
be
an
area
of
 further
study.
The
finding
that
respondents
who
used
the
 Bolus
Wizard™
had
higher
nutrition
knowledge
scale
scores
when
compared
to
adult
pumpers
who
do
 not
use
it
is
also
interesting
to
note.

This
result
may
suggest
that
pumpers
who
use
the
bolus
calculator
 have
 a
 broader
 overall
 comprehension
 of
 pump
 therapy
 and
 diabetes‐related
 nutrition
 knowledge
 in‐ cluding
label
reading
and
carbohydrate
counting
compared
to
respondents
who
do
not
use
it.
 Occurrence
of
hypoglycemia
among
this
study’s
respondents
was
similar
to
findings
from
the
DAFNE
 study
where
18%
of
respondents
in
the
insulin
dose
adjustment
group
experienced
one
or
more
severe
 hypoglycemic
episodes
 in
 the
past
 six
months
 (47).
 
 In
addition,
 results
 regarding
glycemic
 control
de‐ fined
by
respondents’
most
 recent
A1c
were
close
 to
 target
guidelines
and
were
consistent
with
other
 published
studies
assessing
the
benefits
of
flexible
intensive
insulin
self‐management
while
using
a
pump
 (8,16‐21).
 
Commendably,
almost
half
of
respondents
were
within
the
ideal
range
of
≤7.0%
for
A1c
(1).

 The
majority
 of
 respondents
 expressed
 a
 commitment
 to
 their
 self‐care
 by
 regularly
 testing
 their
 A1c
 every
three
to
six
months
as
well
as
an
in‐depth
knowledge
of
their
glycemic
control.

 The
concept
of
a
positive
correlation
between
nutrition
knowledge
and
improved
glycemic
control
 was
supported
by
the
findings
that
higher
nutrition
knowledge
scale
scores
were
associated
with
more
 desirable
A1c
levels
and
a
lack
of
severe
hypoglycemic
reactions.

These
results
are
in
alignment
with
cur‐ rent
research
and
reinforce
the
fundamental
role
of
nutrition
therapy
as
a
means
of
supporting
positive
 health
outcomes
(1,24,25,27‐33).

Based
on
findings
from
the
DCCT
(4,5)
intensive
blood
glucose
control
 and
an
A1c
reduction
of
20%
(9.0%
compared
to
7.1%)
reduced
the
rate
of
retinopathy
by
76%,
kidney
 32
 disease
by
50%,
neuropathy
by
60%,
a
cardiovascular
event
by
42%
and
a
nonfatal
heart
attack,
stroke,
 or
death
from
cardiovascular
causes
by
57%.
 
The
difference
of
0.3%
in
A1c
between
the
high
and
 low
 nutrition
knowledge
groups
can
therefore
be
found
to
be
both
statistically
and
clinically
significant.


 A
majority
of
the
sample
was
committed
to
self‐education
and
to
learning
more
about
how
to
man‐ age
their
diabetes.

Furthermore,
the
finding
that
“self‐educators”
had
higher
nutrition
knowledge
scale
 scores
 compared
with
 “non‐self‐educators”
 and
 that
 a
 positive
 relationship
was
 seen
 between
 higher
 nutrition
knowledge
scale
scores
and
superior
glycemic
control,
emphasize
the
 importance
of
fostering
 an
 attitude
 of
 self‐management
 and
 self‐efficacy
 as
 a
 means
 of
 encouraging
 desirable
 diabetes
 out‐ comes.

Conversely,
it
 is
possible
that
“non‐self‐educators”
recognized
their
increased
need
for
support
 and
visited
their
DEC
more
frequently
and
were
hence
taught
carbohydrate
counting
significantly
more
 often.
 
 However,
we
 did
 not
 assess
 the
 perceived
 need
 for
 support,
 so
 cannot
 confirm
 or
 refute
 this
 possibility.

Although
the
recency
of
a
visit
to
a
DEC
was
not
associated
with
a
higher
nutrition
knowledge
 scale
score
or
a
more
desirable
A1c
level,
it
was
associated
with
a
greater
amount
of
satisfaction
with
the
 level
of
nutrition
support
respondents
were
receiving,
as
well
as
a
broader
scope
of
DHC
team
members
 who
 were
 providing
 nutrition
 support.
 These
 observations
 are
 consistent
 with
 recognized
 self‐ management
 education
 principles,
 including
 that
 self‐management
 education
 is
 most
 effective
 when
 ongoing
 education
 and
 comprehensive
 health
 care
 occur
 together,
 and
 that
 the
 content
 of
 self‐ management
 education
 programs
 be
 individualized
 and
 consider
 the
 individual’s
 readiness
 to
 change,
 learning
style,
ability,
resources
and
motivation
(1,26,31,70).
 The
comments
 to
 the
open‐ended
survey
 items
provided
by
 this
 sample
of
pump
users
 regarding
 the
role
of
nutrition
and
carbohydrate
counting
reinforced
the
value
of
carbohydrate
counting
in
diabe‐ tes
self‐management
education
and
pump
therapy,
as
well
the
importance
of
healthy
and
sensible
eat‐ ing.
 
 The
 sample’s
 overall
 satisfaction
 with
 the
 use
 of
 their
 insulin
 pump
 is
 also
 worth
 noting,
 as
 it
 highlights
the
favourable
quality
of
life
factors
associated
with
insulin
pump
therapy
compared
to
other
 forms
of
insulin
delivery.

In
addition,
pump
users’
recognition
of
the
central
role
their
DHC
team
plays
in
 providing
 support
 reinforces
 this
 survey’s
 finding
 of
 the
 positive
 relationship
 that
was
 found
 between
 number
of
DHC
team
members
who
provide
nutrition
support
and
satisfaction
levels.
 In
considering
the
findings
of
this
survey,
it
is
essential
to
be
aware
of
its
limitations.
One
of
these
 was
the
relatively
small
and
possibly
non‐representative
sample
size.
At
the
time
of
the
survey
distribu‐ tion,
Medtronic
served
approximately
80%
of
Canadian
pump
users,
 totalling
8,800
French
and
English
 speaking
adults
and
children.

Approximately
66%
of
this
group
agreed
to
receive
more
information
from
 Medtronic
 in
 English
 and
77%
of
 this
 group
were
 adults
 (18
 years
 of
 age
 and
 older)
 totalling
 approxi‐ mately
4,472
people.

From
this
group,
e‐mail
addresses
were
available
for
only
891
individuals
and
only
 297
survey
results
were
usable.
Accordingly,
 the
results
 reflect
 the
views
of
a
 relatively
small
group
of
 potential
survey
respondents
and
cannot
be
generalized
with
confidence
to
the
total
population
of
Ca‐ nadian
adult
Medtronic
insulin
pump
users.

Another
potential
limitation
is
that
respondents’
satisfaction
 with
nutrition
support
was
based
on
one
question
rather
than
a
validated
scale.

Although
the
question
 33
 was
clear
and
concise,
additional
questions
would
have
proven
helpful
 in
 strengthening
potential
 rela‐ tionships
with
nutrition
knowledge
and
glycemic
control.

Although
other
studies
have
assessed
satisfac‐ tion
 with
 overall
 diabetes
 management,
 no
 studies
 could
 be
 located
 that
 specifically
 examined
 satisfaction
with
nutrition
support.

An
additional
limitation
pertains
to
the
nutrition
content
area
of
the
 survey
being
based
solely
on
topic
areas
identified
by
the
national
advisory
committee,
and
thus
may
not
 reflect
all
aspects
of
nutrition‐related
knowledge
relevant
to
adult
insulin
pump
users.

Issues
regarding
 the
validity
of
the
nutrition
aspect
of
the
survey
may
also
be
raised
due
to
the
lack
of
reliable
and
vali‐ dated
nutrition
knowledge
surveys
for
adult
insulin
pump
users.

As
a
result,
a
non‐validated
carbohyd‐ rate
 counting
pre‐
and
post
 study
assessment
 test
 (63)
was
used
 to
guide
 the
development
of
 several
 nutrition
and
 label
 reading
questions.
 
Finally,
glycemic
control
was
assessed
by
respondents’
most
 re‐ cent
self‐reported
A1c
test
versus
a
controlled
 laboratory
test
result,
and
could
be
subject
to
 incorrect
 recall.
 Some
strengths
of
the
survey
include
the
use
of
a
national
advisory
committee
of
DHC
experts
who
 provided
input
on
the
relevant
nutrition
domains
identified
in
the
survey,
as
well
as
on
the
survey
design
 itself.
 
The
pilot
testing
of
the
survey
and
the
repeated
national
distribution
of
the
final
survey
 inviting
 pumpers
 to
participate
over
 the
course
of
a
month
were
additional
 strengths
of
 the
study.
 
This
 study
 helps
to
address
a
gap
 in
the
 literature
by
exploring
the
role
of
nutrition
and
carbohydrate
counting
 in
 diabetes
management
in
a
sample
of
adult
insulin
pump
users.

Potential
relationships
among
nutrition
 support,
nutrition
knowledge
and
glycemic
control
were
also
assessed,
in
addition
to
identifying
areas
in
 nutrition
knowledge
that
may
benefit
from
further
attention.
 2.5
 SUMMARY
AND
CONCLUSION
 This
 study
 supports
 the
 concept
 of
 a
 positive
 correlation
 between
 nutrition
 knowledge
 and
 improved
 glycemic
control
as
documented
by
more
desirable
A1c
 levels
and
a
 lack
of
 severe
hypoglycemic
 reac‐ tions.
 
 Respondents
 were
 generally
 well
 educated
 about
 diabetes‐related
 nutrition
 principles
 and
 be‐ lieved
 that
 carbohydrate
 counting
 including
 label
 reading
 played
 a
 critical
 role
 in
 their
 management.

 Gaps
 in
 nutrition
 knowledge
were
 evident
 regarding
 low
 carbohydrate
 vegetables,
 glycemic
 index
 and
 sugar
alcohols
on
labels.

Approximately
half
of
pump
users
relied
upon
two
or
more
DHC
professionals
 to
provide
their
nutrition
support,
with
dietitians
and
DECs
remaining
key
resources
 in
the
provision
of
 their
nutrition
information.

Adult
pump
users
were
generally
satisfied
with
their
nutrition
support,
which
 was
linked
to
the
size
and
scope
of
their
DHC
team.

The
importance
of
self‐management
principles
was
 evident
by
the
large
number
of
pump
users
who
identified
themselves
as
being
a
self‐educator
and
their
 expressed
desire
to
learn
more
about
self‐management
practices
including
advanced
meal
bolus
features
 and
insulin
adjustment
for
various
situations.
 
Findings
also
suggest
that
empowering
adult
pumpers
to
 perceive
themselves
as
self‐educators
may
be
an
effective
strategy
to
enhance
nutrition
knowledge
and
 34
 potentially
improve
glycemic
control.

Respondents’
interest
in
receiving
further
information
about
nutri‐ tion
 for
weight
management
also
demonstrated
 the
 relevance
and
need
 for
 increased
support
and
re‐ sources
 in
this
area.
 
Glycemic
control
of
these
adult
 insulin
pump
users
was
close
to
target
guidelines
 and
pump
users
expressed
appreciation
of
their
pump
as
a
preferred
form
of
insulin
delivery.

This
sam‐ ple
of
 Canadian
 adult
 insulin
 pump
users
were
 knowledgeable
 about
 diabetes‐related
nutrition
princi‐ ples,
intensive
insulin
self‐management
practices
and
were
motivated
to
manage
their
diabetes.
 35
 2.6
 TABLES
 
 Table
1:
Demographic
and
anthropometric
data
of
participants1
 Characteristic
 N
 All
 Male2
 Female3
 Range
 Age,
years
 292
 44.2
±
11.9
 45.9
±
12.6
 43.3
±
11.5
 19
–
79
 Body
mass
index,
kg/m2


 294
 27
±
5.7
 27.9
±
4.9
 26.5
±
6.1
 17.0
–
64.7
 Type
1
diabetes,
%

 276
 92.9
 90.4
 94.3
 
 Time
using
a
pump,
years

 295
 4.3
±
6.0
 3.8
±
5.8
 4.6
±
6.1
 0.5
–
37.0
 Schooling,
%
 Some
university
or
less
 University
graduate
 Graduate
degree
 297
 134
 118
 45
 
 45.1
 39.7
 15.2
 
 46.2
 36.5
 17.3
 
 44.6
 41.5
 14.0
 
 1

Data
are
expressed
as
Mean
±
SD
or
%.
 2

N
for
males
ranged
from
94
to
104.
 3

N
for
females
ranged
from
182
to
193.
 
 36
 
 Table
2:
Relationships
among
survey
variables
 Variable
 Satisfa‐ ction1
 DHC
team
 members2
 Frequency
 of
contact
 with
DEC3
 Nutrition
 knowle‐ dge4

 Frequency
 of
label
 reading5
 Frequency
 taught
 carbo‐ hydrate
 counting6
 Glycemic
 control
 (A1c%)7
 Satisfaction1
 Pearson
Correlation
 Sig.
(2
tailed)
 N
 
 1
 290
 0.412
 .001
 290
 0.254
 .001
 282
 .003
 .962
 290
 .207
 .001
 289
 .193
 .001
 275
 ‐.054
 .399
 245
 DHC
team
members
 Pearson
Correlation2
 Sig.
(2
tailed)
 N
 
 1
 297
 .386
 .001
 289
 .074
 .202
 297
 .186
 .001
 295
 .231
 .001
 282
 ‐.043
 .493
 252
 Frequency
of
contact
 with
DEC3
 Pearson
Correlation
 Sig.
(2
tailed)
 N
 
 
 1
 289
 .079
 .183
 289
 
 .187
 .001
 287
 .310
 .001
 276
 .069
 .289
 246
 Nutrition
knowledge4
 Pearson
Correlation
 Sig.
(2
tailed)
 N
 
 
 
 
 1
 297
 
 .150
 .010
 295
 
 .099
 .096
 282
 
 ‐.171
 .006
 252
 Frequency
of
label
 reading5
 Pearson
Correlation
 Sig.
(2
tailed)
 N
 
 
 
 
 1
 295
 .096
 .110
 280
 ‐.072
 .254
 250
 Frequency
taught
 carbohydrate
counting6
 Pearson
Correlation
 Sig.
(2
tailed)
 N
 
 
 
 
 
 
 1
 282
 0.024
 .707
 242
 Glycemic
control
(A1c
 %)7
 Pearson
Correlation
 Sig.
(2
tailed)
 N
 
 
 
 
 
 
 1
 252
 1

Response
to
the
question
“I
am
very
satisfied
with
the
nutrition
support
I
receive”,
a
five‐point
Likert‐type
scale
was
used
 where
1
=
strongly
disagree
and
5
=
strongly
agree.
 2
 
Determined
from
response
to
the
question
“who
currently
provides
your
nutrition
support
for
your
diabetes
manage‐ ment?
(Please
check
all
that
apply)”,
can
range
from
0
to
5
DHC
professionals.
 3

Response
to
the
question
“when
was
your
last
visit
to
a
DEC?”,
where
2
=
never
been
to
a
DEC,
3
=
more
than
three
years
 ago,
4
=
two
to
three
years
ago,
5
=
one
to
two
years
ago
and
6
=
within
the
last
12
months.
 4

Comprised
of
13
survey
questions.
 37
 5
 
Response
to
 the
question
“how
often
do
you
use
the
 label
 to
count
the
number
of
carbohydrates
 in
your
meal/snack
 versus
estimating?”,
a
five‐point
Likert‐type
scale
was
used
where
1
=
almost
never
and
5
=
almost
always.
 6

Response
to
the
question
“how
many
times
have
you
seen
a
dietitian
to
learn
about
how
insulin
matches
food
(carbo‐ hydrate
counting)”,
where
2
=
I
have
never
met
with
a
dietitian,
3
=
one
time,
4
=
two
times,
5
=
three
to
five
times
and
 6
=
more
than
five
times.
 7

Most
recent
A1c
test
result,
self‐reported.
 
 Table
3:
Characteristics
of
respondents
by
use
of
the
Bolus
Wizard™
calculator
 Variable
 Bolus
Wizard
 Mean
±
SD,
(n)

 No
Bolus
Wizard
 Mean
±
SD,
(n)


 Test
Statistic*
 P
Value
 Satisfaction1
 3.8
±
1.0,
(196)
 3.5
±
1.0,
(94)
 t
=
1.951
 p
=
0.052
 DHC
team
members2
 1.8
±
1.3,
(200)
 1.5
±
1.4,
(97)
 t
=
1.658
 p
=
0.098
 Frequency
of
contact
 with
DEC3
 5.2
±
1.2,
(197)
 5.0
±
1.3,
(92)
 t
=
1.416
 p
=
0.158
 Nutrition
knowledge4
 9.5
±
2.0,
(200)
 8.8
±
2.5,
(97)
 Z
=
–
2.137
 p
=
0.033
 Frequency
of
label
 reading5
 4.4
±
0.8,
(198)
 4.0
±
1.1,
(97)
 Z
=
–
3.026
 p
=
0.002
 Frequency
taught
 carbohydrate
counting6
 4.5
±
1.1,
(190)
 4.6
±
1.3,
(92)
 t
=
–
0.304
 p
=
0.761
 Glycemic
control,


 (A1c
%)7
 7.2
±
0.9,
(166)
 7.2
±
1.1,
(86)
 t
=
–
0.075
 p
=
0.940
 *
 
The
Mann‐Whitney
U
test
was
used
as
a
non‐parametric
equivalent
to
the
independent
samples
t
test
when
Levene’s
 test
for
equality
of
variances
(test
statistic
F)
was
significant.
 1

Response
to
the
question
“I
am
very
satisfied
with
the
nutrition
support
I
receive”,
a
five‐point
Likert‐type
scale
was
used
 where
1
=
strongly
disagree
and
5
=
strongly
agree.
 2
 
Determined
from
response
to
the
question
“who
currently
provides
your
nutrition
support
for
your
diabetes
manage‐ ment?
(Please
check
all
that
apply)”,
can
range
from
zero
to
five
DHC
professionals.
 3

Response
to
the
question
“when
was
your
last
visit
to
a
DEC?”,
where
2
=
never
been
to
a
DEC,
3
=
more
than
three
years
 ago,
4
=
two
to
three
years
ago,
5
=
one
to
two
years
ago
and
6
=
within
the
last
12
months.
 4

Comprised
of
13
survey
questions.
 5
 
Response
to
 the
question
“how
often
do
you
use
the
 label
 to
count
the
number
of
carbohydrates
 in
your
meal/snack
 versus
estimating?”,
a
five‐point
Likert‐type
scale
was
used
where
1
=
almost
never
and
5
=
almost
always.
 6

Response
to
the
question
“how
many
times
have
you
seen
a
dietitian
to
learn
about
how
insulin
matches
food
(carbo‐ hydrate
counting)”,
where
2
=
I
have
never
met
with
a
dietitian,
3
=
one
time,
4
=
two
times,
5
=
three
to
five
times
and
 6
=
more
than
five
times.
 7

Most
recent
A1c
test
result,
self‐reported.
 
 38
 
 Table
4:
Characteristics
of
respondents
by
experience
of
severe
hypoglycemia
 Variable
 No
severe
 hypoglycemia1


 Mean
±
SD,
(n)

 Severe
 hypoglycemia1


 Mean
±
SD,
(n)
 Test
Statistic*
 P
Value
 Satisfaction2
 3.8
±
1.0,
(220)
 3.7
±
1.0,
(70)
 t
=
0.478
 p
=
0.633
 DHC
team
 members3
 1.7
±
1.3,
(226)
 1.6
±
1.2,
(71)
 t
=
0.580
 p
=
0.562
 Frequency
of
 contact
with
DEC4
 5.1
±
1.3,
(197)
 5.2
±
1.1,
(92)
 Z
=
–
0.112
 p
=
0.911
 Nutrition
 knowledge5
 9.5
±
2.0,
(226)
 8.5
±
2.1,
(71)
 t
=
3.275
 p
=
0.001
 Frequency
of
label
 reading6
 4.3
±
0.9,
(224)
 4.2
±
1.0,
(71)
 t
=
0.795
 p
=
0.427
 Frequency
taught
 carbohydrate
 counting7
 4.5
±
1.2,
(215)
 4.7
±
1.2,
(67)
 t
=
–
1.415
 p
=
0.158
 Glycemic
control,

 (A1c
%)8
 7.1
±
1.0,
(188)
 7.3
±
1.1,
(64)
 t
=
–
1.148
 p
=
0.252
 *
 
The
Mann‐Whitney
U
test
was
used
as
a
non‐parametric
equivalent
to
the
independent
samples
t
test
when
Levene’s
 test
for
equality
of
variances
(test
statistic
F)
was
significant.
 1

Determined
from
response
to
the
question
“how
many
times
in
the
LAST
6
MONTHS
have
you
had
a
SEVERE
low
blood
 glucose
reaction
(i.e.,
resulting
in
passing
out
or
needing
someone
else’s
help)?”,
where
1
=
0
times
and
0
=
≥
1
times.
 2

Response
to
the
question
“I
am
very
satisfied
with
the
nutrition
support
I
receive”,
a
five‐point
Likert‐type
scale
was
used
 where
1
=
strongly
disagree
and
5
=
strongly
agree.
 3
 
Determined
from
response
to
the
question
“who
currently
provides
your
nutrition
support
for
your
diabetes
manage‐ ment?
(Please
check
all
that
apply)”,
can
range
from
zero
to
five
DHC
professionals.
 4

Response
to
the
question
“when
was
your
last
visit
to
a
DEC?”,
where
2
=
never
been
to
a
DEC,
3
=
more
than
three
years
 ago,
4
=
two
to
three
years
ago,
5
=
one
to
two
years
ago
and
6
=
within
the
last
12
months.
 5

Comprised
of
13
survey
questions.
 6
 
Response
to
 the
question
“how
often
do
you
use
the
 label
 to
count
 the
number
of
carbohydrates
 in
your
meal/snack
 versus
estimating?”,
a
five‐point
Likert‐type
scale
was
used
where
1
=
almost
never
and
5
=
almost
always.
 7

Response
to
the
question
“how
many
times
have
you
seen
a
dietitian
to
learn
about
how
insulin
matches
food
(carbo‐ hydrate
counting)”,
where
2
=
I
have
never
met
with
a
dietitian,
3
=
one
time,
4
=
two
times,
5
=
three
to
five
times
and
 6
=
more
than
five
times.
 8

Most
recent
A1c
test
result,
self‐reported.
 39
 
 Table
5:
Characteristics
of
self‐educators
and
non‐self‐educators
 Variable
 Self‐educator



 Mean
±
SD,
(n)

 Non‐self‐educator
 Mean
±
SD,
(n)


 Test
Statistic*
 P
Value
 Satisfaction1
 3.6
±
1.0,
(180)
 3.9
±
0.9,
(110)
 Z
=
‐1.945
 P
=
0.052
 DHC
team
 members2
 1.7
±
1.4,
(184)
 1.7
±
1.2,
(113)
 Z
=
‐0.406
 P
=
0.685
 Frequency
of
 contact
with
DEC3
 5.0
±
1.2,
(179)
 5.4
±
1.2,
(110)
 t
=
2.157
 P
=
0.032
 Nutrition
 knowledge4
 9.5
±
2.2,
(184)
 8.8
±
2.1,
(113)
 t
=‐2.614
 P
=
0.009
 Frequency
of
label
 reading5
 4.3
±
1.0,
(183)
 4.3
±
0.9,
(112)
 t
=
0.478
 P
=
0.633
 Frequency
taught
 carbohydrate
 counting6
 4.4
±
1.2,
(175)
 4.8
±
1.1,
(107)
 t
=
2.943
 P
=
0.004
 Glycemic
control,
 (A1c
%)7
 7.2
±
1.0,
(179)
 7.2
±
1.0,
(110)
 t
=
0.614
 P
=
0.539
 *
 
The
Mann‐Whitney
U
test
was
used
as
a
non‐parametric
equivalent
to
the
independent
samples
t
test
when
Levene’s
 test
for
equality
of
variances
(test
statistic
F)
was
significant.
 1

Response
to
the
question
“I
am
very
satisfied
with
the
nutrition
support
I
receive”,
a
five‐point
Likert‐type
scale
was
used
 where
1
=
strongly
disagree
and
5
=
strongly
agree.
 2
 
Determined
from
response
to
the
question
“who
currently
provides
your
nutrition
support
for
your
diabetes
manage‐ ment?
(Please
check
all
that
apply)”,
can
range
from
zero
to
five
DHC
professionals.
 3

Response
to
the
question
“when
was
your
last
visit
to
a
DEC?”,
where
2
=
never
been
to
a
DEC,
3
=
more
than
three
years
 ago,
4
=
two
to
three
years
ago,
5
=
one
to
two
years
ago
and
6
=
within
the
last
12
months.
 4

Comprised
of
13
survey
questions.
 5
 
Response
to
 the
question
“how
often
do
you
use
the
 label
 to
count
the
number
of
carbohydrates
 in
your
meal/snack
 versus
estimating?”,
a
five‐point
Likert‐type
scale
was
used
where
1
=
almost
never
and
5
=
almost
always.
 6

Response
to
the
question
“how
many
times
have
you
seen
a
dietitian
to
learn
about
how
insulin
matches
food
(carbo‐ hydrate
counting)”,
where
2
=
I
have
never
met
with
a
dietitian,
3
=
one
time,
4
=
two
times,
5
=
three
to
five
times
and
 6
=
more
than
five
times.
 7

Most
recent
A1c
test
result,
self‐reported.
 40
 
 Table
6:
 
Nutrition
knowledge
and
glycemic
control
of
respondents
by
number
of
DHC
team
 members
and
frequency
of
contact
with
DEC
 Variable
 Nutrition
knowledge 1











 (n
=
297)
 Glycemic
control2
(A1c%)





 (n
=
252)
 DHC
team
members3,
(n)
 0‐1,
(149)
 2+,
(148)
 
 9.0
±
2.3,
(149)
 9.4
±
2.0,
(148)
 
 7.2
±
1.0,
(119)
 7.2
±
1.0,
(133)
 Test
Statistic
(p
value)
 t
=
1.565
(0.119)
 t
=
0.317
(0.752)
 Frequency
of
contact
with
DEC4,
(n)
 <
1
year,
(172)
 >
1
year,
(117)
 
 9.4
±
2.0,
(172)
 9.1
±
2.3,
(117)
 
 7.2
±
1.1,
(153)
 7.1
±
0.7,
(93)
 Test
Statistic
(p
value)*
 t
=
–
1.032
(0.303)
 Z
=
–
0.256
(0.798)
 1

Comprised
of
13
survey
questions.
 2

Recent
A1c
test
result,
self
reported.
 3
 
Determined
from
response
to
the
question
“who
currently
provides
your
nutrition
support
for
your
diabetes
manage‐ ment?
(Please
check
all
that
apply)”,
responses
can
range
from
0
to
five
DHC
professionals.

Respondents
were
divided
 into
an
approximate
50:50
group
split
and
compared
using
an
independent
samples
t‐test.
 4
 
Responses
to
the
question
“when
was
your
last
visit
to
a
DEC?”.

Respondents
were
divided
into
an
approximate
50:50
 group
split
and
compared
using
an
independent
samples
t‐test.
 *
 
The
Mann‐Whitney
U
test
was
used
as
a
non‐parametric
equivalent
to
the
independent
samples
t
test
when
Levene’s
 test
for
equality
of
variances
(test
statistic
F)
was
significant.
 
 41
 2.7
 FIGURES
 Figure
1:
Subject
selection
for
study 
 
 !"#$#%&'()*&#'(+&,(,)%-(-.( /01(&23'-(43*4(3,)",( 56()*&#',( ")-3"%)2( /70(43*4(3,)",( ")8)#9)2(-:)(,3"9);( 556(43*4(3,)",(( )%-)")2(-:)(,3"9);( <(43*4(3,)",(( 2#2(%.-(*))-(-:)( )'#$#=#'#-;(8"#-)"#&( 51(43*4(3,)",( (:&2(#%,3>8#)%-( 2)*.$"&4:#8(?( %3-"#@.%( A%.+')2$)(2&-&( 60B(43*4(3,)",( (8.*4')-)2(-:)(,3"9);( 105( C)*&'),(( 1D<(( E&'),(( FG8'32)2(#%(2&-&( &%&';,#,( H%8'32)2(#%(2&-&(&%&';,#,( I),4.%,)(I&-)(J(5<KLM( N#K)K(3,&=')("),4.%,),( .3-(.C(-:.,)(+:.( ")8)#9)2(-:)(,3"9);O( 42
 2.8
 ACKNOWLEDGMENTS
 This
study
was
supported
by
Medtronic
of
Canada,
Ltd.
 43
 2.9
 REFERENCES
 1)
Canadian
Diabetes
Association
Clinical
Practice
Guidelines
Expert
Committee.
Canadian
Diabetes
 Association
2008
clinical
practice
guidelines
for
the
prevention
and
management
of
diabetes
in
 Canada.
Can
J
Diabetes
2008;32
(Suppl
1):S1‐S201.
 (2)
Health
Canada.
Diabetes
in
Canada
–
2nd
ed.,
2002.
.
http://www.phac‐aspc.gc.ca/publicat/dic‐ dac2/pdf/dic‐dac2_en.pdf
.
Accessed
October
26th,
2010.
 (3)
Public
Health
Agency
of
Canada.
Report
from
the
National
Diabetes
Surveillance
System:
Diabetes
in
 Canada,
2009.
http://www.ndss.gc.ca
.
Accessed
October
19th,
2010.
 (4)
Diabetes
Control
and
Complications
Trial
(DCCT)
Research
Group.
The
effect
of
intensive
treatment
of
 diabetes
on
the
development
and
progression
of
long‐term
complications
in
insulin‐dependent
 diabetes
mellitus.
New
Engl
J
Med
1993;329:977‐986.
 (5)
Diabetes
Control
and
Complications
Trial
Research
Group.
Intensive
diabetes
treatment
and
 cardiovascular
disease
in
patients
with
type
1
diabetes.
New
Engl
J
Med
2005;353(25):2643‐53.
 (6)
UK
Prospective
Diabetes
Study
(UKPDS)
Group.
Intensive
blood‐glucose
control
with
sulphonylureas
 or
insulin
compared
with
conventional
treatment
and
risk
of
complications
in
patients
with
type
 2
diabetes
(UKPDS
33).
Lancet
1998;352:837‐853.
 (7)
Pickup
JC,
Keen
H,
Parsons
JA,
et
al.
Continuous
subcutaneous
insulin
infusion:
an
approach
to
 achieving
normoglycaemia.
BMJ
1978:1:204‐207.
 (8)
Scheiner
G,
Sobel
RJ,
Smith
DE,
et
al.
Successful
outcomes
with
insulin
pump
therapy.
Diabetes
Educ
 2009;35(Suppl.
2):S29‐S41.
 (9)
Walsh
J,
Roberts
R.
Pumping
insulin:
everything
you
need
for
success
on
a
smart
insulin
pump.
4th
ed.
 San
Diego:
Torrey
Pines
Press;
2006.
 (10)
Bode
BW,
Tamborlane
WV,
Davidson
PC.
Insulin
pump
therapy
in
the
21st
century.
Postgrad
Med
 2002;111(5):69‐77.
 (11)
Pickup
JC,
Keen
H.
Continuous
subcutaneous
insulin
infusion
at
25
years.
Diabetes
Care
 2002;25(3):593‐598.
 (12)
Pickup
JC,
Kidd
J,
Burmiston
S,
Yemane
N.
Determinants
of
glycaemic
control
in
type
1
diabetes
 during
intensified
therapy
with
multiple
daily
insulin
injections
or
continuous
subcutaneous
 insulin
infusion:
importance
of
blood
glucose
variability.
Diabetes
Metab
Res
Rev
2006;22:232‐ 237.
 (13)
Lauritzen
T,
Pramming
S,
Deckert
T,
Binder
C.
Pharmacokinetics
of
continuous
subcutaneous
insulin
 infusion.
Diabetologia
1983;24:326‐329.
 (14)
Gross
T,
Kayne
D,
King
A,
et
al.
A
bolus
calculator
is
an
effective
means
of
controlling
postprandial
 glycemia
in
patients
on
insulin
pump
therapy.
Diabetes
Tech
Therap
2003;5:365‐369.
 44
 (15)
Zisser
H,
Robinson
L,
Bevier
W,
et
al.
Bolus
calculator:
a
review
of
four
“smart”
insulin
pumps.
 Diabetes
Tech
Therap
2008;10(6):441‐444.
 (16)
Fatourechi
MM,
Kudva
YC,
Murad
MH,
et
al.
Hypoglycemia
with
intensive
insulin
therapy:
a
 systematic
review
and
meta‐analyses
of
randomized
trials
of
continuous
subcutaneous
insulin
 infusion
versus
multiple
daily
injections.
J
Clin
Endocrinol
Metab
2009;94(3):729‐740.
 (17)
Jeitler
K,
Horvath
K,
Berghold
A,
et
al.
Continuous
subcutaneous
insulin
infusion
versus
multiple
daily
 insulin
injections
in
patients
with
diabetes
mellitus:
systematic
review
and
meta‐analysis.
 Diabetologia
2008;51:941‐951.
 (18)
Bolli
GB,
Kerr
D,
Reena
T,
et
al.
Comparison
of
multiple
daily
insulin
injection
regimen
(basal
once‐ daily
glargine
plus
mealtime
lispro)
and
continuous
subcutaneous
insulin
infusion
(lispro)
in
type
 1
diabetes.
Diabetes
Care
2009;32(7):1170‐1176.
 (19)
Pickup
JC,
Sutton
AJ.
Severe
hypoglycaemia
and
glycaemic
control
in
Type
1
diabetes:
meta‐analysis
 of
multiple
daily
insulin
injections
compared
with
continuous
subcutaneous
insulin
infusion.
 Diabetic
Med
2008;25:765‐774.
 (20)
Pickup
JC,
Renard
E.
Long‐acting
insulin
analogs
versus
insulin
pump
therapy
for
the
treatment
of
 type
1
and
type
2
diabetes.
Diabetes
Care
2008;31(Suppl.
2):S140‐S145.
 (21)
Pickup
JC,
Mattock
M,
Kerry
S.
Glycaemic
control
with
continuous
subcutaneous
insulin
infusion
 compared
with
intensive
insulin
injection
in
patients
with
type
1
diabetes:
meta‐analysis
of
 randomised
controlled
trials.
BMJ
2002;324:705‐708.
 (22)
Nicolucci
A,
Maione
A,
Franciosi
M,
et
al.
Quality
of
life
and
treatment
satisfaction
in
adults
with
type
 1
diabetes:
a
comparison
between
continuous
subcutaneous
insulin
infusion
and
multiple
daily
 injections:
The
Equality
1
Study
Group.
Diabetic
Med
2008;25:213‐220.
 (23)
Hammond
P,
Liebel
A,
Grunder
S.
International
survey
of
insulin
pump
users:
Impact
of
continuous
 subcutaneous
insulin
infusion
therapy
on
glucose
control
and
quality
of
life.
Prim
Care
Diabetes
 2007;1(3):143‐146.
 (24)
Franz
MJ,
Boucher
JL,
Green‐Pastors
J,
Powers
MA.
Evidence‐based
nutrition
practice
guidelines
for
 diabetes
and
scope
and
standards
of
practice.
J
Am
Diet
Assoc
2008;108:S52‐S58.
 (25)
Kulkarni
K,
Castle
G,
Gregory
R,
et
al.
Nutrition
practice
guidelines
for
type
1
diabetes
mellitus
 positively
affect
dietitian
practices
and
patient
outcomes.
J
Am
Diet
Assoc
1998;98:62‐70.
 (26)
Clark
M.
Diabetes
self‐management
education.
A
review
of
published
studies.
Prim
Care
Diabetes
 2008;2:113‐120.
 (27)
Delahanty
LM.
Clinical
significance
of
medical
nutrition
therapy
in
achieving
diabetes
outcomes
and
 the
importance
of
the
process.
J
Am
Diet
Assoc
1998;98(1):28‐30.
 (28)
Anderson
EJ,
Delahanty
L,
Richardson
M,
et
al.
Nutrition
interventions
for
intensive
therapy
in
the
 diabetes
control
and
complications
trial.
The
Diabetes
Control
and
Complications
Trial
(DCCT).
J
 Am
Diet
Assoc
1993;93(7):768‐772.
 (29)
Wilson
C,
Acton
K,
Brown
T,
et
al.
Effects
of
clinical
nutrition
education
and
educator
discipline
on
 glycemic
control
outcomes
in
the
Indian
Health
Service.
Diabetes
Care
2003;26(9):2500‐2504.
 45
 (30)
Willaing
I,
Ladelund
S,
Jorgensen
T,
et
al.
Nutritional
counseling
in
primary
health
care:
a
randomized
 comparison
of
an
intervention
by
general
practitioner
or
dietician.
Eur
J
Cardiovasc
Prev
Rehabil
 2004;11:513‐520.
 (31)
Franz
MJ,
Warshaw
H,
Daly
AE,
et
al.
Evolution
of
diabetes
medical
nutrition
therapy.
Postgrad
Med
 2003;79:30‐35.
 (32)
Delahanty
LM,
Halford
BN.
The
role
of
diet
behaviors
in
achieving
improved
glycemic
control
in
 intensively
treated
patients
in
the
Diabetes
Control
and
Complications
Trial.
Diabetes
Care
 1993;16(11):1453‐1458.
 (33)
DCCT
Research
Group.
Expanded
role
of
the
dietitian
in
the
Diabetes
Control
and
Complications
 Trial:
implications
for
clinical
practice.
J
Am
Diet
Assoc
1993;93:758‐764.
 (34)
Muhlhauser
I,
Jorgens
V,
Berger
M,
et
al.
Bicentric
evaluation
of
a
teaching
and
treatment
 programme
for
type
1
(insulin
dependent)
diabetic
patients:
improvement
of
metabolic
control
 and
other
measures
of
diabetes
care
for
up
to
22
months.
Diabetologia
1983;25:470‐476.
 (35)
Muhlhauser
I,
Bruckner
I,
Berger
M,
et
al.
Evaluation
of
an
intensified
insulin
treatment
and
teaching
 programme
as
routine
management
of
type
1
(insulin
dependent)
diabetes:
The
Bucharest‐ Dusseldorf
Study.
Diabetologia
1987;30:681‐690.
 (36)
Muhlhauser
I,
Bott
U,
Overmann
H,
et
al.
Liberalized
diet
in
patients
with
type
1
diabetes.
J
intern
 Med
1995;237(6):591‐597.
 (37)
Jorgens
V,
Gruber
M,
Bott
U,
et
al.
Effective
and
safe
translation
of
intensified
insulin
therapy
to
 general
internal
medicine
departments.
Diabetologia
1993;36:99‐105.
 (38)
Plank
J,
Kohler
G,
Rakovac
I,
et
al.
Long‐term
evaluation
of
a
structured
outpatient
education
 programme
for
intensified
insulin
therapy
in
patients
with
type
1
diabetes:
a
12‐year
follow‐up.
 Diabetologia
2004;47:1370‐1375.
 (39)
Pieber
TR,
Brunner
GA,
Schnedl
WJ,
et
al.
Evaluation
of
a
structured
outpatient
group
education
 program
for
intensive
insulin
therapy.
Diabetes
Care
1995;18;625‐630.
 (40)
Muller
U,
Femerling
M,
Berger
M.
et
al.
Intensified
treatment
and
education
of
Type
1
diabetes
as
 clinical
routine.
Diabetes
Care
1999;22(Suppl.
2):B29‐33.
 (41)
Lowe
J,
Linjawi
S,
Mensch
M,
et
al.
Flexible
eating
and
flexible
insulin
dosing
in
patients
with
 diabetes:
Results
of
an
intensive
self‐management
course.
Diabetes
Res
Clin
Pract
2008
;80:439‐ 443.
 (42)
Sumner
J,
Dyson
P,
Allan
S.
Local
application
of
CHO
counting
and
insulin
dose
adjustment.
J
 Diabetes
Nursing
2003;7(2):59‐61.
 (43)
Kinch
A,
Ruddy
L,
Oswald
G.
Local
Implementation
of
a
carbohydrate
counting
system.
J
Diabetes
 Nursing
2004;8(1):28‐30.
 (44)
Everett
J,
Jenkins
E,
Kerr
D,
Cavan
DA.
Implementation
of
an
effective
outpatient
intensive
education
 programme
for
patients
with
type
1
diabetes.
Practical
Diabetes
Int
2003;20(2):51‐55.
 (45)
Voevodin
M,
Steele
C,
Pierce
K,
Colman
P.
Eating
and
pumping:
evaluating
the
nutrition
service
of
 the
insulin
pump
clinic
at
the
Royal
Melbourne
Hospital.
Nutr
Diet
2003;60(2):122‐125.
 46
 (46)
Oswald
G,
Kinch
A,
Ruddy
E.
Transfer
to
a
patient
centred,
carbohydrate
counting
and
insulin
 matching
programme
in
a
shortened
time
frame:
a
structured
education
programme
for
type
1
 diabetes
incorporating
intensified
conventional
therapy
and
CSII.
Practical
Diabetes
Int
 2004;21(9):334‐338.
 (47)
DAFNE
Study
Group.
Training
in
flexible,
intensive
insulin
management
to
enable
dietary
freedom
in
 people
with
type
1
diabetes:
dose
adjustment
for
normal
eating
(DAFNE)
randomised
controlled
 trial.
BMJ
2003;325:746.
 (48)
Samann
A,
Muhlhauser
I,
Bender
R,
et
al.
Glycaemic
control
and
severe
hypoglycemia
following
 training
in
flexible
intensive
insulin
therapy
to
enable
dietary
freedom
in
people
with
type
1
 diabetes:
a
prospective
implementation
study.
Diabetologia
2005;48:1965
–
1970.
 (49)
Trento
M,
Trinetta
A,
Borgo
E,
et
al.
Carbohydrate
counting
improves
coping
ability
and
metabolic
 control
in
patients
with
type
1
diabetes
managed
by
Group
Care.
J
Endocrinol
Invest.
2010
May
3
 [Epub
ahead
of
print].
 (50)
Almazadeh
R,
Berhe
T,
Wyatt
DT.
Flexible
insulin
therapy
with
glargine
insulin
improved
glycemic
 control
and
reduced
severe
hypoglycemia
among
preschool‐aged
children
with
type
1
diabetes
 mellitus.
Pediatrics
2005;115:1320‐1324.
 (51)
Waller
H,
Eiser
C,
Knowles
J,
et
al.
Pilot
study
of
a
novel
educational
programme
for
11‐16
year
olds
 with
type
1
diabetes:
the
KICK‐OFF
course.
Arch
Dis
Child
2008;93:927‐931.
 (52)
Mehta
SN,
Quinn
N,
Volkening
LK,
et
al.
Impact
of
carbohydrate
counting
on
glycemic
control
in
 children
with
type
1
diabetes.
Diabetes
Care
2009;32(6):1014‐1016.
 (53)
Starostina
EG,
Antisferov
M,
Galstyan
GR,
et
al.
Effectiveness
and
cost‐benefit

analysis
of
intensive
 treatment
and
teaching
programmes
for
type
1
diabetes
in
Moscow.
Diabetologia
1994;37:170‐ 176.
 (54)
Kulkarni
K.
Carbohydrate
counting:
a
practical
meal‐planning
option
for
people
with
diabetes.
 Clinical
Diabetes
2005;23(3):120‐124.
 (55)
Gillespie
SJ,
Kulkarni
K,
Daly
AE.
Using
carbohydrate
counting
in
diabetes
clinical
practice.
J
Am
Diet
 Assoc
1998;98(8):897‐905.
 (56)
Pytka
E.
Nutritional
strategies
in
Type
1
Diabetes:
calories
are
important,
but
carbohydrates
count!
 Can.
Diabetes
2009;22(2):3‐6.
 (57)
Warshaw
HS,
Bolderman
KM.
Practical
carbohydrate
counting:
a
how‐to
teach
guide
for
health
 professionals.
2nd
ed.
Alexandria:
American
Diabetes
Association,
Inc.;
2008.
 (58)
Chiesa
G,
Piscopo
MA,
Rigamonti
A,
et
al.
Insulin
therapy
and
carbohydrate
counting.
Acta
Biomed
 2005;76;Suppl.3:44‐48.
 (59)
Jenkins
E.
Carbohydrate
counting:
successful
dietary
management
of
type
1
diabetes.
J
Diabetes
 Nursing
2006;10(4):150‐154.
 (60)
Wheeler
ML,
Pi‐Sunyer
FX.
Carbohydrate
issues:
type
and
amount.
J
Am
Diet
Assoc
2008;108:S34‐ S39.
 47
 (61)
Kelley
D.
Sugars
and
starch
in
the
nutritional
management
of
diabetes
mellitus.
Am
J
Clin
Nutr
 2003;78(4):858S‐864.
 (62)
Diabetes
History
(2.0).
Michigan
Diabetes
Research
and
Training
Center,
1998.
 http://www.med.umich.edu/mdrtc/profs/survey.html#dmh
.
Accessed
October
26th,
2010.
 (63)
Bergenstal
RM,
Tamborlane
WV,
Ahmann
A,
et
al.
for
the
STAR
3
Study
Group.
Effectiveness
of
 sensor‐augmented
insulin
pump
therapy
in
type
1
diabetes.
NEJM
2010;363:311‐320.
 (64)
World
Health
Organization.
WHO
Technical
Report
Series
894:
Obesity:
Preventing
and
Managing
 the
Global
Epidemic.
A
Report
of
a
WHO
Consultation.
Geneva,
2000.
 (65)
Statistics
Canada.
Catalogue
no.
82‐003‐XPE.
Health
Reports,
Vol.
21,
no.1,
March
2010.
 (66)
Canadian
Diabetes
Association.
Beyond
The
Basics:
Meal
Planning
for
Healthy
Eating,
Diabetes
 Prevention
and
Management.
http://www.diabetes.ca/for‐ professionals/resources/nutrition/beyond‐basics/.

Accessed
Oct.
20th,
2010.
 (67)
Brand‐Miller
J,
Hayne
S,
Petocz
P,
et
al.
Low
glycemic
index
diets
in
the
management
of
diabetes:
a
 meta‐analysis
of
randomized
controlled
trials.
Diabetes
Care
2003;26:2261‐2267.
 (68)
Health
Canada.
Eating
Well
with
Canada’s
Food
Guide.
Ottawa,
ON:
Health
Products
and
Food
 Branch,
Office
of
Nutrition
and
Promotion;
2007.
Publication
H39‐166/1990E.
 (69)
Shashaj
B,
Busetto
E,
Sulli
N.
Benefits
of
a
bolus
calculator
in
pre‐
and
postprandial
glycaemic
control
 and
meal
flexibility
of
paediatric
patients
using
continuous
subcutaneous
insulin
infusion
(CSII).
 Diabetic
Medicine
2008;25:1036‐1042.
 (70)
Vallis
TM,
Higgins‐Browser
I,
Edwards
L,
et
al.
The
role
of
diabetes
education
in
maintaining
lifestyle
 changes.
Can
J
Diabetes
2005;29:193‐202.
 
 
 48
 CHAPTER
3:
CONCLUSION
 3.1
 GENERAL
DISCUSSION
AND

 SUMMARY
OF
CURRENT
STATE
OF
KNOWLEDGE
 Successful
 diabetes
 management
 is
 synonymous
 with
 the
 pursuit
 for
 near‐normoglycemia
 (1,2)
 com‐ bined
with
a
minimal
degree
of
perceived
lifestyle
intervention
for
the
person
with
diabetes.

Achieving
 this
 balance
 becomes
 significantly
more
 challenging
 for
 people
who
 are
 insulin‐dependent
 due
 to
 the
 sheer
complexity
of
the
numerous
factors
that
affect
glycemia
(i.e.,
food
choices,
activity,
insulin,
medi‐ cations,
hormones,
stress,
etc.).

The
development
of
insulin
pump
therapy
(3),
the
introduction
of
basal‐ bolus
insulin
regimes
(4‐7),
the
widespread
acceptance
of
client‐empowered
insulin
dose
adjustment
and
 carbohydrate
counting
(8‐36)
have
revolutionized
diabetes
management.
 The
insulin
pump
uses
advanced
technology
with
exclusive
insulin
delivery
options.
 
 Insulin
pumps
 offer
people
with
 insulin‐dependent
diabetes
many
quality
of
 life
(37,38)
and
glycemic
advantages
(39‐ 43)
when
compared
with
insulin
syringes
and
pens.

Pump
users
require
a
deeper
understanding
of
the
 various
 aspects
 involved
 in
 flexible
 intensive
 insulin
 self‐management
 and
 diabetes‐related
 problem
 solving,
yet
little
is
known
about
the
dietary
knowledge
and
practices
of
this
distinctive
group.

This
study
 explored
adult
insulin
pump
users’
nutrition
education
and
knowledge,
and
how
it
related
to
their
level
 of
satisfaction
with
nutrition
support,
sources
of
nutrition
support,
and
glycemic
control.

Research
find‐ ings
are
intended
to
fill
existing
gaps
in
the
current
literature
and
help
direct
and
advance
future
nutri‐ tion‐related
educational
efforts.
 This
chapter
summarizes
the
information
related
to
and
obtained
from
this
study.

The
chapter
be‐ gins
with
a
presentation
of
general
study
findings
with
reference
to
the
research
objectives.
 
An
evalu‐ ation
of
 study
 strengths
and
 limitations
 is
 then
provided
along
with
 some
practical
 applications
of
 the
 findings.

The
chapter
concludes
with
some
suggested
avenues
for
further
research
on
this
topic.
 49
 3.2
 GENERAL
CONCLUSIONS
 This
study
contributes
to
the
current
body
of
knowledge
as
it
relates
to
the
dietary
habits
of
adult
insulin
 pump
users
by
assessing
what
adult
pumpers
know
and
do
regarding
the
role
of
nutrition
and
carbohyd‐ rate
counting
in
diabetes
management.

Demographic
and
anthropometric
characteristics
of
this
sample
 of
adult
pumpers
in
addition
to
their
level
of
satisfaction
with
nutrition
support,
sources
of
nutrition
in‐ formation,
and
glycemic
control
were
also
assessed.
 The
specific
objectives
and
key
 findings
 from
this
study
are
summarized
 in
Table
7.
 
Study
partici‐ pants
were
slightly
older
and
heavier
than
those
in
the
intensive
arm
of
the
Diabetes
Control
and
Compli‐ cations
 Trial
 (DCCT)
 (1)
 and
 Dose
 Adjustment
 For
 Normal
 Eating
 (DAFNE)
 (28)
 studies.
 
 Findings
 are
 consistent
with
the
current
global
trend
toward
 increased
body
weight
associated
with
obesity
and
re‐ search
results
from
the
2007‐2009
Canadian
Health
Measures
Survey
for
adults
(44).

Respondents
were
 also
well‐educated,
predominantly
had
type
1
diabetes,
and
had
been
using
an
insulin
pump
for
varying
 amounts
of
time.

Although
respondents
were
from
across
Canada,
the
largest
representation
was
from
 Ontario.
 
There
were
no
significant
differences
between
men
and
women
however
 the
majority
of
 re‐ spondents
were
women.
 Approximately
half
of
this
sample
of
adult
pumpers
relied
upon
two
or
more
diabetes‐related
health
 care
professionals
to
provide
them
with
nutrition
education.

Although
dietitians
were
identified
as
being
 the
most
frequently
reported
source
of
nutrition
 information,
other
health
care
professionals
 including
 diabetes
education
centres
(DEC)
were
clearly
significant.
 
These
findings
are
 in
alignment
with
current
 practice
guidelines
that
promote
the
dietitian
in
taking
a
lead
role
in
providing
nutrition
education
while
 being
part
of
a
multi‐
and
interdisciplinary
team
of
diabetes
health
care
(DHC)
professionals
that
share
a
 comprehensive
plan
of
care
based
on
the
needs
and
expectations
of
the
individual
(9,15,22,45‐51).
 Respondents
demonstrated
a
good
understanding
of
fundamental
nutrition
principles
including
ap‐ propriate
nutrition‐related
treatment
of
hypoglycemia.

A
strong
reliance
on
food
labels
was
evident
by
 the
majority
of
respondents
who
indicated
they
rely
on
label
reading
“most”
or
“almost
all”
of
the
time.

 This
use
of
food
labels
is
noteworthy
based
on
its
small
but
favourable
correlation
with
higher
nutrition
 knowledge
scores.
 
Nutrition
knowledge
was
also
found
to
be
associated
with
more
desirable
glycemic
 control
based
on
respondents’
last
A1c
test
and
a
lack
of
severe
hypoglycemic
episodes.

This
finding
is
 consistent
with
previous
research
that
encourages
the
use
of
proven
adult‐oriented
teaching
techniques
 and
learning
approaches
to
support
a
strong
nutrition
knowledge
base
as
a
means
of
improving
glycemic
 control
and
minimizing
diabetes‐related
complications
(9,10,15,48,49,51).
 
Gaps
 in
nutrition
knowledge
 were
seen
in
three
areas:
1)
appropriate
counting
of
available
carbohydrate
(in
grams)
of
low
carbohyd‐ rate
vegetables;
2)
glycemic
index
and
its
post‐prandial
effect
on
glycemia;
and
3)
correct
consideration
 of
sugar
alcohols
in
label
reading
and
carbohydrate
counting.
 50
 Most
 respondents
 also
 demonstrated
 skilful
 insight
 regarding
 intensive
 insulin
 self‐management
 principles
 illustrated
 by
 their
 knowledge
 of
 carbohydrate
 to
 insulin
 ratios,
 correction
 factors/insulin
 sensitivity
factors,
appropriate
basal‐bolus
insulin
adjustment
and
the
use
of
a
reasonable
maximum
car‐ bohydrate
load
range
at
meals
and
snacks
to
support
optimal
post‐prandial
glycemia.

Study
findings
also
 indicate
that
only
two‐thirds
of
respondents
were
using
the
Bolus
Wizard™
calculator,
a
technology
with
 the
potential
to
support
more
accurate
bolus
dosing
and
superior
glycemic
control
(52‐54).


 Interestingly,
one
fifth
of
the
respondents
were
choosing
to
do
the
math
on
their
own
in
addition
to
 some
pumpers
who
are
opting
to
simply
follow
a
sliding
scale
of
insulin
based
on
their
pre‐prandial
blood
 glucose
reading.
 
The
reasons
as
to
why
all
adult
 insulin
pump
users
were
not
taking
advantage
of
this
 unique
pump
feature
were
not
explored.
 
A
possible
explanation
however,
may
stem
from
pump
users
 thinking
of
their
bolus
doses
in
terms
of
the
amount
of
insulin
they
require
based
on
past
experience
ra‐ ther
than
actually
taking
the
time
to
count
their
carbohydrate
load
at
meals/snacks.

This
theory
is
in
ac‐ cordance
 with
 study
 findings
 that
 indicate
 that
 respondents
 who
 rely
 on
 using
 the
 Bolus
 Wizard™,
 compared
to
respondents
who
do
not,
actually
read
labels
more
frequently.

Other
possible
explanations
 for
respondents
not
always
choosing
to
use
the
Bolus
Wizard™
may
be
related
to
frustration
around
in‐ accurate
Bolus
Wizard™
dose
suggestions
due
 to
maladjusted
personal
pump
rate
settings
 (i.e.,
 carbo‐ hydrate
 to
 insulin
 ratio
and
 insulin
 sensitivity/correction
 factor)
and
perhaps
a
 feeling
of
discomfort
 in
 using
a
pump
feature
they
have
not
been
properly
trained
on.
 Adult
 pumpers
 who
 indicated
 they
 use
 the
 Bolus
Wizard™
 also
 had
 significantly
 higher
 nutrition
 knowledge
scale
scores
compared
to
pumpers
who
did
not
use
it.

This
finding
potentially
indicates
that
 Bolus
Wizard™
users
have
a
better
understanding
of
diabetes‐related
nutrition
 information
and
carbo‐ hydrate
counting
skills
involved
in
insulin
pump
therapy.

Reliance
on
the
Bolus
Wizard™
was
not
associ‐ ated
with
a
greater
 level
of
satisfaction
with
nutrition
support,
a
 larger
DHC
team,
more
 frequent
DEC
 visits,
 a
 higher
 frequency
 of
 being
 taught
 carbohydrate
 counting,
more
 desirable
 glycemic
 control
 de‐ fined
by
respondents’
last
A1c
test
or
fewer
severe
hypoglycemic
episodes.
 Occurrences
of
severe
hypoglycemia
among
this
study’s
respondents
were
similar
to
findings
from
 the
DAFNE
study
where
approximately
a
fifth
of
respondents
experienced
one
or
more
severe
hypogly‐ cemic
 episodes
 (28).
 
 Respondents
who
 had
 not
 experienced
 any
 severe
 low
 blood
 glucose
 reactions
 were
found
to
have
higher
nutrition
knowledge
scores
compared
to
other
respondents
who
had
at
least
 one
severe
low
blood
glucose
reaction
in
the
past
6
months.

No
significant
differences
were
found
be‐ tween
 the
 two
groups
of
 respondents
 regarding
 their
 level
of
 satisfaction
with
nutrition
 support,
DHC
 team
size,
frequency
of
DEC
visits,
number
of
times
being
taught
carbohydrate
counting,
glycemic
control
 defined
by
respondents’
last
A1c
test
or
use
of
the
Bolus
Wizard™
calculator.

The
near‐normoglycemia
 achieved
by
 this
 sample
of
 adult
pumpers
based
on
 their
 last
 self‐reported
A1c
 test
 is
 consistent
with
 other
 research
 findings
 assessing
 the
 glycemic
 control
 of
 people
 using
 insulin
 pumps
 (4,39‐43,55)
 and
 continues
to
be
impressive
with
close
to
half
of
respondents
achieving
an
A1c
within
target
levels
(≤7%).

 Respondents
also
demonstrated
a
 strong
 commitment
 to
 self‐care
by
 regularly
 testing
 their
A1c
every
 51
 three
to
six
months,
which
is
also
in
accordance
with
the
Canadian
Diabetes
Association
(CDA)
practice
 guidelines
(9).
 The
significance
of
self‐management
education
(SME)
in
diabetes
care
is
evident
by
the
finding
that
 over
half
of
participants
identified
themselves
as
being
a
“self‐educator”.

Although
“self‐educators”
had
 slightly
 higher
 nutrition
 knowledge
 scale
 scores
 than
 “non‐self‐educators”,
 no
 differences
 in
 glycemic
 control
(i.e.,
A1c
or
occurrences
of
severe
hypoglycemia)
were
found
between
the
two
groups.

However,
 when
respondents
were
assessed
in
their
entirety,
higher
nutrition
knowledge
scale
scores
were
associ‐ ated
with
more
desirable
glycemic
control.
 These
 findings
 indirectly
 support
 the
 value
 of
 empowering
 adult
 insulin
 pump
 users
 to
 perceive
 themselves
as
“self‐educators”
as
a
means
of
encouraging
the
development
of
nutrition
knowledge
and
 potentially
 improving
glycemic
 control.
 
 These
 factors
 should
ultimately
help
 to
 limit
 the
development
 and
progression
of
diabetes‐related
complications
and
co‐morbidities.
 
 “Non‐self‐educators”
may
have
 been
aware
of
their
greater
need
for
support
as
they
visited
their
DEC
significantly
more
often
than
“self‐ educators”
and
were
hence
taught
carbohydrate
counting
more
frequently.

However,
because
perceived
 need
for
support
was
not
assessed,
this
cannot
be
confirmed
or
refuted.

When
looking
at
the
group
of
 respondents
as
a
whole,
the
recency
of
a
visit
to
a
DEC
was
not
associated
with
higher
nutrition
know‐ ledge
scale
scores
or
a
more
desirable
A1c
however,
it
was
associated
with
a
greater
degree
of
satisfac‐ tion
 regarding
 the
 level
of
nutrition
 support
 respondents
were
 receiving
as
well
 as
 the
use
of
 a
 larger
 DHC
team
to
provide
nutrition
education.

These
results
coincide
with
current
research
that
encourages
 the
 implementation
of
SME
principles
as
a
means
of
developing
a
greater
sense
of
 satisfaction
 for
 the
 person
with
diabetes
regarding
their
care,
 improved
glycemic
control
and
a
more
effective
relationship
 with
their
DHC
team
(9,48,50,56).
 Respondents
expressed
substantial
interest
in
learning
more
about
various
nutrition‐related
aspects
 of
insulin
pump
therapy
to
support
optimal
glycemic
control
in
addition
to
effective
strategies
to
support
 weight
management.

In
response
to
the
open‐ended
item
asking
for
comments
on
the
role
of
nutrition
 and
carbohydrate
 counting
 in
diabetes
management,
participants’
noted
 the
extensive
value
of
 carbo‐ hydrate
 counting
 and
 the
 importance
 of
 proper
 nutrition
 and
 sensible
 eating.
 Enthusiasm
 for
 pump
 therapy
compared
to
other
forms
of
insulin
delivery
was
also
expressed
and
the
central
role
of
the
DHC
 team
was
noted.
 In
 summary,
 core
 study
 findings
 support
 a
 positive
 correlation
 between
 nutrition
 knowledge
 and
 improved
glycemic
control
defined
by
more
desirable
A1c
levels
and
a
lack
of
hypoglycaemic
reactions.

 Satisfaction
 with
 nutrition
 support
 was
 linked
 to
 the
 size
 and
 scope
 of
 a
 person’s
 DHC
 team.
 
 Self‐ management
education
has
a
central
role
in
pump
therapy
and
diabetes
care.

Empowering
adult
pump‐ ers
to
perceive
themselves
as
a
“self‐educator”
may
be
an
effective
strategy
to
enhance
nutrition
know‐ ledge
and
potentially
 improve
glycemia.
 
Finally,
 this
sample
of
adult
pumpers
was
motivated
and
well
 educated
about
nutrition
and
carbohydrate
counting,
flexible
intensive
insulin
self‐management,
and
had
 good
glycemic
control.
 52
 3.3
 STRENGTHS
AND
LIMITATIONS
 A
survey
was
designed
to
characterize
adult
insulin
pump
users’
level
of
satisfaction
with
nutrition
sup‐ port,
sources
of
nutrition
information,
nutrition
knowledge
and
glycemic
control.

Relationships
amongst
 the
 above‐mentioned
 variables
were
 also
 assessed
 in
 an
 attempt
 to
 gain
 a
 broader
 understanding
 of
 what
adult
insulin
pump
users
know
and
do
regarding
the
role
of
nutrition
and
carbohydrate
counting
in
 diabetes
management.
 Some
strengths
of
this
study
include
the
extensive
process
involved
in
the
design
of
the
final
survey.

 This
included
the
recruitment
and
collaboration
with
a
national
diabetes
expert
advisory
committee
who
 assisted
with
the
identification
of
key
nutrition
and
diabetes
SME
principles
and
provided
helpful
insight
 regarding
the
original
design
of
the
survey.

This
was
followed
by
the
pilot
testing
of
the
second
version
 of
the
survey
with
adult
pumpers
known
to
the
investigative
team
and
members
of
an
adult
insulin
pump
 support
group.

Finally,
the
repeated
national
distribution
of
the
third
and
final
version
of
the
survey
by
 Medtronic
 inviting
Medtronic
 adult
 insulin
pump
users
 to
participate
 and
 complete
 the
on‐line
 survey
 over
the
course
of
month
in
addition
to
the
added
incentive
of
being
entered
into
a
draw
to
win
a
gift
 certificate
to
the
Medtronic
on‐line
store.
 This
 survey
 also
 had
 numerous
 limitations
 including
 the
 relatively
 small
 and
 possibly
 non‐ representative
sample
size.
At
the
time
of
the
survey
distribution,
Medtronic
served
approximately
80%
 of
Canadian
pump
users
totalling
8,800
French
and
English
speaking
adults
and
children.

Approximately
 66%
of
this
group
agreed
to
receive
more
information
from
Medtronic
in
English
and
77%
of
this
group
 were
adults
(18
years
of
age
and
older)
totalling
approximately
4,472
people.

However,
from
this
group,
 e‐mail
addresses
were
available
for
only
891
individuals
and
only
297
survey
results
were
usable.
 Accordingly,
the
results
reflect
the
views
of
a
relatively
small
group
of
potential
survey
respondents
 and
cannot
be
generalized
with
confidence
to
the
total
population
of
Canadian
adult
Medtronic
 insulin
 pump
users.

Potential
reasons
for
the
fact
that
only
20%
of
Medtronic
customers
provided
an
email
ad‐ dress
after
agreeing
to
receive
more
information
from
Medtronic
are
important
to
consider.

Firstly,
it
is
 unlikely
due
 to
adults’
 lack
of
access
 to
a
computer
or
 the
 internet.
 
Based
on
a
 report
 from
Statistics
 Canada,
Canada
was
close
to
achieving
universal
access
to
high
technology
at
home
in
2000.
 
Although
 the
 article
 focuses
 on
 youth,
 it
 states
 that
 nearly
 nine
 out
 of
 10
 young
 Canadians
 had
 a
 computer
 at
 home,
and
seven
out
of
10
had
access
to
the
internet
at
home
(57).

These
findings
must
surely
be
similar
 for
adults
especially
since
this
study
was
conducted
eight
years
after
the
original
data
were
collected
by
 Statistics
Canada.

Another
explanation
for
having
such
a
relatively
small
sample
size
may
have
been
indi‐ vidual’s
 hesitation
 to
 share
 their
 email
 address
 in
 the
 fear
 that
 they
would
be
 inundated
by
 company
 emails.
 
 An
 alternative
 option
 for
 survey
 distribution
 that
may
 have
 encouraged
 a
 larger
 sample
 size,
 could
have
been
to
use
a
mail
survey,
however
the
cost
of
a
mail
survey
would
have
been
prohibitive
and
 could
not
have
been
supported
by
the
study
budget.
 53
 In
addition,
 the
potential
of
study
findings
to
represent
only
Medtronic
customers
with
higher
so‐ cioeconomic
status
is
probable
due
to
the
unfortunate
fact
that
in
2008
little
financial
government
sup‐ port
 was
 available
 to
 assist
 people
 with
 diabetes
 with
 the
 purchase
 of
 a
 pump
 (approx.
 $6500)
 or
 supplies
(approx.
$250/month),
thus
limiting
the
access
of
pump
therapy
to
adults
who
were
able
to
af‐ ford
it
on
their
own
or
had
third
party
medical
insurance
(4).
 Other
potential
limitations
of
the
survey
are
related
to
the
survey
questions
themselves.

For
exam‐ ple,
statistical
analysis
regarding
respondents’
satisfaction
with
nutrition
support
was
based
on
one
ques‐ tion
 rather
 than
a
validated
 scale.
 
Although
 the
original
 survey
 contained
 several
questions
 regarding
 satisfaction,
it
was
felt
the
phrasing
of
the
questions
did
not
give
an
accurate
depiction
of
respondent’s
 true
level
of
satisfaction
and
ultimately
resulted
in
the
use
of
only
one
question
that
was
clear
and
con‐ cise.

Additional
questions
would
have
proven
helpful
in
strengthening
potential
relationships
with
nutri‐ tion
 knowledge
 and
 glycemic
 control.
 
 Although
 other
 studies
 have
 assessed
 satisfaction
 with
 overall
 diabetes
management,
no
studies
could
be
located
that
specifically
examined
satisfaction
with
nutrition
 support.

An
additional
limitation
pertains
to
the
nutrition
content
area
of
the
survey
being
based
solely
 on
topic
areas
identified
by
the
national
advisory
committee,
and
thus
may
not
reflect
all
aspects
of
nu‐ trition‐related
knowledge
relevant
to
adult
 insulin
pump
users.
 
Also,
 the
 lack
of
 reliable
and
validated
 nutrition
knowledge
surveys
for
adult
insulin
pump
users
resulted
in
the
use
a
non‐validated
carbohyd‐ rate
counting
study
assessment
test
to
help
guide
the
development
of
several
nutrition
and
label
reading
 questions
(58).

 Another
potential
design
flaw
of
the
survey
was
the
option
to
skip
questions
in
their
entirety
if
re‐ spondents
did
not
know
the
answer.

This
resulted
in
incomplete
data
sets
and
the
deletion
of
thirty‐one
 respondents.

Designing
the
survey
to
only
allow
participants
to
proceed
to
the
next
question
by
choos‐ ing
a
 response
option
would
potentially
 rectify
 this
 issue.
 
However,
 this
would
not
be
consistent
with
 obtaining
ethics
approval,
as
the
guidelines
stipulate
that
respondents
have
the
option
of
choosing
not
to
 answer
questions.


Finally,
glycemic
control
was
assessed
by
respondents’
most
recent
self‐reported
A1c
 test
versus
a
controlled
laboratory
test
result.
 3.4
 APPLICATIONS
 This
study
fills
a
gap
in
the
literature
by
exploring
what
a
sample
of
adult
insulin
pump
users
know
and
do
 regarding
the
role
of
nutrition
and
carbohydrate
counting
in
diabetes
management.

It
also
assesses
po‐ tential
 relationships
 among
 satisfaction
with
 nutrition
 support,
 sources
 of
 nutrition
 support,
 nutrition
 knowledge
and
glycemic
control.

As
a
result
this
study
helps
to
direct
and
focus
nutrition
education
ef‐ forts
 to
 support
optimal
glycemic
 control
 and
minimize
 the
development
and
progression
of
diabetes‐ related
complications
and
co‐morbidities.
 54
 The
DHC
team,
including
dietitians
and
DECs
in
particular,
can
use
study
findings
to
enhance
diabe‐ tes
 education
 efforts
 by
 reinforcing
 self‐management
 education
 principles
 such
 as
 empowerment
 and
 self‐efficacy
regarding
insulin
dose
adjustment
and
general
diabetes
management.

Emphasizing
the
im‐ portance
of
counting
the
carbohydrate
 in
 low
carbohydrate
vegetables,
 reinforcing
the
application
and
 value
of
 following
a
 low
GI
diet,
and
 label
 reading
with
 sugar
alcohols
may
be
helpful
 concepts
 to
 im‐ prove
nutrition
knowledge
and
potentially
glycemic
control.
 
 The
multi‐
and
 interdisciplinary
nature
of
 the
DHC
team
combined
with
an
emphasis
on
sharing
a
comprehensive
plan
of
care
demands
 the
dis‐ semination
 of
 accurate
 and
 consistent
 nutrition
 and
 diabetes‐related
 educational
 materials.
 
 The
 Ca‐ nadian
Diabetes
Nutrition
Committee
has
done
an
excellent
 job
 in
developing
such
resources,
many
of
 which
are
free
upon
request.
 
The
widespread
adoption
of
these
resources
amongst
DHC
professionals
 should
be
encouraged
to
promote
the
use
of
reliable
messages
regarding
nutrition,
carbohydrate
count‐ ing,
and
diabetes
care.
 The
 finding
that
adult
 insulin
pump
users
who
perceive
themselves
as
being
a
“self‐educator
“
do
 not
visit
their
DEC
as
often
as
“non‐self‐educators”
begs
the
questioning
of
why
this
is
the
case
and
could
 warrant
additional
exploration.

Although
“self‐educators”
may
feel
that
they
do
not
need
the
extra
nu‐ trition
and
diabetes‐related
support
from
their
DEC
and
are
competent
to
manage
their
diabetes
more
 independently,
it
is
possible
that
some
adult
pumpers
are
not
having
their
education
needs
met
resulting
 in
less
frequent
DEC
use.

Ensuring
DECs
have
educators
that
are
comfortable
with
insulin
pump
technol‐ ogy
and
developing
classes
that
are
designed
to
meet
the
specific
needs
of
this
unique
insulin‐dependent
 population
group
may
result
in
DECs
playing
a
larger
role
in
the
management
of
adult
pumpers
regard‐ less
of
whether
they
perceive
themselves
as
being
a
“self‐educator”
or
not.

Findings
from
this
study
help
 identify
areas
of
further
interest
by
adult
pumpers
and
include
when
to
use
advanced
bolus
options
(i.e.,
 normal,
 square
 or
 combo
 bolus),
 appropriate
 insulin
 adjustment
 in
 special
 situations
 (i.e.,
 eating
 out,
 holiday,
vacation,
etc.),
exercise,
nutrition
for
weight
management,
healthy
eating
guidelines,
etc.
 3.5
 FUTURE
DIRECTIONS
 The
design
and
findings
from
this
study
support
numerous
avenues
of
future
research.

One
possible
op‐ tion
would
 involve
the
fine‐tuning
of
 the
nutrition
knowledge
aspect
of
 the
electronic
survey.
 
 It
could
 then
potentially
be
used
as
a
 standardized
evaluative
 tool
 in
assessing
 the
nutrition
and
 carbohydrate
 counting
skills
of
adults
using
 flexible
 intensive
 insulin
self‐management
therapy.
 
A
 tool
of
 this
nature
 has
the
potential
to
identify
areas
of
nutrition
and
carbohydrate
counting
that
may
be
preventing
opti‐ mal
glycemic
control
defined
by
A1c
test
results
and
the
frequency
of
severe
hypoglycemia.
 A
 cross‐sectional
 study
 exploring
 the
 potential
 barriers
 and
 frustrations
 adult
 insulin
 pump
 users
 have
regard
the
use
of
their
“smart
pump”
bolus
calculator
(i.e.,
Bolus
Wizard™)
would
also
be
of
interest
 due
to
the
noted
glycemic
advantages
associated
with
its
use.
 55
 Another
potential
research
initiative
would
be
to
conduct
a
comparative
study
using
the
same
sur‐ vey
with
adults
using
multiple
daily
 injections.
 
Findings
could
identify
potential
differences
 in
nutrition
 knowledge
 and
 carbohydrate
 counting
 skills
 between
 adults
 using
 multiple
 daily
 injections
 vs.
 pump
 therapy.

Results
could
then
possibly
be
used
to
guide
insulin
pump
training
efforts
to
support
a
smooth
 and
successful
transition
from
one
method
of
insulin
delivery
to
another.
 Finally,
the
area
of
satisfaction
in
relation
to
nutrition
support
has
not
been
widely
developed
and
 would
help
to
direct
future
education
efforts
by
the
DHC
team
to
support
desired
behavioural
and
gly‐ cemic
outcomes.
Conducting
a
qualitative
study
with
focus
groups
may
support
exploratory
research
of
 this
nature.
 56
 3.6
 TABLES
 Table
7:
Summary
of
specific
study
objectives
and
key
research
findings1
 Objective
1:

Demographic
and
anthropometric
characteristics
of
adult
insulin
pump
users
 SEX
(n):
male
(104),
female
(193).
 AGE
(mean
years
±
SD,
n):
all
(44.2
±
11.9,
292),
male
(45.9
±12.6,
103),
female
(43.3
±
11.5,
189),
range
 (19
–
79).
 BODY
MASS
INDEX
(mean
Kg/m2,
n):

all
(27
±5.7,
294),
male
(27.9
±
4.9,
104),
female
(26.5
±
6.1,
190),
 range
(17.0
–
64.7).
 TYPE
1
DIABETES
(%,
n):
all
(92.9,
276),
male
(90.4,
94),
female
(94.3,
182).
 TIME
USING
A
PUMP
(mean
years
±SD,
n):

all
(4.3
±
6.0,
295),
male
(3.8
±
5.8,
104),
female
(4.6
±6.1,
 191),
range
(0.5
–
37.0).
 SCHOOLING
(%,
n):
 • Some
University
or
less:
all
(45.1,
134),
male
(46.2,
48),
female
(44.6,
86).
 • University
graduate:
all
(39.7,
118),
male
(36.5,
38),
female
(41.5,
80).
 • Graduate
degree:
all
(15.2,
45),
male
(17.3,
18),
female
(14.0,
27).
 Objective
2:
Characterize
adult
pump
users’
level
of
satisfaction
with
nutrition
support
 Respondents
(n
=
290)
mean
satisfaction
score2
was
3.7
±
1.0
out
of
a
possible
score
of
5.0.
 Objective
3:
Characterize
adult
pump
users’
sources
of
nutrition
information
 Respondents
used
a
mean
of
1.7
±
1.3
health
care
professionals
for
their
diabetes
management3.
 Respondents
identified
dietitians
(50.2%)
as
their
main
source
of
nutrition
support,
in
addition
to
their
 DEC
(50.2%),
followed
by
specialists
(30.3%),
nurses
(19.9%)
and
general
practitioners
(17.8%).
 A
large
portion
of
respondents
(62.0%)
indicated
they
are
a
“self‐educator”.
 Of
289
respondents,
the
majority
(59.5%)
indicated
they
had
visited
a
DEC
in
the
last
12
months
and
an
 additional
16.3%
indicated
they
had
visited
a
DEC
in
the
past
one
to
two
years.
 Respondents
mean
DEC
score4
was
5.2
±
1.2
out
of
a
possible
score
of
6.0.
 Of
282
respondents,
over

half
(58.5%)
indicated
they
had
seen
a
dietitian
to
learn
about
carbohydrate
 counting
≥
three
times
while
20.2%
indicated
they
had
been
taught
carbohydrate
counting
twice
and
 16.3%
indicated
they
had
only
been
taught
carbohydrate
counting
once.

Only
5.0%
of
respondents
 indicated
they
had
never
been
taught
how
to
count
carbohydrates
by
a
dietitian.

 Respondents
mean
number
of
times
being
taught
carbohydrate
counting
score5
was
4.6
±
1.2
out
of
a
 possible
score
of
6.0.
 57
 Objective
4:

 Characterize
adult
pump
users’
nutrition
knowledge

 GENERAL
NUTRITION:
 • The
overall
mean
nutrition
knowledge
scale
score6
for
respondents
was
70.8
±
16.9%
or
9.2
±
2.2
out
 of
a
possible
score
of
13.
 • Almost
all
respondents
(89.9%)
identified
carbohydrate
as
the
macronutrient
that
is
fully
converted
 to
sugar
2
hours
after
eating,
if
eaten
on
its
own.
 • The
majority
of
respondents
correctly
indicated
that
fats
(72.4%)
and
protein
(88.9%)
do
not
contain
 carbohydrate.
 • All
respondents
agreed
that
starchy
vegetables
(i.e.,
potatoes,
peas,
corn,
winter
squash,
beans)
 contain
carbohydrate.
 • More
than
a
quarter
of
respondents
(37.4%)
falsely
indicated
that
some
vegetables
(i.e.,
broccoli,
 tomatoes,
green
beans
and
cauliflower)
do
not
contain
carbohydrate.
 • Most
respondents
(83.2%)
correctly
indicated
that
the
addition
of
fat,
protein,
and
fibre
will
slow
the
 digestion
of
carbohydrate
when
included
in
the
same
meal.
 GLYCEMIC
INDEX
(GI):
Over
three‐quarters
of
respondents
(76.4%)
stated
they
were
familiar
with
the
 concept
of
GI.

However
of
those
respondents
only
approximately
two‐thirds
(70.5%)
correctly
chose
 the
food
item
with
the
highest
GI
from
the
food
list
provided.

 TREATMENT
OF
HYPOGLYCEMIA:
The
majority
of
respondents
(89.9%)
indicated
an
appropriate
answer
 when
questioned
about
how
to
treat
a
low
blood
glucose.
 LABEL
READING:
 • Respondents
(n
=
295)
mean
frequency
of
label
reading
score7
was
4.3
±
0.9
out
of
a
possible
score
 of
5.0.
 • The
majority
of
respondents
(84.4%)
correctly
indicated
that
when
reading
food
labels,
the
gram
 count
for
“carbohydrate”
is
more
important
than
the
gram
count
for
“sugar”
(n
=
294).
 • Almost
all
of
respondents
(99%)
correctly
indicated
that
food
labels
with
the
claim
“no
added
sugar”
 will
NOT
raise
blood
glucose
at
all
was
false.
 • Almost
all
of
respondents
(98%)
accurately
identified
the
correct
serving
size.
 • Almost
all
of
respondents
(93.9%)
properly
identified
the
carbohydrate
for
a
half
serving.
 • In
the
2
cases
presented,
only
59.1%
(n
=
296)
and
59.6%
of
respondents
properly
identified
the
 amount
of
available
carbohydrate
by
subtracting
all
of
the
fibre
from
the
total
amount
of
 carbohydrate
.
 • Only
6.4%
of
respondents
correctly
subtracted
all
of
the
fibre
and
half
of
the
sugar

alcohols
to
 identify
the
total
amount
of
available
carbohydrate
(n
=
295).
 USE
OF
THE
BOLUS
CALCULATOR
(i.e.,
Bolus
Wizard™):

Response
to
the
question
“how
do
you
decide
 how
much
insulin
to
give
yourself
when
eating
a
meal
or
snack”:
 • Approximately
two‐thirds
of
respondents
(67.3%)
stated
they
use
the
Bolus
Wizard™
calculator.
 • A
fifth
(20.2%)
of
respondents
stated
they
calculate
their
own
bolus
insulin
dose
using
their
personal
 CIR
and
CF/
ISF.
 • Less
than
a
tenth
(7.1%)
of
respondents
indicated
that
they
use
a
sliding
scale
based
on
their
pre‐ meal/snack
blood
glucose
levels.
 58
 PRINCIPLES
OF
FLEXIBLE
INTENSIVE
INSULIN
SELF‐MANAGEMENT:
 • Approximately
two‐thirds
of
respondents
(64.6%)
indicated
they
have
a
range
of
carbohydrates
they
 try
to
stay
within
at
meals
and
snacks.
 • For
females,
the
mean
upper
range
of
carbohydrates
at
meals
was
59.8
±24.0
grams
(n
=
117)
and
 25.8
±
12.2
grams
at
snacks
(n
=
112).
 • For
men,
the
mean
upper
range
of
carbohydrates
they
eat
at
meals
was
86.6
±
26.6
grams
(n
=
64)
 and
34.8
±
14.3
grams
at
snacks
(n
=
60).
 • The
majority
of
respondents
(86.2%)
indicated
that
they
knew
their
CIR
and
CF/ISF
(69.9%)
for
their
 first
meal
of
the
day
(n
=
296).
 • For
females,
the
mean
CIR
was
11.1
±4.5
grams
(n
=
160)
and
mean
CF/ISF
was
2.6
±
1.4
mmol/L
(n
=
 130).
 • For
men,
the
mean
CIR
was
9.6
±
3.6
grams
(n
=
95)
and
mean
CF/ISF
was
2.2
±
1.4
mmol/L
(n
=
77).
 • Over
three‐quarters
of
participants
(82.5%)
correctly
indicated
that
they
would
reduce
their
basal
 insulin
if
their
blood
glucose
dropped
overnight
or
if
they
skipped
a
meal.
 Objective
5:


 Characterize
adult
pump
users’
glycemic
control
 SEVERE
LOW
BLOOD
GLUCOSE
REACTIONS8:
 • Approximately
a
quarter
(23.7%)
of
respondents
reported
having
one
or
more

severe
low
blood
 glucose
reaction
in
the
last
6
months
while
three‐quarters
(76.3%)
of
respondents
denied
 experiencing
any
(n
=
296).
 • Almost
two‐thirds
of
respondents
(64%)
indicated
having
their
A1c
test
done
within
the
last
three
 months
while
an
additional
26.9%
indicated
having
it
done
within
the
last
six
months.
 A1C
TEST9:
 • The
majority
of
respondents
(84.8%)
indicated
that
they
knew
the
result
of
their
most
recent
A1c
 test
(n
=
252).
 • The
mean
A1c
test9
was
7.2%
±
1.0
and
ranged
from
5.1
–
11.1%
(n
=
252).
 • Almost
half
of
respondents
(47.6%)
indicated
their
latest
A1c
test9
result
was
≤
7.0%
(n
=
252).
 59
 Objective
6:


 Assess
whether
relationships
exist
among
adult
insulin
pumps
users’
understanding
of
 nutrition6,
satisfaction
with
nutrition
support2,
support
from
their
DHC
team
regarding
 nutrition3,
and
glycemic
control9
 CHARACTERISTICS
OF
RESPONDENTS
USING
BIVARIATE
CORRELATION:
 • Satisfaction2
with
nutrition
support
was
found
to
be
positively
correlated
with
the
number
of
DHC
 team
members3
that
provide
nutrition
support
(r
=
0.412,
p
=
0.001),
frequency
of
contact
with
a
 DEC4
(r
=
0.254,
p
=
0.001),
frequency
of
label
reading7
(r
=
0.207,
p
=
0.001)
and
frequency
of
being
 taught
carbohydrate
counting5
(r
=
0.193,
p
=
0.001).
 • The
number
of
DHC
team
members3
who
provide
nutrition
support
was
found
to
be
positively
 correlated
with
the
frequency
of
contact
with
a
DEC4
(r
=
0.386,
p
=
0.001),
frequency
of
label
 reading7
(r
=
0.186,
p
=
0.001),
and
frequency
of
being
taught
carbohydrate
counting5
(r
=
0.231,
p
=
 0.001).
 • Frequency
of
contact
with
a
DEC4
was
found
to
be
positively
correlated
with
frequency
of
label
 reading7(r
=
0.187,
p
=
0.001)
and
frequency
of
times
being
taught
carbohydrate
counting5
(r
=
0.310,
 p
=
0.001).
 • A
small
positive
correlation
was
found
between
nutrition
knowledge6
and
frequency
of
label
 reading7
(r
=
0.150,
p
=
0.010).
 • A
small
negative
correlation
was
found
between
nutrition
knowledge6
and
glycemic
control9
(i.e.,
 those
with
higher
nutrition
knowledge
scale
scores
had
lower
A1c
values)
(r
=
–
0.171,
p
=
0.006).
 CHARACTERISTICS
OF
RESPONDENTS
BY
USE
OF
THE
BOLUS
WIZARD™
CALCULATOR:
Use
the
Bolus
 Wizard™
(n
=
200)
vs.
those
who
do
not
(n
=
97):
 • A
significant
relationship
was
found
between
people
who
use
the
Bolus
Wizard™
and
nutrition
 knowledge6
(Z
=
‐2.137,
p
=
0.033)
and
the
frequency
of
label
reading7
to
determine
the
quantity
of
 carbohydrate
they
are
consuming
(Z
=
‐3.026,
p
=
0.002).
 • No
significant
differences
were
found
regarding
satisfaction2
(t
=
1.951,
p
=
0.052),
DHC
team
 members3
(t
=
1.658,
p
=
0.098),
frequency
of
DEC
visits4
(t
=
1.416,
p
=
0.158),
frequency
of
times
 being
taught
carbohydrate
counting5
(t
=
–
0.304,
p
=
0.761),
A1c
test9
(t
=
–
0.075,
p
=
0.940)
or
 occurrence
of
severe
hypoglycemia8
(x2

=
0.055,
p
=
0.814).
 COMPARISON
OF
RESPONDENTS
BY
EXPERIENCE
OF
SEVERE
HYPOGLYCEMIC
EVENTS8
in
the
past
6
 months:
No
events
(n
=
226)
vs.
those
who
had
≥1
(n
=
71):
 • Respondents
with
no
significant
hypoglycemic
events8
had
significantly
higher
nutrition
knowledge
 scale
scores6
(t
=
3.275,
p
=
0.001).
 • No
significant
differences
were
found
regarding
satisfaction2
(t
=
0.478,
p
=
0.633),
DHC
team
 members3
(t
=
0.580,
p
=
0.562),
frequency
of
DEC
visits4
(Z
=
–
0.112,
p
=
0.911),
frequency
of
label
 reading7
(t
=
0.795,
p
=
0.427),
frequency
of
times
being
taught
carbohydrate
counting5
(t
=
–
1.415,
p
 =
0.158),
glycemic
control9
(t
=
‐1.148,
p
=
0.252)
or
use
of
Bolus
Wizard™
calculator
(x2
=
0.055,
p
=
 0.814).
 60
 CHARACTERISTICS
OF
SELF‐EDUCATORS
(n
=
184)
vs.
non‐self‐educators
(n
=
113):
 • Self‐educators
scored
significantly
higher
on
the
nutrition
knowledge
scale6
(t
=
2.614,
p
=
0.009).
 • Non‐self‐educators
had
a
 significantly
 greater
 frequency
of
 contact
with
 their
DEC4
 (t
 =
2.157,
p
 =
 0.032)
and
were
taught
carbohydrate
counting5
more
often
(t
=
2.943,
p
=
0.004).
 • No
significant
differences
were
found
regarding
satisfaction2
(Z
=
–
1.945,
p
=
0.052),
number
of
DHC
 team
members3
who
provide
nutrition
support
(Z
=
‐0.406,
p
=
0.685),
frequency
of
label
reading7
(t
 =
0.478,
p
=
0.633),
glycemic
control9
 (t
=
0.614,
p
=
0.539),
use
of
Bolus
Wizard™
calculator
 (x2
=
 0.078,
p
=
0.780),
or
occurrence
of
severe
hypoglycemia8
(x2
=
0.076,
p
=
0.782).
 o COMPARISON
OF
DICHOTOMOUS
GROUPS
based
on
an
approximate
50:50
group
split
 for
number
of
 DHC
team
members3
who
provide
nutrition
support
(0
–
1
vs.
≥
2),
frequency
of
contact
with
a
DEC4
(≤
 1
year
vs.
>1
year),
and
nutrition
knowledge6
(high
vs.
low):
 • No
 differences
 in
 nutrition
 knowledge6
 (t
=
 1.565,
p
 =
 0.119)
 or
 glycemic
 control9
 (t
 =
 0.317,
p
 =
 0.752)
were
observed
between
the
two
DHC
team
member
groups3.
 • No
differences
in
nutrition
knowledge6
(t
=
‐1.032,
p
=
0.303)
or
glycemic
control9
(Z
=
–
0.256,
p
=
 0.798)
were
observed
between
the
two
DEC
groups4.
 • Respondents
in
the
high
nutrition
knowledge
group6
had
more
desirable
A1c
test
results
compared
 to
respondents
in
the
lower
nutrition
knowledge
group6
(t
=
‐2.341,
p
=
0.020).
 Objective
7:


 Potential
topics
of
further
interest
related
to
pumping
(optional,
multiple
choice
and
open‐ ended)
(n
=
297)
 o Use
 of
 different
 bolus
 delivery
 options
 (i.e.,
 normal,
 square
 or
 dual
 wave)
 based
 on
 different
meal
 choices
(63%).
 o Appropriate
 insulin
 adjustments
 when
 eating
 out
 (i.e.,
 restaurants,
 vacation,
 other
 people’s
 homes,
 etc.)
 (54.9%),
exercising
(55.7),
based
on
food
choices
and
carbohydrate
counting
(33.7%),
and
blood
 glucose
values
(26.6%).
 o Nutrition
for
weight
management
(49.8%).
 o General
guidelines
for
healthy
eating
(29.3%).
 Objective
8:


 The
role
of
nutrition
and
carbohydrate
counting
in
diabetes
management
(optional,
open‐ ended
item),
(n
=
97)
 o The
critical
role
carbohydrate
counting
plays
in
their
diabetes
management
(48.5%,
n
=
47).
 o The
importance
of
proper
nutrition
and
sensible
eating
(18.6%,
n
=
18).
 o The
extent
to
which
they
enjoy
using
their
pump
(13.4%,
n
=
13).
 o The
importance
of
support
from
their
DHC
team
(6%,
n
=
6).
 1

Unless
otherwise
indicated,
n
=
297.

Any
exclusion
of
missing
data
is
specifically
noted.

For
raw
data
on
univariate
re‐ sponses
to
all
survey
items,
see
Appendix
7.1
and
for
raw
data
on
multivariate
responses,
see
Appendix
7.2.
 2

Response
to
the
question
“I
am
very
satisfied
with
the
nutrition
support
I
receive”,
a
five‐point
Likert‐type
scale
was
used
 where
1
=
strongly
disagree
and
5
=
strongly
agree.
 61
 3
 
Determined
from
response
to
the
question
“who
currently
provides
your
nutrition
support
for
your
diabetes
manage‐ ment?
(Please
check
all
that
apply)”,
can
range
from
zero
to
five
DHC
professionals.
 4
 
Response
to
the
question
“when
was
your
 last
visit
 to
a
DEC?”,
where
2
=
never
been
to
a
DEC,
3
=
more
than
three
 years
ago,
4
=
two
to
three
years
ago,
5
=
one
to
two
years
ago
and
6
=
within
the
last
12
months.
 5

Response
to
the
question
“how
many
times
have
you
seen
a
dietitian
to
learn
about
how
insulin
matches
food
(carbo‐ hydrate
counting)”,
where
2
=
I
have
never
met
with
a
dietitian,
3
=
one
time,
4
=
two
times,
5
=
three
to
five
times
and
 6
=
more
than
five
times.
 6

Comprised
of
13
survey
questions.
 7
 
Response
to
 the
question
“how
often
do
you
use
the
 label
 to
count
the
number
of
carbohydrates
 in
your
meal/snack
 versus
estimating?”,
a
five‐point
Likert‐type
scale
was
used
where
1
=
almost
never
and
5
=
almost
always.
 8

Severe
hypoglycemic
episode
was
defined
as
“resulting
in
passing
out
or
needing
someone
else’s
help”.
 9

Most
recent
A1c
test
result,
self‐reported.
 62
 3.7
 REFERENCES
 (1)
Diabetes
Control
and
Complications
Trial
(DCCT)
Research
Group.
The
effect
of
intensive
treatment
of
 diabetes
on
the
development
and
progression
of
long‐term
complications
in
insulin‐dependent
 diabetes
mellitus.
New
Engl
J
Med
1993;329:977‐986.
 (2)
UK
Prospective
Diabetes
Study
(UKPDS)
Group.
Intensive
blood‐glucose
control
with
sulphonylureas
 or
insulin
compared
with
conventional
treatment
and
risk
of
complications
in
patients
with
type
 2
diabetes
(UKPDS
33).
Lancet
1998;352:837‐53.
 (3)
Pickup
JC,
Keen
H,
Parsons
JA,
et
al.
Continuous
subcutaneous
insulin
infusion:
an
approach
to
 achieving
normoglycaemia.
BMJ
1978:1:204‐207.
 4)
Scheiner
G,
Sobel
RJ,
Smith
DE,
et
al.
Successful
outcomes
with
insulin
pump
therapy.
Diabetes
Educ
 2009;35(Suppl.
2):S29‐S41.
 (5)
Bode
BW,
Tamborlane
WV,
Davidson
PC.
Insulin
pump
therapy
in
the
21st
century.
Postgrad
Med
 2002;111(5):69‐77.
 (6)
Pickup
JC,
Keen
H.
Continuous
subcutaneous
insulin
infusion
at
25
years.
Diabetes
Care
 2002;25(3):593‐598.
 (7)
Walsh
J,
Roberts
R.
Pumping
insulin:
everything
you
need
for
success
on
a
smart
insulin
pump.
4th
ed.
 San
Diego:
Torrey
Pines
Press;
2006.
 (8)
Rabasa‐Lhoret
R,
Garon
J,
Langelier
H,
et
al.
Effects
of
meal
carbohydrate
content
on
insulin
 requirements
in
type
1
diabetic
patients
treated
intensively
with
basal‐bolus
(ultralente‐regular)
 insulin
regimen.
Diabetes
Care
1999;22(5):667‐673.
 (9)
Canadian
Diabetes
Association
Clinical
Practice
Guidelines
Expert
Committee.
Canadian
Diabetes
 Association
2008
clinical
practice
guidelines
for
the
prevention
and
management
of
diabetes
in
 Canada.
Can
J
Diabetes
2008;32
(Suppl
1):S1‐S201.
 (10)
Anderson
EJ,
Delahanty
L,
Richardson
M,
et
al.
Nutrition
interventions
for
intensive
therapy
in
the
 diabetes
control
and
complications
trial.
The
Diabetes
Control
and
Complications
Trial
(DCCT).
J
 Am
Diet
Assoc
1993;93(7):768‐772.
 (11)
Kulkarni
K.
Carbohydrate
counting:
a
practical
meal‐planning
option
for
people
with
diabetes.
Clin
 Diabetes
2005;23(3):120‐124.
 (12)
Gillespie
SJ,
Kulkarni
KD,
Daly
AE.
Using
carbohydrate
counting
in
diabetes
clinical
practice.
J
Am
Diet
 Assoc
1998;98(8):897‐905.
 (13)
Sumner
J,
Dyson
P,
Allan
S.
Local
application
of
CHO
counting
and
insulin
dose
adjustment.
J
 Diabetes
Nursing
2003;7(2):59‐61.
 (14)
Kelley
D.
Sugars
and
starch
in
the
nutritional
management
of
diabetes
mellitus.
Am
J
Clin
Nutr
 2003;78(suppl):858S‐864.
 63
 (15)
Franz
MJ,
Boucher
JL,
Green‐Pastors
J,
Powers
MA.
Evidence‐based
nutrition
practice
guidelines
for
 diabetes
and
scope
and
standards
of
practice.
J
Am
Diet
Assoc
2008;108:S52‐S58.
 (16)
Warshaw
HS,
Bolderman
KM.
Practical
carbohydrate
counting:
a
how‐to
teach
guide
for
health
 professionals.
2nd
ed.
Alexandria:
American
Diabetes
Association,
Inc.;
2008.
 (17)
Oswald
G,
Kinch
A,
Ruddy
E.
Transfer
to
a
patient
centred,
carbohydrate
counting
and
insulin
 matching
programme
in
a
shortened
time
frame:
a
structured
education
programme
for
type
1
 diabetes
incorporating
intensified
conventional
therapy
and
CSII.
Practical
Diabetes
Int
 2004;21(9):334‐338.
 (18)
Everett
J,
Jenkins
E,
Kerr
D,
Cavan
DA.
Implementation
of
an
effective
outpatient
intensive
education
 programme
for
patients
with
type
1
diabetes.
Practical
Diabetes
Int
2003;20(2):51‐55.
 (19)
Plank
J,
Kohler
G,
Rakovac
I,
et
al.
Long‐term
evaluation
of
a
structured
outpatient
education
 programme
for
intensified
insulin
therapy
in
patients
with
type
1
diabetes:
a
12‐year
follow‐up.
 Diabetologia
2004;47:1370‐1375.
 (20)
Voevodin
M,
Steele
C,
Pierce
K,
Colman
P.
Eating
and
pumping:
evaluating
the
nutrition
service
of
 the
insulin
pump
clinic
at
the
Royal
Melbourne
Hospital.
Nutr
Diet
2003;60(2):122‐125.
 (21)
Almazadeh
R,
Berhe
T,
Wyatt
DT.
Flexible
insulin
therapy
with
glargine
insulin
improved
glycemic
 control
and
reduced
severe
hypoglycemia
among
preschool‐aged
children
with
type
1
diabetes
 mellitus.
Pediatrics
2005;115:1320‐1324.
 (22)
Delahanty
LM,
Halford
BN.
The
role
of
diet
behaviors
in
achieving
improved
glycemic
control
in
 intensively
treated
patients
in
the
Diabetes
Control
and
Complications
Trial.
Diabetes
Care
 1993;16(11):1453‐1458.
 (23)
Waller
H,
Eiser
C,
Knowles
J,
et
al.
Pilot
study
of
a
novel
educational
programme
for
11‐16
year
olds
 with
type
1
diabetes:
the
KICK‐OFF
course.
Arch
Dis
Child
2008;93:927‐931.
 (24)
Lowe
J,
Linjawi
S,
Mensch
M,
et
al.
Flexible
eating
and
flexible
insulin
dosing
in
patients
with
 diabetes:
results
of
an
intensive
self‐management
course.
Diabetes
Resear
Clin
Prac
 2008;80:439‐443.
 (25)
Mehta
SN,
Quinn
N,
Volkening
LK,
et
al.
Impact
of
carbohydrate
counting
on
glycemic
control
in
 children
with
type
1
diabetes.
Diabetes
Care
2009;32(6):1014‐1016.
 (26)
Trento
M,
Trinetta
A,
Borgo
E,
et
al.
Carbohydrate
counting
improves
coping
ability
and
metabolic
 control
in
patients
with
type
1
diabetes
managed
by
Group
Care.
J
Endocrinol
Invest.
2010
May
3
 [Epub
ahead
of
print].
 (27)
Pytka
E.
Nutritional
strategies
in
type
1
diabetes:
calories
are
important,
but
carbohydrates
count!
 Can
Diabetes
2009;22(2):3‐6.
 (28)
DAFNE
Study
Group.
Training
in
flexible,
intensive
insulin
management
to
enable
dietary
freedom
in
 people
with
type
1
diabetes:
dose
adjustment
for
normal
eating
(DAFNE)
randomised
controlled
 trial.
BMJ
2003;325:746.
 64
 (29)
Muhlhauser
I,
Jorgens
V,
Berger
M,
et
al.
Bicentric
evaluation
of
a
teaching
and
treatment
 programme
for
type
1
(insulin
dependent)
diabetic
patients:
improvement
of
metabolic
control
 and
other
measures
of
diabetes
care
for
up
to
22
months.
Diabetologia
1983;25:470‐476.
 (30)
Muhlhauser
I,
Bott
U,
Overmann
H,
et
al.
Liberalized
diet
in
patients
with
type
1
diabetes.
J
intern
 Med
1995;237(6):591‐597
 (31)
Starostina
EG,
Antisferov
M,
Galstyan
GR,
et
al.
Effectiveness
and
cost‐benefit

analysis
of
intensive
 treatment
and
teaching
programmes
for
type
1
diabetes
in
Moscow.
Diabetologia
1994;37:170‐ 176.
 (32)
Chiesa
G,
Piscopo
MA,
Rigamonti
A,
et
al.
Insulin
therapy
and
carbohydrate
counting.
Acta
Biomed
 2005;76;Suppl.3:44‐48.
 (33)
Jenkins
E.
Carbohydrate
counting:
successful
dietary
management
of
type
1
diabetes.
J
Diabetes
 Nursing
2006;10(4):150‐154.
 (34)
Wheeler
ML,
Pi‐Sunyer
FX.
Carbohydrate
Issues:
Type
and
Amount.
J
Am
Diet
Assoc
2008;108:S34‐ S39.
 (35)
Muhlhauser
I,
Bruckner
I,
Berger
M,
et
al.
Evaluation
of
an
intensified
insulin
treatment
and
teaching
 programme
as
routine
management
of
type
1
(insulin
dependent)
diabetes:
The
Bucharest‐ Dusseldorf
Study.
Diabetologia
1987;30:681‐690
 (36)
Samann
A,
Muhlhauser
I,
Bender
R,
et
al.
Glycaemic
control
and
severe
hypoglycemia
following
 training
in
flexible
intensive
insulin
therapy
to
enable
dietary
freedom
in
people
with
type
1
 diabetes:
a
prospective
implementation
study.
Diabetologia
2005;48:1965‐1970.
 (37)
Nicolucci
A,
Maione
A,
Franciosi
M,
et
al.
Quality
of
life
and
treatment
satisfaction
in
adults
with
type
 1
diabetes:
a
comparison
between
continuous
subcutaneous
insulin
infusion
and
multiple
daily
 injections:
The
Equality
1
Study
Group.
Diabetes
Med
2008;25:213‐220.
 (38)
Hammond
P,
Liebel
A,
Grunder
S.
International
survey
of
insulin
pump
users:
impact
of
continuous
 subcutaneous
insulin
infusion
therapy
on
glucose
control
and
quality
of
life.
Prim
Care
Diabetes
 2007;1(3):143‐146.
 (39)
Fatourechi
MM,
Kudva
YC,
Murad
MH,
et
al.
Hypoglycemia
with
intensive
insulin
therapy:
A
 systematic
review
and
meta‐analyses
of
randomized
trials
of
continuous
subcutaneous
insulin
 infusion
versus
multiple
daily
injections.
J
Clin
Endocrinol
Metab
2009;94(3):729‐740.
 (40)
Pickup
JC
SA.
Severe
hypoglycaemia
and
glycaemic
control
in
type
1
diabetes:
meta‐analysis
of
 multiple
daily
insulin
injections
compared
with
continuous
subcutaneous
insulin
infusion.
 Diabetic
Med
2008;25:765‐774.
 (41)
Pickup
JC,
Mattock
M,
Kerry
S.
Glycaemic
control
with
continuous
subcutaneous
insulin
infusion
 compared
with
intensive
insulin
injection
in
patients
with
type
1
diabetes:
meta‐analysis
of
 randomised
controlled
trials.
BMJ
2002;324:705‐708.
 (42)
Jeitler
K,
Horvath
K,
Berghold
A,
et
al.
Continuous
subcutaneous
insulin
infusion
versus
multiple
daily
 insulin
injections
in
patients
with
diabetes
mellitus:
systematic
review
and
meta‐analysis.
 Diabetologia
2008;51:941‐951.
 65
 (43)
Bolli
GB,
Kerr
D,
Reena
T,
et
al.
Comparison
of
multiple
daily
insulin
injection
regimen
(basal
once‐ daily
glargine
plus
mealtime
lispro)
and
continuous
subcutaneous
insulin
infusion
(lispro)
in
type
 1
diabetes.
Diabetes
Care
2009;32(7):1170‐1176.
 (44)
Statistics
Canada
.
Catalogue
no.
82‐003‐XPE.
Health
Reports,
Vol.
21,
no.1,
March
2010.
 (45)
Wilson
C,
Acton
K,
Brown
T,
et
al.
Effects
of
clinical
nutrition
education
and
educator
discipline
on
 glycemic
control
outcomes
in
the
Indian
Health
Service.
Diabetes
Care
2003;26(9):2500‐2504.
 (46)
Willaing
I,
Ladelund
S,
Jorgensen
T,
et
al.
Nutritional
counseling
in
primary
health
care:
a
randomized
 comparison
of
an
intervention
by
general
practitioner
or
dietician.
Eur
J
Cardiovasc
Prev
Rehabil
 2004;11:513‐520.
 (47)
DCCT
Research
Group.
Expanded
role
of
the
dietitian
in
the
Diabetes
Control
and
Complications
 Trial:
implications
for
clinical
practice.
J
Am
Diet
Assoc
1993;93:758‐764.
 (48)
Clark
M.
Diabetes
self‐management
education.
a
review
of
published
studies.
Prim
Care
Diabetes
 2008;2:113‐120.
 (49)
Delahanty
LM.
Clinical
significance
of
medical
nutrition
therapy
in
achieving
diabetes
outcomes
and
 the
importance
of
the
process.
J
Am
Diet
Assoc.
1998;98(1):28‐30.
 (50)
Franz
MJ,
Warshaw
H,
AE
Daly,
Green‐Pastors
J,
et
al.
Evolution
of
diabetes
medical
therapy.
 Postgrad
Med
2003;79:30‐35.
 (51)
Kulkarni
K,
Castle
G,
Gregory
R,
et
al
for
the
Diabetes
Care
and
Education
Dietetic
Practice
Group.
 Nutrition
practice
guidelines
for
type
1
diabetes
mellitus
positively
affect
dietitian
practices
and
 patient
outcomes.
J
Am
Diet
Assoc.
1998;98:62‐70.
 (52)
Gross
T,
Kayne
D,
King
A,
et
al.
A
bolus
calculator
is
an
effective
means
of
controlling
postprandial
 glycemia
in
patients
on
insulin
pump
therapy.
Diabetes
Tech
Therap
2003;5:365‐369.
 (53)
Zisser
H,
Robinson
L,
Bevier
W,
et
al.
Bolus
calculator:
a
review
of
four
“smart”
insulin
pumps.
 Diabetes
Tech
Therap
2008;10(6):441‐444.
 (54)
Shashaj
B,
Busetto
E,
Sulli
N.
Benefits
of
a
bolus
calculator
in
pre‐
and
postprandial
glycaemic
control
 and
meal
flexibility
of
paediatric
patients
using
continuous
subcutaneous
insulin
infusion
(CSII).
 Diabetic
Med
2008;25:1036‐1042.
 (55)
Pickup
JC,
Renard
E.
Long‐acting
insulin
analogs
versus
insulin
pump
therapy
for
the
treatment
of
 type
1
and
type
2
diabetes.
Diabetes
Care
2008;31(Suppl.
2):S140‐S145
 (56)
Vallis
TM,
Higgins‐Browser
I,
Edwards
L,
et
al.
The
role
of
diabetes
education
in
maintaining
lifestyle
 changes.
Can
J
Diabetes
2005;29:193‐202.
 (57)
Statistics
Canada:
The
Daily.
Computer
access
at
school
and
at
home.
October
29th,
2002;
Available
 at:
http://www.statcan.gc.ca/daily‐quotidien/021029/dq021029a‐eng.htm.
Accessed
Nov.
17th,
 2010.
 (58)
Bergenstal
RM,
Tamborlane
WV,
Ahmann
A,
et
al.
for
the
STAR
3
Study
Group.
Effectiveness
of
 sensor‐augmented
insulin
pump
therapy
in
type
1
diabetes.
NEJM
2010;363:311‐320.
 
 66
 APPENDIX
1:
 METHODOLOGIES
OF
SURVEY
DEVELOPMENT
WITH
 THE
NATIONAL
EXPERT
ADVISORY
COMMITTEE
AND
 PILOT
STUDY
GROUP
 1.1
 SURVEY
DEVELOPMENT
 The
electronic
survey
exploring
what
adult
 insulin
pump
users
know
and
do
–
the
role
of
nutrition
and
 carbohydrate
 counting
 in
diabetes
management
was
developed
 in
 three
phases.
 
 The
 first
 and
 second
 phases
were
conducted
with
the
support
and
guidance
of
a
national
diabetes
expert
advisory
committee
 while
the
third
phase
was
conducted
as
a
pilot
study.

The
following
sections
address
each
of
these
three
 phases
in
more
detail.
 1.1.1
 Formation
of
national
diabetes
advisory
committee
 Sharon
Zeiler,
Senior
Manager
of
Nutrition
 Initiatives
and
Strategies,
Research
and
Professional
Educa‐ tion
 for
 the
Canadian
Diabetes
Association
 circulated
an
email
 from
Amrit
Malkin,
 the
 study’s
 student
 investigator
 to
 members
 of
 the
 Canadian
 Diabetes
 Association
 Nutrition
 Committee
 on
 August
 28th,
 2007.

The
email
outlined
the
specific
objectives
of
the
study
and
requested
that
potential
expert
panel
 members
provide
their
expertise,
support
and
guidance
on
1)
ensuring
appropriate
 identification
of
all
 nutrition‐related
domains
involved
in
flexible
intensive
insulin
self‐management
relevant
to
adult
insulin
 pump
users
and
2)
reviewing
and
editing
test
item
questions
for
each
of
the
identified
nutrition
domains.

 The
time
commitment
for
the
 initial
task
was
suggested
to
take
approximately
5
–
10
minutes.
 
An
ap‐ proximate
estimation
of
20‐30
minutes
was
suggested
on
one
or
two
future
occasions.
 1.1.2
 Survey
development:
phase
one
 The
final
number
of
expert
panel
committee
members
for
the
first
phase
of
the
survey
design
consisted
 of
 11
 diabetes
 health
 care
 professionals
 including
 eight
 dietitians,
 one
 nurse,
 one
 insulin
 pump
 user/trainer
 and
 one
 endocrinologist.
 Advisory
 members
 were
 requested
 to
 respond
 with
 their
 com‐ ments
by
September
14th,
2007.
 The
original
list
of
nutrition
domains
that
were
identified
as
playing
a
fundamental
role
in
intensive
 insulin
self‐management
were
as
follows:
 • Frequency
of
blood
glucose
testing
and
monitoring
 • Knowledge
of
high
carbohydrate
foods
 67
 • Ability
to
make
insulin
adjustments
based
on
blood
glucose
values,
food,
and
exercise
 • Carbohydrate
counting
 • Ability
to
read
food
labels
and
make
adjustments
for
fibre
and
sugar
alcohols
 • Impact
of
fibre,
glycemic
index,
protein
and
fats
on
blood
glucose
levels
 • Appropriate
use
of
insulin
to
carbohydrate
ratios
 • Appropriate
use
of
correction
factor/insulin
sensitivity
factor
 • Appropriate
adjustments
for
exercise
 • Appropriate
treatment
of
hypoglycemia
 • Appropriate
treatment
of
hyperglycemia
 Comments
from
the
advisory
committee
included
the
following:
 • The
difficulty
in
separating
self‐management
education
from
nutrition
knowledge
 • Importance
of
a
dietitian
to
be
open
to
individual
learning
needs
of
clients
 • Timing
of
blood
glucose
testing
(before
and
after
all
meals,
just
before,
only
when
feeling
low
 or
high,
etc.)
 • Knowledge
of
blood
glucose
targets
before
and
after
meals
 • Frequency
of
site
rotation
 • Action
profile
of
rapid
acting
insulin
 • Problem
solving
and
appropriate
insulin
adjustment
regarding:
 o Basal‐bolus
insulin
adjustment
 o Carbohydrate
to
insulin
ratio
 o Alcohol
 o Sick
day
management
(carbohydrates,
water,
insulin,
monitoring)
 o Checking
for
and
treating
ketones
 o Stress
 o Hormones
(menopause,
menstruation)
 o Travel
 • Inquiry
regarding
spacing
of
meals
 • Use
of
different
meal
bolus
delivery
options
(normal,
square
and
dual
wave)
and
when
they
 are
appropriate
 68
 • Knowledge
and
use
of
appropriate
carbohydrate
ranges
at
meals
and
snacks
 • Understanding
of
what
a
healthy
diet
is
and
a
diet
to
support
weight
management
 • The
incorporation
of
some
sort
of
diet
assessment
 1.1.3
 Survey
development:
phase
two
 On
November
7th,
2007,
the
expert
advisory
committee
was
contacted
again
via
email
to
participate
in
a
 review
of
the
first
draft
of
the
survey.

They
were
reminded
of
survey
objectives
and
asked
to
follow
the
 following
steps:
 • To
print
off
a
hard
copy
of
the
survey
(a
PDF
file
was
attached
to
the
email)
and
follow
along
 while
completing
 the
online
survey.

They
were
also
asked
 to
print
off
a
copy
of
 the
Survey
 Question
Identification
Guide
(a
file
was
attached
to
the
email.)

See
Table
8.
 • To
access,
complete
and
electronically
submit
the
online
survey.
The
survey
was
suggested
to
 take
approximately
15
minutes
to
complete.
 • To
add
any
suggestions
or
comments
to
THE
PRINTED
COPY
of
 the
survey
regarding
as
 they
 make
their
way
through
it.

Areas
of
interest
included:
 o Appropriateness
of
questions
 o Design
and
wording
of
questions
 o Is
anything
missing/needs
to
be
added
 o Is
anything
not
needed,
etc.
 At
the
end
of
the
survey,
the
national
advisory
committee
was
requested
to
add
comments
about
 your
overall
impression
of
the
survey
and/or
any
other
suggestions.
 The
national
advisory
committee
was
then
requested
to
mail
a
hard
copy
with
their
comments
back
 to
 the
 student
 investigator
by
November
23rd,
2007
 (financial
 compensation
 for
mailing
was
available
 upon
request).
 The
 final
number
of
expert
panel
 committee
members
 for
 the
second
phase
of
 the
survey
design
 consisted
 of
 nine
 diabetes
 health
 care
 professionals
 including
 seven
 dietitians,
 one
 nurse,
 and
 one
 endocrinologist.

Feedback
from
the
expert
advisory
committee
was
recorded
and
implemented
into
the
 design
of
the
second
draft
of
the
survey
which
was
conducted
as
a
pilot
study.
 All
members
of
 the
pilot
study
were
sent
a
 thank
you
email
 for
all
of
 their
support,
guidance
and
 expertise
on
the
design
of
the
survey
on
December
10,
2007.
 69
 1.1.4
 Survey
development:
phase
three
 A
pilot
study
using
a
second
version
of
the
survey
was
conducted
with
insulin
pump
users
known
to
the
 student
investigator
(n=11)
and
members
of
an
insulin
pump
support
group
in
Burnaby,
British
Columbia
 (n=65).

Of
the
76
adult
insulin
pump
users
that
were
contacted
via
email
26
people
attempted
to
access
 the
survey.
 
Four
people
did
not
meet
the
survey
criteria,
 two
did
not
respond
to
any
questions
and
1
 completed
the
survey
but
did
not
submit
it.

In
total
19
respondents
completed
the
survey
for
a
response
 rate
of
25%.

The
first
email
invitation
to
complete
the
pilot
survey
was
sent
out
on
March
30th,
2008
and
 a
reminder
email
was
sent
out
on
April
4th,
2008.

The
pilot
survey
closed
on
April
7th,
2008.
 The
pilot
 study
participants
were
directed
 to
 the
electronic
 survey
via
a
 link
 located
on
 the
email
 invitation
and
were
asked
to
complete
the
survey
in
one
sitting
as
they
would
only
be
granted
access
to
it
 once.

Participants
were
then
asked
to
follow
the
following
steps:
 1)
 To
do
their
best
to
answer
all
of
the
questions
 2)
 To
keep
notes
of
any
changes
they
would
like
to
see
(wording,
add
or
delete
a
specific
ques‐ tion,
etc.)
on
a
separate
piece
of
paper
 3)
 To
keep
track
of
how
much
time
the
survey
took
you
to
complete
(Section
A
–
E)
 4)
 To
provide
feedback
on
the
survey
(Section
F).
 Respondents
were
informed
that
all
feedback
would
be
totally
anonymous.

Contact
information
for
 the
student
investigator
was
provided
should
any
participant
have
any
questions
or
concerns.

A
copy
of
 the
 pilot
 study
 is
 available
 in
 Appendix
 2
 and
 results
 of
 Section
 F
 of
 the
 pilot
 study
 are
 available
 in
 Appendix
3.
 Amendments
were
made
to
the
third
draft
and
final
draft
of
the
survey.

Medtronic
distributed
the
 survey
to
891
adult
 insulin
pump
users
on
July
9th,
 July
16th,
 July
30th
 (was
originally
scheduled
for
July
 23th
but
was
delayed
due
to
server
problems)
and
closed
on
August
11th,
2008
(was
originally
scheduled
 to
close
on
August
4th,
2008).
 70
 1.2
 TABLE
 Table
8:
Identification
of
nutrition
domains
relevant
to
adult
insulin
pump
users
 Question
#
 Question
Focus
 Section
A:
Diabetes
self‐care
behaviour
&
management
practices
 1.
 Satisfaction
with
diabetes
health
care
team
support
&
care
 2.
 Main
provider
of
nutrition
education
on
their
diabetes
health
care
team
 3.
 Support
from
diabetes
health
care
team
 4.
 Support
from
a
Diabetes
Education
Centre
 5.
 Support
from
a
dietitian
 6.
 Support
from
a
dietitian
 7.
 Frequency
of
blood
glucose
monitoring/week
 8.
 Frequency
of
blood
glucose
monitoring/day
 9.
 Routine
of
blood
glucose
monitoring
 10.
 Routine
of
blood
glucose
monitoring
 11.
 Personal
blood
glucose
goals
before
and
after
meal
(*
Skip
logic,
Yes/No,
No
goes
to
question
#14)
 12.
 Personal
blood
glucose
goals
before
meals
 13.
 Personal
blood
glucose
goals
after
meals
 14.
 Frequency
of
rotation
of
infusion
set
 15.
 Experience
with
Continuous
Glucose
Monitoring
System
(*Skip
logic,
Yes/No,
No
goes
to
question
 #17)


 16.
 Experience
with
Continuous
Glucose
Monitoring
System
 17.
 Use
of
diabetes
identification
 18.
 Treatment
of
low
blood
glucose,
symptom
management
 19.
 Knowledge
of
basal
and
bolus
insulin
adjustment
 20.
 Knowledge
of
type
of
insulin
used
in
pump
 21.
 Knowledge
of
action
profile
of
insulin
(*Skip
logic,
Yes/No,
No
goes
to
question
#23)
 22.
 Action
profile
of
insulin
(onset,
peak,
duration)
 23.
 Affect
of
food,
portions,
insulin,
exercise,
alcohol,
stress,
illness,
menstruation,
travel,
shift
work
 on
blood
sugar
readings
 71
 Table
8:
Identification
of
nutrition
domains
relevant
to
adult
insulin
pump
users
 Question
#
 Question
Focus
 Section
B:
Understanding
of
specific
nutrition
domains
relevant
to
flexible
intensive
insulin
self‐management
 and
carbohydrate
counting
 24.
 Ability
to
carbohydrate
count
–
How
determine
bolus
insulin
for
meal/snack
 25.
 Knowledge
of
carbohydrate
to
insulin
ratio
(*Skip
logic,
Yes/No,
No
goes
to
Question
#27)
 26.
 Carbohydrate
to
insulin
ratio
 27.
 Knowledge
of
correction
factor/insulin
sensitivity
factor
(*Skip
logic,
Yes/No,
No
goes
to
question
 #29)
 28.
 Correction
factor/Insulin
sensitivity
factor
 29.
 How
carbohydrates
affect
blood
glucose
 30.
 Knowledge
of
carbohydrate
foods
 31.
 How
fat,
protein
&
fibre
affect
blood
glucose
 32.
 Label
reading
carbs
vs.
sugars
 33.
 Label
reading
–
serving
size
determination
 34.
 Label
reading
–
available
carbs
(subtract
fibre)
 35.
 Label
reading
–
available
carbs
(fibre
&
serving
size)
 36.
 Label
reading
–
available
carb
(sugar
alcohol)
 37.
 No
added
sugar
claim
 38.
 Frequency
of
severe
low
blood
glucose
reactions
in
past
6
months
 39.
 Timing
of
last
A1c
test
(*Skip
logic,
Never
done
goes
to
Section
D)
 40.
 Knowledge
of
last
A1c
test
(*Skip
logic,
Yes/No,
No
goes
to
question
#42)
 41.
 Last
A1c
test
 
Section
C:
Glycemic
control
 42.
 Knowledge
of
usual
A1c
range
(*Skip
logic,
Yes/No,
No
goes
to
question
#44)
 43.
 Usual
A1c
test
range
 44.
 Knowledge
of
desired
A1c
test
range
(*Skip
logic,
Yes/No,
No
goes
to
Section
D)
 45.
 Desired
A1c
test
range
 72
 
 Table
8:
Identification
of
nutrition
domains
relevant
to
adult
insulin
pump
users
 Question
#
 Question
Focus
 Section
D:
Demographic
and
anthropometric
data
 46.
 Age
(years)
 47.
 Sex
(M/F)
 48.
 Height
 49.
 Weight
 50.
 Age
of
type
1
diagnosis
 51.
 Years
using
a
pump
 52.
 Marital
status
 53.
 Formal
education
 54.
 Province/Territory
of
residence
 Section
E:
Desire
for
additional
nutrition
or
diabetes
self‐care
info
 55.
 Nutrition
and
diabetes
self‐care
information
options
 56.
 Comments
on
survey
or
role
of
nutrition
in
diabetes
management
 
 73
 APPENDIX
2:
 COPY
OF
PILOT
STUDY
 74
 
 75
 
 76
 
 77
 
 78
 
 79
 
 80
 
 81
 
 82
 
 83
 
 84
 
 85
 
 86
 
 87
 
 88
 
 89
 
 90
 
 91
 
 92
 
 93
 
 94
 
 95
 
 96
 
 97
 
 98
 99
 APPENDIX
3:

RESULTS
OF
PILOT
SURVEY
–
SECTION
F
 The
pilot
survey
was
comprised
of
four
sections:
 • Section
A:
Nutrition
support
from
diabetes
health
care
team
 • Section
B:
Information
on
diabetes
management
 • Section
C:
Information
on
blood
glucose
control
 • Section
D:
Relevant
Information
about
participant
 • Section
E:
Additional
information
that
participants’
felt
was
important
to
their
diabetes
man‐ agement
 • Section
F
was
added
to
the
pilot
study
for
the
purpose
of
gathering
information
about
the
sur‐ vey
(relevance,
format,
design,
time
of
completion,
etc.).

All
pilot
study
participants
provided
 feedback
anonymously.

The
following
includes
feedback
specifically
noted
in
Section
F.
 100
 Question
45:

How
would
you
rate
the
following
elements
of
this
survey?
 Table
9:
Pilot
survey
question
45
–
How
would
you
rate
the
following
elements
of
this
survey?
 Rating,
(%,
n)
 Survey
Elements
 Excellent
 Very
Good
 Good
 Fair
 Poor
 Response
 count
 Colour
scheme
 25.0%,
2
 37.5%,
3
 12.5%,
1
 25.0%,
2
 0.0%,
0
 8
 Size
and
visibility
 of
text
 16.7%,
1
 50.0%,
3
 33.3%,
2
 0.0%,
0
 0.0%,
0
 8
 Ease
of
 completion
 14.3%,
1
 57.1%,
4
 28.6%,
2
 0.0%,
0
 0.0%,
0
 7
 Overall
 44.4%,
8
 27.8%,
5
 22.2%,
4
 5.6%,
1
 0.0%,
0
 18
 Answered
 question
 
 
 
 
 
 20
 Skipped
question
 
 
 
 
 
 4
 
 Summary:
 There
was
a
formatting
error
 in
this
question
that
only
allowed
respondents
to
fill
 in
one
rating
choice
 (i.e.,
 excellent,
 very
 good,
 etc.)
 per
 column
 (i.e.,
 a
 respondent
 could
not
 fill
 in
 “Very
Good”
 for
 colour
 scheme
and
ease
of
completion).

Because
of
this
error
it
is
difficult
to
summarize
respondents’
true
feel‐ ings
about
 the
above
aspects
of
 the
survey.
 
However,
90%
of
 respondents
provided
an
Overall
 score.

 Thirteen
participants
(72%
of
respondents
who
answered
the
question)
thought
the
survey
was
Excellent
 or
Very
Good.

Four
respondents
(22.2%
of
respondents
who
answered
the
question)
thought
the
survey
 was
Good.
 
Only
 1
 participant
 thought
 the
 survey
 overall
was
 Fair.
 
 There
were
 no
 lower
 scores.
 
 Al‐ though
not
all
respondents
answered
other
aspects
of
this
question,
of
the
respondents
who
did
there
 did
not
appear
to
be
any
alarming
issues.
 101
 Question
46:

Do
you
feel
your
nutrition
knowledge
regarding
your
diabetes
 management
was
assessed
appropriately?
 Table
10:

Pilot
survey
question
46
–
Do
you
feel
your
nutrition
knowledge
regarding
your
 diabetes
management
was
assessed
appropriately?
 Response
 Frequency
 %
 Yes
 14
 70.0
 No
(Please
share
your
comments
below)
 6
 30.0
 Total
 20
 100
 Missing
 4
 
 Total
 24
 
 Please
note
that
the
30%
(n
=
6)
of
respondents
who
stated
“no”
is
not
actually
accurate
as
only
one
 out
 of
 six
 response
 comments
were
 related
 to
 the
 survey.
 
 All
 other
 comments
were
 personal
 issues
 regarding
the
quality
of
nutrition
support
that
had
received
in
the
past.
 102
 
 Table
11:
Pilot
survey
question
46
–
Comments
 Response
 Comments
 1.
 Most
often
I
feel
like
I
already
know
more
about
nutrition
and
pumping
than
the
nutrition‐ ist
at
the
diabetes
centre,
so
often
the
visit
is
not
useful.
 2.
 When
first
using
the
Pump
I
felt
Medtronic
Nurses/Instructor
would
be
more
hands
on
in
 the
first
days
and
they
were
not,
I
struggled
on
my
own
for
awhile
and
did
not
feel
their
 accessiblity
was
there.
Nutrition
or
carb
counts
were
touched
on
but
not
indepth.
 3.
 Hahahahah...
if
food/insulin
were
only
that
simple!
 4.
 Technical
issue
on
question
45.
I
can
only
select
an
answer
for
one
of
the
four
questions.
If
I
 select
Colour
scheme
=
Very
Good
that
selection
disappears
when
I
select
a
grade
for
the
 next
row
(Ease
of
competion
etc...)
 5.
 It
depends
on
what
about
my
nutrition
knowledge
you
are
trying
to
assess.
 6.
 I
think
you
could
have
asked
even
more
specific
questions.
There
is
so
much
more
to
nutri‐ tion
knowledge
and
counting
carbs
etc.
that
you
could
have
explored
the
knowledge
of
 your
participants
more,
regarding
for
example,
glycemic
index,
counting
carbs
for
specific
 ‘trouble’
foods,
what
we
do
when
we
eat
out,
how
exactly
do
we
carb
count,
what
types
of
 foods
do
we
typically
eat
to
give
a
balanced
meal,
types
of
snacks,
do
we
ever
eat
sugar,
 what
do
we
do
when
we
need
to
guestimate,
etc.
etc.
The
survey
was
good
but
I
felt
like
I
 had
more
valuable
information
to
give....but
maybe
that
is
beyond
the
scope
of
what
you
 wanted??
 Please
note
all
comments
were
transcribed
verbatim;
errors
in
spelling
or
grammar
were
not
corrected.
 Summary:
 • Dietitians
at
Diabetes
Education
Centres
are
not
as
knowledgeable
about
as
should
be.

A
gap
 exists
in
dietitians’
understanding
of
pumping.
 • Not
enough
hands
on
support
with
training.
 • Not
enough
nutrition
support
regarding
carb
counting
given
at
training.
 • Not
specific
enough,
had
more
info
to
give.
 Areas
lacking:
 • Carb
counting
for
“trouble
foods”.
 • What
do
we
eat
when
eating
out.
 • What
do
we
eat
to
obtain
a
balanced
meal.
 • Types
of
snacks.
 • Do
we
eat
sugar.
 • How
do
we
guesstimate.
 103
 Question
47:

Did
you
find
any
questions
unclear?
 Table
12:
Pilot
survey
question
47
–
Did
you
find
any
questions
unclear?
 Response
 Frequency
 %
 Yes
(Please
share
your
comments
below)
 3
 15.8
 No

 16
 84.2
 Total
 19
 100
 Missing
 5
 
 Total
 24
 
 
 Table
13:
Pilot
survey
question
47
–
Comments
 Response
 Comments
 1.
 I
think
there
should
have
been
a
no
support
on
nutrition
option
in
the
first
questions
ask‐ ing
about
who
provided
support.
 2.
 Question
45
wouldn’t
let
me
answer
very
good
in
more
than
one
category.
“very
good”
is
 my
answer
for
all
of
#45.
 3.
 Some
where
at
the
beginning
but
I
need
to
go
back
to
I
believe
page
3
or
4?
to
comment?
 4.
 The
question
about
what
foods
do
not
contain
carbohydrates.
I
do
not
count
carbos
in
 meat,
etc.
However,
some
cheeses
do
have
carbohydrates
which
need
to
be
counted.
 5.
 The
label
and
questions
22
–
24.
Possibly
you
were
hoping
to
catch
people
making
an
er‐ ror
on
the
carb?
See
earlier
question
#44
for
my
comments
on
this.
 Please
note
all
comments
were
transcribed
verbatim;
errors
in
spelling
or
grammar
were
not
corrected.
 Summary:
 • Question
45
has
a
design
error.
 • Some
cheeses
have
carbs
&
need
to
be
counted.
 • Adjusted
Question
16
to
HARD
cheese.
 104
 Question
48:
 Is
there
anything
you
would
change,
add
or
delete
from
this
 survey?
 Table
14:

Pilot
survey
question
48
–
Is
there
anything
you
would
change,
add
or
delete
from
this
 survey?
 Response
 Frequency
 %
 Yes
(Please
share
your
comments
below)
 5
 27.8
 No

 13
 72.2
 Total
 18
 100
 Missing
 6
 
 Total
 24
 
 
 Table
15:

Pilot
survey
question
48
–
Comments
 Response
 Comments
 1.
 A
bit
too
long.
 2.
 Q45
needs
to
be
fixed.
 3.
 See
comment
above
about
survey
question
45.
 4.
 You
can’t
click
“good”
for
more
than
one
element
in
question
#45.
 5.
 You
asked
a
question
about
‘Are
you
pregnant?’
but
didn’t
seem
to
follow‐up
with
any
 other
questions
that
may
have
been
of
value
to
you.
Maybe
asking
number
of
weeks
gesta‐ tion,
is
this
the
first
or
second
etc.
pregnacy?,
questions
about
changes
to
BG
management,
 difficulties
encountered
with
nutrition
requiremnts
etc.
Maybe
asking
number
of
years
we
 have
been
diabetic
not
just
the
number
of
years
on
the
pump?
That
would
give
you
an
idea
 about
how
long
we
have
had
to
management
our
diabetes
and
therefore
give
an
idea
of
 how
much
knowledge
we
may
have
acquired
or
how
long
it
takes
to
gain
the
necessary
 knowledge?
 6.
 Make
either
the
label
or
questions
on
questions
22
–
24
clearer.
 Please
note
all
comments
were
transcribed
verbatim;
errors
in
spelling
or
grammar
were
not
corrected.
 Summary:
 • Question
45
has
a
design
error.
 • Too
long.
 • More
questions
regarding
pregnancy,
blood
glucose
management
&
nutrition.
 • Add
a
question
regarding
length
of
time
having
diabetes.
 105
 Question
49:


Please
add
any
comments
about
this
survey
that
you
have
not
 yet
addressed.
 Table
16:

Pilot
survey
question
49:
Please
add
any
comments
about
this
survey
that
you 
 have
not
yet
addressed.
 Response
 Comments
 1.
 I
have
erratic
blood
sugars.
I
would
like
more
information
on
my
own
individual
nutri‐ tion
and
any
connections
that
could
be
made
to
the
variable
blood
sugars
and
vari‐ able
levels
of
daily
insulin
totals
with
no
change
in
daily
food
intake,
time,
amounts,
 carbohydrates.
 2.
 You
really
ought
to
ask
if
they
are
really
a
minimed
pump
user...
most
people
will
lie
 just
to
see
what
the
survey
is
about.
:‐)
 Please
note
all
comments
were
transcribed
verbatim;
errors
in
spelling
or
grammar
were
not
corrected.
 Summary:
 • Desire
to
have
individualized
counselling
regarding
nutrition,
insulin
&
BG
management.
 • Should
ask
if
Medtronic
pumper
(Answer:
this
was
done
in
consent).
 • No
inquiry
about
hypoglycemia
prevention
due
to
continuous
glucose
monitoring
system.
 Question
50:

How
long
did
it
take
you
to
complete
this
survey?
 Table
17:
Pilot
survey
question
50
–
How
long
did
it
take
you
to
complete
the
survey?
 Response
 Frequency
 %
 Less
than
15
minutes
 13
 68.4
 Approximately
20
minutes
 4
 21.1
 Approximately
30
minutes
 1
 5.3
 More
than
30
minutes
 1
 5.3
 Total
 19
 100
 Missing
 5
 
 Total
 24
 
 106
 
 Table
18:
Pilot
survey
question
50
–
Comments
 Response
 Comments
 1.
 They
key
to
these
survey’s
is
the
post
survey
follow
up.
I.e.
take
an
email
address
at
the
 beggining
and
provide
answers
or
guideance
on
teh
issues
raised
in
the
survey.
thanks,
Gra‐ eme
 2.
 I
was
not
asked
how
many
severe
hypoglycemic
reactions
I
discover
with
continuous
blood
 glucose
monitoring
(alarms)and
treat
–
In
March
I
treated
24.
 3.
 It
would
have
taken
less
time
if
I
had
not
been
interrupted
for
about
7
minutes.
 4.
 Note
that
question
#45
does
not
allow
you
to
enter
to
same
answer
for
each
question,
 which
is
why
there
are
2
questions
unanswered.
the
second
and
third
part
of
the
question
 should
be
rates
as
‘excellent’.
 Please
note
all
comments
were
transcribed
verbatim;
errors
in
spelling
or
grammar
were
not
corrected.
 Summary:
 • Survey
takes
approximately
15
–
30
minutes
to
complete.
 • No
other
concerns.
 107
 APPENDIX
4:
 COPY
OF
FINAL
SURVEY
 
 108
 
 109
 
 110
 
 111
 
 112
 113
 
 114
 
 115
 
 116
 
 117
 
 118
 
 119
 
 120
 
 121
 
 122
 
 123
 
 124
 
 125
 126
 
 127
 
 128
 
 129
 
 130
 
 131
 

 132
 APPENDIX
5:
 COPY
OF
CONSENT
LETTER
 
 
 COVER
LETTER
 
 Study
Title:
What
Adult
Insulin
Pump
Users
Know
and
Do
–
The
Role
of
Nutrition
and

 

 Carbohydrate
Counting
in
Diabetes
Management
 
 Principal
Investigator:

Dr.
Susan
Barr,
PhD,
RD,
Professor
of
Nutrition,
Faculty
of
Land
and
 Food
Systems,
University
of
British
Columbia



 Co‐Investigators:

Amrit
Malkin,
RD,
CDE;
Karol
Traviss,
MSc,
RD;
Dr.
Clarissa
Wallace
MD,
 FRCPC
(Faculty
of
Land
and
Food
Systems,
Faculty
of
Medicine)
 
 Purpose:


 This
project
is
being
conducted
to:
 • Learn
more
about
the
practices
of
adult
insulin
pump
users
regarding
the
role
of
 nutrition
and
carbohydrate
counting
in
diabetes
management
 
 Survey
results
will:
 • Direct
future
nutrition
education
efforts
by
identifying
potential
gaps
in
nutrition
 knowledge
that
may
be
preventing
optimal
glycemic
control
 • Assess
whether
relationships
exist
among
adult
pump
users’
understanding
of
nutrition,
 support
from
their
diabetes
health
care
team
regarding
nutrition,
and
glycemic
control
 
 This
questionnaire
is
part
of
the
master
degree
thesis
of
a
graduate
student
named
Amrit
 Malkin.

Amrit
is
conducting
this
research
under
the
direction
of
Dr.
Susan
Barr,
a
Univer‐ sity
of
British
Columbia
professor
in
Human
Nutrition.

Medtronic
of
Canada
Ltd.
is
provid‐ ing
financial
support
for
the
study.

 
 Study
Procedures:
 You
are
being
invited
to
take
part
in
this
research
study
as
you
are
a
Canadian
adult
(age
19
 years
and
older)
using
a
Medtronic
insulin
pump.

This
survey
will
take
15
–
30
minutes
of
 your
time
on
a
one
time
basis.


Your
name
will
be
entered
in
to
a
raffle
to
win
one
of
three
 $100
gift
certificates
to
the
Medtronic
MiniMed
on‐line
store.

Chances
of
winning
are
 about
1/300.
 
 133
 Your
participation
in
this
online
survey
is
completely
voluntary.

You
can
refrain
from
par‐ ticipating
at
anytime
and
this
will
not
affect
your
entry
into
the
raffle.

You
are
not
obligated
 to
complete
any
questions
you
do
not
feel
comfortable
answering.
 
 There
are
no
known
risks
associated
with
participation.
Although
there
are
no
direct
ben‐ efits
for
you
in
participating,
we
expect
that
research
findings
will
be
used
to
develop
more
 effective
nutrition
resources
to
promote
better
diabetes
management.
 
 When
the
study
has
been
completed,
you
will
receive
an
e‐mail
from
Medtronic
of
Canada
 Ltd.
with
a
link
that
will
allow
you
to
view
a
summary
of
study
results.

 
 For
this
survey,
a
commercial
online
survey
company
is
being
used
 (www.surveymonkey.com).

This
company
was
selected
due
to
its
high
user
ratings,
no
 spam
policy,
and
high
degree
of
data
security.

No
subject
email
addresses
will
be
provided
 to
the
survey
company.

Please
be
advised
that
any
information
provided
to
a
US
company
 is
subject
to
the
Patriot
Act.
 
 Confidentiality:
 Should
you
choose
to
participate,
all
information
you
provide
will
be
completely
anony‐ mous.

The
researchers
will
not
have
access
to
any
personal
information
at
any
time.

The
 survey
data
will
only
be
accessible
to
the
investigative
team
working
on
this
project.

Your
 responses
and
comments
will
be
collated
into
a
summary
and
you
will
remain
completely
 anonymous
in
study
reports.

All
data
will
be
kept
on
a
password‐protected
computer
and
 use
encryption
software.

Information
gathered
in
this
research
study
may
be
published
or
 presented
in
public
forums.

 
 Contact
Information
About
The
Study:
 If
you
have
any
concern
about
your
rights
as
a
research
subject
while
participating
in
this
 study,
contact
the
‘Research
Subject
Information
Line
in
the
University
of
British
Columbia
 Office
Of
Research
Services’
at
604‐822‐8598.

If
you
have
any
questions
about
this
study
 before
or
during
participation,
you
can
contact
Amrit
Malkin
or
Dr.
Susan
Barr.
 
 Statement
of
Consent:
 You
have
legal
rights
as
a
participant
in
a
research
study.

Your
participation
in
this
study
is
 completely
voluntary;
you
may
choose
to
withdraw
at
any
time
without
any
consequences
 to
you
whatsoever.

By
completing
this
online
survey,
you
are
implying
your
consent
to
par‐ ticipate.
 The
researchers
recommend
that
you
keep
a
copy
of
this
consent
for
your
records.
 134
 APPENDIX
6:
 COPY
OF
SURVEY
INVITATIONS
 6.1
 Initial
invitation
 
 
 Dear
Medtronic
customer:
 
 We
are
excited
to
invite
you
to
take
part
in
a
Medtronic
sponsored
research
study
conducted
by
 The
University
of
British
Columbia
entitled
What
Adult
Insulin
Pump
Users
Know
and
Do
–
The
 Role
of
Nutrition
and
Carbohydrate
Counting
in
Diabetes
Management.

The
attached
question‐ naire
will
take
15‐30
minutes
to
complete.

Your
responses
will
be
completely
anonymous.


 By
receiving
this
email,
you
will
be
entered
in
to
a
raffle
to
win
one
of
three
$100
dollar
gift
certifi‐ cates
to
the
Medtronic
of
Canada
Ltd.
on‐line
store.
Your
chances
of
winning
are
approximately
 1/300.
 The
survey,
and
a
more
complete
explanation
of
the
study,
can
be
accessed
at:

 https://www.surveymonkey.com/s.aspx?sm=CoZaeyL6Gw2trTDOqDJjAg_3d_3d

 **
Once
you
open
the
survey
you
will
not
be
able
to
access
it
again.


Please
complete
the
survey
 in
one
sitting.
 **
The
survey
will
close
on
August
4th
,
2008.
 
 Sincerely,
 
 Dr.
Susan
Barr,
PhD,
RD
 
 
 
 
 
 Department
of
Human
Nutrition
 University
of
British
Columbia
















































































































































 
 
 135
 6.2
Week
#2
 
 
 Dear
Medtronic
customer:
 
 If
you
have
already
completed
the
Medtronic
sponsored
on‐line
survey
entitled
What
Adult
Insulin
 Pump
Users
Know
and
Do
–
The
Role
of
Nutrition
and
Carbohydrate
Counting
in
Diabetes
Man‐ agement
please
disregard
this
message.

We
are
unable
to
know
who
has
completed
the
survey
as
 your
responses
are
completely
anonymous.
 If
you
have
not
yet
had
the
time
to
complete
the
survey
please
take
15
–
30
minutes
to
do
so.

Your
 feedback
is
important
as
this
survey
is
designed
with
your
best
interests
in
mind.
 The
survey,
and
additional
information
about
the
study,
can
be
accessed
at:

 https://www.surveymonkey.com/s.aspx?sm=CoZaeyL6Gw2trTDOqDJjAg_3d_3d

 **
Once
you
open
the
survey
you
will
not
be
able
to
access
it
again.


Please
complete
the
survey
 in
one
sitting.
 **
The
survey
will
close
on
August
4th,
2008.
 
 Sincerely,
 
 Dr.
Susan
Barr,
PhD,
RD
 
 
 
 
 
 Department
of
Human
Nutrition
 University
of
British
Columbia

















































































































































 
 136
 6.3
Week
#3
 
 
 Dear
Medtronic
customer:
 
 This
is
your
last
opportunity
to
complete
the
Medtronic
sponsored
on‐line
survey
entitled
What
 Adult
Insulin
Pump
Users
Know
and
Do
–
The
Role
of
Nutrition
and
Carbohydrate
Counting
in
 Diabetes
Management.


If
you
have
already
submitted
the
survey
please
disregard
this
message
 and
we
apologize
for
any
inconvenience.

We
are
unable
to
know
who
has
completed
the
survey
as
 your
responses
are
completely
anonymous.
 The
survey
should
take
15
–
30
minutes
to
complete.

Your
feedback
is
important
as
this
survey
is
 designed
with
your
best
interests
in
mind.
 The
survey,
and
more
information
about
the
study,
can
be
accessed
at:

 https://www.surveymonkey.com/s.aspx?sm=CoZaeyL6Gw2trTDOqDJjAg_3d_3d

 **
Once
you
open
the
survey
you
will
not
be
able
to
access
it
again.


Please
complete
the
survey
 in
one
sitting.
 **
The
survey
will
close
on
Monday
August
11th,
2008.
 
 Sincerely,
 
 Dr.
Susan
Barr,
PhD,
RD
 
 
 
 
 
 Department
of
Human
Nutrition
 University
of
British
Columbia

















































































































































 137
 APPENDIX
7:
 RESULTS
OF
FINAL
SURVEY
 7.1
 UNIVARIATE
RESPONSES
 Question
2:

 These
questions
ask
about
the
nutrition
support
you
have
 recently
received.
 Question
2
contains
three
independent
questions.
 Table
19:
Survey
question
2A
–
I
am
very
satisfied
with
the
nutrition
support
I
receive
 

Score
 Response
 Frequency
 
%
 5
 Strongly
Agree
 57
 19.7
 4
 Agree
 144
 49.7
 3
 Not
Sure
 40
 13.8
 2
 Disagree
 45
 15.5
 1
 Strongly
Disagree
 4
 1.4
 
 Total
 290
 100.0
 Mean
=
3.7,
SD
=
1.0
 Table
20:
Survey
question
2B
–
The
nutrition
support
I
have
received
in
the
last
few
years
is
just
 about
perfect
 

Score
 Response
 Frequency
 
%
 5
 
Strongly
Agree
 29
 10.2
 4
 Agree
 136
 47.7
 3
 Not
Sure
 57
 20.0
 2
 Disagree
 55
 19.3
 1
 Strongly
Disagree
 8
 2.8
 
 Total
 285
 100
 Mean
=
3.4,
SD
=
1.0
 Table
21:
Survey
question
2C
–
There
are
things
about
the
nutrition
support
I
receive
that
could
 be
better
 

Score
 Response
 Frequency
 
%
 1
 Strongly
Agree
 26
 9.1
 2
 Agree
 108
 37.9
 3
 Not
Sure
 70
 24.6
 4
 Disagree
 68
 23.9
 5
 Strongly
Disagree
 13
 4.6
 
 Total
 285
 100
 Mean
=
2.8,
SD
=
1.1
 138
 Question
3:


 Who
currently
provides
the
nutrition
support
for
your
diabetes
 management?
(Please
check
all
that
apply)
 Table
22:
Survey
question
3
–
Who
currently
provides
the
nutrition
support
for
your
diabetes
 management?
(Please
check
all
that
apply)
 Current
Provider
 Frequency
 N
=
297
 %
 Generalist
 53
 17.8
 Specialist
 90
 30.3
 Nurse
 59
 19.9
 Dietitian
 149
 50.2
 Diabetes
Education
Centre
 149
 50.2
 Medtronic
Help
Line
 10
 3.4
 I
educate
myself
 184
 62.0
 Do
not
have
one
 29
 9.8
 Other
 27
 9.1
 
 Question
4:


 How
do
you
find
the
nutrition
support
provided
by
the
 following
members
of
your
diabetes
health
care
team?
 All
participants
were
included
for
each
health
care
professional
option.

The
response

“not
applicable”
 was
counted
as
missing.
 
Resulting
percentages
for
each
health
care
provider
are
displayed
as
percent‐ ages
(100%).
 Table
23:
Survey
question
–
How
do
you
find
the
nutrition
support
provided
by
the
following
 members
of
your
diabetes
health
care
team?
 Current
Provider,
(n)
 Exce‐ llent
 Very
 Good
 Good
 
 Fair
 
 Poor
 
 %
 Mean
 SD
 Score
 5
 4
 3
 2
 1
 
 
 
 Generalist,
(167)
 7.8
 13.2
 28.7
 28.1
 22.1
 100
 2.56
 1.20
 Specialist,
(191)
 16.2
 17.8
 35.6
 20.4
 9.9
 100
 3.10
 1.20
 Nurse,
(157)
 19.1
 26.8
 33.8
 15.3
 5.1
 100
 3.39
 1.11
 Dietitian,
(202)
 33.2
 34.2
 22.3
 7.9
 2.5
 100
 3.88
 1.04
 Diabetes
Education
 Centre,
(204)
 31.4
 32.8
 24.5
 7.4
 3.9
 100
 3.80
 1.08
 Medtronic,
(98)
 13.3
 18.4
 37.8
 17.3
 13.3
 100
 3.01
 1.20
 139
 Question
5:

When
was
your
last
visit
to
a
Diabetes
Education
Centre
(DEC)?
 The
 survey
 response
 “I
 do
not
 recall”
was
originally
 assigned
a
 score
of
 “1”
but
was
 re‐evaluated
and
 added
to
“Missing”
responses
which
were
not
included
in
the
mean
score.
 Table
24:
Survey
question
5
–
When
was
your
last
visit
to
a
Diabetes
Education
Centre?
 Score
 Last
Visit
 Frequency
 
%
 6
 Within
the
last
12
months
 172
 59.5
 5
 1‐2
years
 47
 16.3
 4
 2‐3
years
 20
 6.9
 3
 More
than
3
years
ago
 41
 14.2
 2
 Never
been
to
a
DEC
 9
 3.1
 
 Total
 289
 100.0
 
 Missing,
I
do
not
recall
 8
 
 
 
 
 Total
 297
 
 Mean
=
5.2,
SD
=
1.2
 Question
6:

When
was
your
last
visit
with
a
dietitian?
 The
 survey
 response
 “I
 do
not
 recall”
was
originally
 assigned
a
 score
of
 “1”
but
was
 re‐evaluated
and
 added
to
“Missing”
responses
which
were
not
included
in
the
mean
score.
 Table
25:
Survey
question
6
–
When
was
your
last
visit
with
a
dietitian?
 Score
 Last
Visit
 Frequency
 %
 6
 Within
the
last
12
months
 146
 50.3
 5
 1
–
2
years
ago
 54
 18.6
 4
 2
–
3
years
ago
 24
 8.3
 3
 More
than
3
years
ago
 63
 21.7
 2
 I
have
never
met
with
a
dietitian
 3
 1
 
 Total
 290
 100
 
 Missing,
I
do
not
recall
 7
 
 
 Total
 297
 
 Mean
=
5.0,
SD
=
1.3
 140
 Question
7:


 How
many
times
have
you
seen
a
dietitian
to
learn
about
how
 insulin
matches
food
(carbohydrate
counting)?
 The
 survey
 response
 “I
 do
not
 recall”
was
originally
 assigned
a
 score
of
 “1”
but
was
 re‐evaluated
and
 added
to
“Missing”
responses
which
were
not
included
in
the
mean
score.
 Table
26:
Survey
question
7
–
How
many
times
have
you
seen
a
dietitian
to
learn
about
how
 insulin
matches
food
(carbohydrate
counting)?
 Score
 Number
of
Visits
 Frequency
 
%
 6
 More
than
5
times
 66
 23.4
 5
 3
–
5
times
 99
 35.1
 4
 2
times
 57
 20.2
 3
 1
time
 46
 16.3
 2
 I
have
never
met
with
a
dietitian
 14
 5.0
 
 Total
 282
 100
 
 Missing,
I
do
not
recall
 15
 
 
 Total
 297
 
 Mean
=
4.6,
SD
=
1.2
 Question
8:


 How
do
you
decide
how
much
insulin
to
give
yourself
when
 eating
a
meal/snack?
 Survey
 responses
 to
 
 “Other”
and
“Missing”
were
combined
and
added
 to
 the
category
“Does
not
use
 Bolus
Wizard”
for
survey
calculations
and
were
included
in
survey
calculations.
 
 Table
27:
Survey
question
8
–
How
do
you
decide
how
much
insulin
to
give
yourself
when
eating
a
 meal/snack?
 Score
 Method
 Frequency
 %
 0
 Count
(or
estimate)
the
number
of
carbohydrates
&
calculate
my
 own
insulin
dose
using
a
sliding
scale
based
on
pre‐meal/snack
 blood
glucose
readings
 21
 7.1
 0
 Count
(or
estimate)
the
number
of
carbohydrates
&
calculate
my
 own
insulin
dose
using
my
carbohydrate
to
insulin
ratio
&
insulin
 sensitivity/corrective
factor
 60
 20.2
 1
 Count
(or
estimate)
the
number
of
carbohydrates
&
rely
on
the
 bolus
wizard
calculator
 200
 67.3
 
 Total
 281
 94.6
 0
 Other
&
Missing
 16
 5.4
 
 Total
 297
 100
 141
 Question
9:


 How
often
do
you
USE
THE
LABEL
TO
COUNT
the
number
of
 carbohydrates
in
your
meal/snack
versus
ESTIMATING?
 “Missing”
responses
were
not
included
in
the
mean
score.
 Table
28:
Survey
question
9
–
How
often
do
you
USE
THE
LABEL
TO
COUNT
the
number
of
 carbohydrates
in
your
meal/snack
versus
ESTIMATING?
 Score
 Response
 Frequency
 %
 1
 Almost
Never
 5
 1.7
 2
 Occasionally
 11
 3.7
 3
 About
Half
the
time
 35
 11.9
 4
 Most
of
the
time
 87
 29.5
 5
 Almost
always
 57
 53.2
 
 Total
 295
 100
 
 Missing
 2
 
 
 Total
 297
 
 Mean
=
4.3
,
SD
=
0.9
 Question
10:

Do
you
have
a
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at
 MEALS
and
SNACKS?
 Table
29:
Survey
question
10
–
Do
you
have
a
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at
 MEALS
and
SNACKS?
 Response
 Frequency
 Valid
%
 Yes
 192
 64.6
 No
 105
 35.4
 Total
 297
 100
 Missing
 0
 
 Total
 297
 
 
 142
 Question
11:

What
is
the
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at
 MEALS
and
SNACKS?
 Participants
were
asked
the
lower
and
upper
range
of
carbohydrates
they
normally
eat
at
both
meals
and
 snacks.

The
range
for
women
and
men
was
determined
by
subtracting
the
upper
range
from
the
lower
 range.
 Range
=
Upper
Range
–
Lower
Range
 The
average
amount
of
carbohydrate
participants
eat
at
meals
and
snacks
was
determined
by
adding
the
 lower
and
upper
range
together
and
dividing
by
2.
 Average
=
(Upper
Range

+
Lower
Range)
 
 
 












2
 
 Table
30:
Survey
question
11
–
What
is
the
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at
MEALS?
 Sex
 Frequency
 %
 Range
 mean
 Range
SD
 
Upper
 range
 mean
 Upper
 range
SD
 Average
 mean
 Average
 SD
 Female
 117
 60.6
 23.7
 14.2
 59.8
 24
 47.9
 12.8
 Missing
 76
 39.4
 
 
 
 
 
 
 Total
 193
 100
 
 
 
 
 
 
 
 Male
 64
 61.5
 36.5
 19.6
 86.6
 26.6
 68.4
 22.6
 Missing
 40
 38.5
 
 
 
 
 
 
 Total
 104
 100
 
 
 
 
 
 
 
 Table
31:
Survey
question
11
–
What
is
the
RANGE
OF
CARBOHYDRATES
you
try
to
eat
at
SNACKS?
 Sex
 Frequency
 %
 Range
 mean
 Range
SD
 Upper
 range
 mean
 Upper
 range
SD
 Average
 mean
 Average

 SD
 Female
 112
 58
 12.8
 9.2
 25.8
 12.2
 19.4
 8.9
 Missing
 81
 42
 
 
 
 
 
 
 Total
 193
 100
 
 
 
 
 
 
 
 Male
 60
 57.7
 18
 10.2
 34.8
 14.3
 25.8
 11.2
 Missing
 44
 42.3
 
 
 
 
 
 
 Total
 104
 100
 
 
 
 
 
 
 143
 Question
12:

Do
you
know
your
CARBOHYDRATE
TO
INSULIN
RATIO
for
your
 first
meal
of
the
day?
 Table
32:
Survey
question
12
–
Do
you
know
your
CARBOHYDRATE
TO
INSULIN
RATIO
for
your
 first
meal
of
the
day?
 Response
 Frequency
 %
 Yes
 256
 86.2
 No
 41
 13.8
 Total
 297
 100
 Missing
 0
 
 Total
 297
 
 
 Question
13:

What
is
your
CARBOHYDRATE
TO
INSULIN
RATIO
for
your
first
 meal
of
the
day?
 Table
33:
Survey
question
13
–
What
is
your
CARBOHYDRATE
TO
INSULIN
RATIO
for
your
first
 meal
of
the
day?
 Sex
 Frequency
 %
 Mean
 SD
 95%
CI
 Women
 160
 82.9
 11.1
 4.5
 10.4,
11.8
 Missing
 33
 17.1
 
 
 
 Total
 193
 100
 
 
 
 
 Men
 95
 91.3
 9.6
 3.6
 8.9,
10.3
 Missing
 9
 8.7
 
 
 
 Total
 104
 100
 
 
 
 
 144
 Question
14:

Do
you
know
your
CORRECTIVE/INSULIN
SENSITIVITY
FACTOR
 (ISF)
is
for
your
first
meal
of
the
day?
 Table
34:
Survey
question
14
–
Do
you
know
your
CORRECTIVE/INSULIN
SENSITIVITY
FACTOR
is
 for
your
first
meal
of
the
day?
 Response
 Frequency
 
%
 Yes
 207
 69.9
 No
 89
 30.1
 Total
 296
 100
 Missing
 1
 
 Total
 297
 
 
 Question
15:

What
is
your
CORRECTIVE/INSULIN
SENSITIVITY
FACTOR
for
 your
first
meal
of
the
day?
 Table
35:
Survey
question
15
–
What
is
your
CORRECTIVE/INSULIN
SENSITIVITY
FACTOR
for
your
 first
meal
of
the
day?
 Sex
 Frequency
 %
 Mean
 SD
 95%
CI
 Female
 130
 67.4
 2.6
 1.4
 2.4,
2.8
 Missing
 63
 32.6
 
 
 
 Total
 193
 100
 
 
 
 
 Male
 77
 74
 2.2
 1.4
 1.9,
2.5
 Missing
 27
 26
 
 
 
 Total
 104
 100
 
 
 
 
 145
 Question
16:

If
eaten
on
its
own,
which
nutrient
is
fully
converted
to
sugar
2
 hours
after
eating?
 Respondents
who
correctly
answered
“carbohydrate”
were
assigned
a
 score
of
 “1”.
 
All
other
answers
 including
non‐responders
(“Missing”)
were
assigned
a
score
of
“0”.
 Table
36:
Survey
question
16
–
If
eaten
on
its
own,
which
nutrient
is
fully
converted
to
sugar
2
 hours
after
eating?
 Score
 Nutrient
 Frequency
 %
 0
 Fat
 8
 2.7
 1
 Carbohydrate
 267
 89.9
 0
 Protein
 6
 2
 0
 I
do
not
know
 12
 4
 
 Total
 293
 98.7
 0
 Missing
 4
 1.3
 
 Total
 297
 100
 
 Question
17:

Which
of
the
food
groups
below
DO
NOT
contain
 carbohydrates:
(Please
check
all
that
apply)
 Respondents
were
assigned
a
score
of
“1”
if
they
correctly
selected
“Protein”
and
“Fat”
and
did
not
se‐ lect
any
of
the
other
6
food
group
options.

Respondents
were
given
a
score
of
“0”
if
they
choose
other‐ wise.
 
 This
 would
 result
 in
 a
 max
 score
 of
 “8”
 for
 this
 question.
 
 It
 was
 assumed
 that
 all
 survey
 respondents
(n
=
297)
answered
the
question
in
its
entirety.
 Table
37:
Survey
question
17
–
Which
of
the
food
groups
below
DO
NOT
contain
 CARBOHYDRATES:
(Please
check
all
that
apply)
 Score
 Food
Group
 Frequency
(N
=
297)
 
%
 0
 High
sugar
foods
 2
 0.7
 0
 Vegetables
 111
 37.4
 0
 Fruit
&
fruit
juices
 2
 0.7
 0
 Grains
 0
 0
 1
 Fats
 215
 72.4
 1
 Protein
 264
 88.9
 0
 Starchy
vegetable
 0
 0
 0
 Milk
&
yogurt
 8
 2.7
 
 146
 Question
18:

How
do
fats,
protein,
and
fibre
affect
the
digestion
of
 carbohydrates
when
included
in
the
same
meal?
 Table
38:
Survey
question
18
–
How
do
fats,
protein,
and
fibre
affect
the
digestion
of
 carbohydrates
when
included
in
the
same
meal?
 Score
 Affect
on
Digestion
 Frequency
 %
 0
 Speed
up
 15
 5.1
 1
 Slow
down
 247
 83.2
 0
 No
affect
 7
 2.4
 0
 I
do
not
know
 28
 9.4
 
 Total
 297
 100
 
 Missing
 0
 
 
 Total
 297
 
 
 Question
19:

Are
you
familiar
with
the
concept
of
glycemic
index?
 Respondents
who
correctly
answered
“Yes”
were
assigned
a
 score
of
 “1”.
 
All
other
answers
 including
 non‐responders
(“Missing”)
were
assigned
a
score
of
“0”.

Respondents
who
answered
“No”
progressed
 to
question
21
as
skip
logic
was
used.
 Table
39:
Survey
question
19
–
Are
you
familiar
with
the
concept
of
glycemic
index?
 Score
 Familiar
with
GI
 Frequency
 %
 1
 Yes
 227
 76.4
 0
 No
 70
 23.6
 
 Total
 297
 100
 
 Missing
 0
 
 
 Total
 297
 
 
 147
 Question
20:

What
food
in
the
list
below
has
the
HIGHEST
glycemic
index?
 Respondents
who
correctly
answered
“Cornflakes”
were
assigned
a
score
of
“1”.
 
All
other
answers
 in‐ cluding
non‐responders
(“Missing”)
were
assigned
a
score
of
“0”.

Non‐responders
(“Missing”)
were
not
 included
in
survey
calculations.

Respondents
who
answered
“No”
to
question
19
progressed
to
directly
 to
question
21,
accounting
for
the
“Missing”
responses
in
question
20.
 
 Table
40:
Survey
question
20
–
What
food
in
the
list
below
has
the
HIGHEST
glycemic
index?
 Score
 Food
 Frequency
 %
 0
 Oatmeal
 22
 9.7
 1
 Cornflakes
 160
 70.5
 0
 Lentils
 16
 7.0
 0
 Eggs
 3
 1.3
 0
 Whole
wheat
bread
 26
 11.5
 
 Total
 227
 100
 
 Missing
 70
 
 
 Total
 297
 
 
 Question
21:

If
your
blood
glucose
drops
on
its
own
overnight
or
if
you
skip
a
 meal,
what
insulin
would
you
reduce?
 
 Table
41:

Survey
question
21
–
If
your
blood
glucose
drops
on
its
own
overnight
or
if
you
skip
a
 meal,
what
insulin
would
you
reduce?
 Score
 Type
of
Insulin
 Frequency
 %
 1
 Basal
(background)
insulin
 245
 82.5
 0
 Bolus
(meal/snack)
insulin
 44
 14.8
 0
 I
do
not
know
 8
 2.7
 
 Total

 297
 100
 
 Missing
 0
 
 
 Total
 297
 
 
 148
 Question
22:

When
reading
food
labels,
the
gram
count
for
“carbohydrates”
 is
more
important
than
the
gram
count
for
“sugar”.
 Respondents
who
correctly
answered
“True”
were
assigned
a
score
of
“1”.
 
All
other
answers
were
as‐ signed
a
score
of
“0”.

Non‐responders
(“Missing”)
were
not
included
in
survey
calculations.
 Table
42:

Survey
question
22
–
When
reading
food
labels,
the
gram
count
for
“carbohydrates”
is
 more
important
than
the
gram
count
for
“sugar”
 Score
 Response
 Frequency
 %
 1
 True
 248
 84.4
 0
 False
 31
 10.5
 0
 I
do
not
know
 15
 5.1
 
 Total
 294
 100
 
 Missing
 3
 
 
 Total
 297
 
 
 Figure
2:
Survey
question
23
to
25
–
Nutrition
Facts
label
#1
 
 149
 Question
23:

What
is
the
serving
size
for
this
bread?
 Table
43:
Survey
question
23
–
What
is
the
serving
size
for
this
bread?
 Score
 Serving
Size
 Frequency
 %
 0
 1
slice
 3
 1
 0
 ½
slice
 1
 0.3
 1
 2
slices
 291
 98
 0
 4
slices
 1
 0.3
 0
 I
do
not
know
 1
 0.3
 
 Total
 297
 100
 
 Missing
 0
 
 
 Total
 297
 
 
 Question
24:

How
many
grams
of
available
carbohydrate
should
be
counted
 for
1
serving?
 Respondents
who
correctly
answered
“26
grams”
were
assigned
a
score
of
“1”.

All
other
answers
were
 assigned
a
score
of
“0”.

Non‐responders
(“Missing”)
were
not
included
in
survey
calculations.
 Table
44:
Survey
question
24
–
How
many
grams
of
available
carbohydrate
should
be
counted
 for
1
serving?
 Score
 Available
Carbohydrate
 Frequency
 %
 0
 15
grams
 11
 3.7
 0
 24
grams
 3
 1
 1
 26
grams
 175
 59.1
 0
 33
grams
 101
 34.1
 0
 66
grams
 4
 1.4
 0
 I
do
not
know
 2
 0.7
 
 Total
 296
 100
 
 Missing
 1
 
 
 Total
 297
 
 
 150
 Question
25:

How
many
grams
of
available
carbohydrate
should
be
counted
 if
you
eat
only
1
slice
of
bread?
 Respondents
that
selected
both
13
grams
and
17
grams
of
available
carbohydrate
were
added
together
 when
assessed
for
properly
adjusting
for
a
half
serving
(despite
17
grams
not
accounting
for
the
proper
 subtraction
of
fibre).
 
 Table
45:

Survey
question
25
–
How
many
grams
of
available
carbohydrate
should
be
counted
if
 you
eat
only
1
slice
of
bread?
 Score
 Available
Carbohydrate
 Frequency
 %
 0
 12
grams
 7
 2.4
 1
 13
grams
 177
 59.6
 0
 17
grams
 102
 34.3
 0
 33
grams
 10
 3.4
 0
 I
do
not
know
 1
 0.3
 
 Total
 297
 100
 
 Missing
 0
 
 
 Total
 297
 100
 
 Figure
3:
Survey
question
26
–
Nutrition
Facts
label
#2
 
 151
 Question
26:

How
many
grams
of
available
carbohydrate
should
be
counted
 for
1
serving?
 Participants
who
correctly
answered
“14
grams”
were
assigned
a
score
of
“1”.
 
All
other
answers
were
 assigned
a
score
of
“0”.

Non‐responders
(“Missing”)
were
not
included
in
survey
calculations.
 Table
46:

Survey
question
26
–
How
many
grams
of
available
carbohydrate
should
be
counted
for
 1
serving?
 Score
 Available
Carbohydrate
 Frequency
 %
 0
 11
grams
 18
 6.1
 1
 14
grams
 19
 6.4
 0
 17
grams
 145
 49.3
 0
 18
grams
 1
 0.3
 0
 21
grams
 109
 36.9
 0
 I
do
not
know
 3
 1
 
 Total
 295
 100
 
 Missing
 2
 
 
 Total
 297
 
 
 Question
27:

When
a
label
states
“No
Added
Sugar”
that
means
it
will
NOT
 raise
blood
glucose
at
all.
 Table
47:

Survey
question
27
–
When
a
label
states
“No
Added
Sugar”
that
means
it
will
NOT
 raise
blood
glucose
at
all
 Score
 Familiar
with
GI
 Frequency
 %
 1
 Yes
 294
 99.0
 0
 No
 3
 1.0
 0
 I
do
not
know
 0
 0
 
 Total
 297
 100
 
 Missing
 0
 
 
 Total
 297
 
 
 152
 Question
28:

What
do
you
USUALLY
do
if
you
have
low
blood
glucose?
 “Other”
responses
were
assessed
as
being
appropriate
or
not
appropriate
and
were
 included
in
the
re‐ sponse
total.

“Appropriate
Other”
responses
were
given
a
score
of
“1”
while
all

“Other”
responses
were
 given
a
score
of
“0”.
 Table
48:
Survey
question
28
–
What
do
you
USUALLY
do
if
you
have
a
low
blood
glucose?
 Score
 Treatment
 Frequency
 %
 0
 Eat
a
high
fat
food
 3
 1
 1
 Eat
15
grams
of
fast
acting
carbs
 222
 74.8
 1
 Eat
15
grams
of
fast
acting
carbs
 plus
15
grams
of
protein
 28
 9.4
 0
 Have
a
snack
 10
 3.4
 0
 Eat
until
you
feel
better
 9
 3
 0
 I
do
not
know
 0
 01
 1
 Other:
Appropriate
 17
 5.7
 0
 Other:
Not
Appropriate
 5
 1.7
 0
 Other:
Unable
to
Access
 3
 1.0

 Total
 297
 100

 Missing
 0
 

 Total
 297
 
 Question
29:

How
many
times
in
the
LAST
6
MONTHS
have
you
had
a
 SEVERE
low
blood
glucose
reaction
(i.e.
resulting
in
passing
out
 or
needing
someone
else’s
help)?
 “I
do
not
recall”
were
not
included
in
survey
calculations.
 Table
49:
Survey
question
29
–
How
many
times
in
the
LAST
6
MONTHS
have
you
had
a
SEVERE
low
 blood
glucose
reaction
(i.e.
resulting
in
passing
out
or
needing
someone
else’s
help)?
 Score
 Number
of
Times
 Frequency
 %
 1
 0
times
 226
 76.3
 0
 1
–
3
times
 58
 19.6
 0
 4
–
6
times
 10
 3.4
 0
 7
–
12
times
 2
 0.7
 0
 More
than
12
times
 0
 0
 
 Total
 296
 100
 
 Missing,
I
do
not
recall
 1
 
 
 Total
 297
 
 153
 Question
30:

When
was
the
last
time
you
had
an
A1c
test
done
(a
test
that
 measures
 your
average
blood
glucose
level
over
the
past
2‐3
 months)?
 Table
50:
Survey
question
30
–
When
was
the
last
time
you
had
an
A1c
test
done
(a
test
that
 measures
your
average
blood
glucose
level
over
the
past
2‐3
months)?
 Score
 Last
A1C
Test
 Frequency
 %
 7
 Within
the
last
3
months
 190
 64
 6
 Within
the
last
6
months
 80
 26.9
 5
 Within
the
last
year
 23
 7.7
 4
 1
–
2
years
ago
 3
 1
 3
 2
–
3
years
ago
 0
 0
 2
 More
than
3
years
ago
 1
 0.3
 1
 I
do
not
recall
 0
 0
 
 Total
 297
 100
 
 Missing
 0
 
 
 Total
 297
 
 Mean
=
6.5,
SD
=
0.7
 Question
31:

Do
you
know
the
result
of
your
MOST
RECENT
A1c
test?
 Table
51:
Survey
question
31
–
Do
you
know
the
result
of
your
MOST
RECENT
A1c
test?
 Score
 Response
 Frequency
 %
 1
 Yes
 252
 84.8
 0
 No
 45
 15.2
 
 Total
 297
 100
 
 Missing
 0
 
 
 Total
 297
 
 
 154
 Question
32:

What
was
the
result
of
your
MOST
RECENT
A1c
test?
 Table
52:
Survey
question
32
–
What
was
the
result
of
your
MOST
RECENT
A1c
test?
 
 Frequency
 %
 Mean
 Range
 SD
 95%
CI
 A1c
 252
 84.8
 7.2
 5.1
–
11.1
 1.0
 7.1,
7.3
 Missing
 45
 15.2
 
 
 
 
 Total
 297
 100
 
 
 
 
 
 Questions
33
–
43
inclusive:
Characteristics
of
survey
respondents
 Table
53:
Survey
questions
33
–
43
inclusive:
Characteristics
of
survey
respondents
 Characteristic
 Frequency
 %
 Mean
 SD
 Range
 Sex
 297
 100
 
 
 
 Female
 Male
 193
 104
 65
 35
 
 
 
 Age,
years
 292
 98.3
 44.2
 11.9
 19
–
79
 Female
 Male
 189
 103
 97.9
 99
 43.3
 45.9
 11.5
 12.6
 19
–
75
 19
–
79
 Body
Mass
Index
(BMI),
Kg/m2
 294
 99
 27.0
 5.7
 17.0
–
64.7
 Female
 Male
 190
 104
 98.3
 100
 26.5
 27.9
 6.1
 4.9
 17.0
–
64.7
 21.0
–
49.3
 Type
of
Diabetes
 
 
 
 
 
 Type
1
 Female
 Male
 276
 182
 94
 92.9
 94.3
 90.4
 
 
 
 Type
2
 19
 6.4
 
 
 
 I
do
not
know
 2
 0.7
 
 
 
 Pregnant
 4
 1.3
 
 
 
 Time
using
a
pump,
years
 295
 99.3
 4.3
 6
 0.5
–
37.0
 Female
 Male
 191
 104
 
 4.6
 3.8
 6.1
 5.8
 
 155
 Table
53:
Survey
questions
33
–
43
inclusive:
Characteristics
of
survey
respondents
 Characteristic
 Frequency
 %
 Mean
 SD
 Range
 Medtronic
pump
model
 289
 97.3
 
 
 
 507
 1
 0.3
 
 
 
 508
 3
 1
 
 
 
 511
 3
 0.3
 
 
 
 512
 10
 3.4
 
 
 
 712
 13
 4.4
 
 
 
 515
 14
 4.7
 
 
 
 715
 27
 9.1
 
 
 
 522
 82
 27.6
 
 
 
 722
 138
 46.5
 
 
 
 Lives
alone
 282
 94.9
 
 
 
 Yes
 31
 10.4
 
 
 
 No
 251
 84.5
 
 
 
 Schooling
 297
 100
 
 
 
 Some
high
school
 8
 2.7
 
 
 
 High
school
graduate
 33
 11.1
 
 
 
 Some
university
of
technical
school
 93
 31.3
 
 
 
 University
graduate
 118
 39.7
 
 
 
 Graduate
degree
 45
 15.2
 
 
 
 Province
of
residence
 296
 99.7
 
 
 
 Alberta
 22
 7.4
 
 
 
 British
Columbia
 53
 17.8
 
 
 
 Manitoba
 10
 3.4
 
 
 
 New
Brunswick
 16
 5.4
 
 
 
 Newfoundland
&
Labrador
 26
 8.8
 
 
 
 Northwest
Territories
 0
 0
 
 
 
 Nova
Scotia
 24
 8.1
 
 
 
 Nunavut
 0
 0
 
 
 
 Ontario
 130
 43.8
 
 
 
 Prince
Edward
Island
 1
 0.3
 
 
 
 Quebec
 9
 3
 
 
 
 Saskatchewan
 4
 1.3
 
 
 
 Yukon
 1
 0.3
 
 
 
 156
 Question
44:

Which
of
the
following
topics
would
you
like
more
information
 on?
(Please
check
all
that
apply)
 Table
54:

Survey
question
44
–
Which
of
the
following
topics
would
you
like
more
information
 on?
(Please
check
all
that
apply)

 Coding
 Topics
 Frequency
 %
 1
 General
guidelines
for
healthy
eating
 85
 28.6
 2
 Nutrition
for
weight
management
 147
 49.5
 3
 Insulin
adjustments
based
on
blood
 glucose
values
 79
 26.6
 4
 Different
bolus
delivery
options
 187
 63
 5
 Insulin
adjustments
based
on
food
 choices
and
carbohydrate
counting
 97
 32.7
 6
 Insulin
adjustments
when
eating
out
 163
 54.9
 7
 Insulin
adjustments
based
on
 exercise
regime
 162
 54.4
 8
 Other:
Healthy
eating
(1)
 3
 1
 9
 Other:
Weight
management
(2)
 1
 0.3
 10
 Other:
Insulin
adjustment
based
on
 blood
glucose
values
(3)

 8
 2.7
 11
 Other:
Insulin
adjustment
based
on
 food
choices
and
carbohydrate
 counting
(5)
 3
 1
 12
 Other:
Insulin
adjustment
based
on
 exercise
regime
(7)
 3
 1
 13
 Other:
No
further
info
required
 6
 2
 14
 Other:
Other
 5
 1.7
 15
 Other:
Healthy
eating
and
exercise
(1
 &
7)
 1
 0.3
 16
 Other:
Hormones
 2
 0.7
 17
 Other:
Temporary
removal
 guidelines
 2
 0.7
 18
 Other:
Sick
day
management
 3
 1
 
 Total
 297
 

 157
 Question
45:

Do
you
have
any
comments
on
the
role
of
nutrition
or
 carbohydrate
counting
in
diabetes
management?
 Table
55:
Survey
question
45
–
Do
you
have
any
comments
on
the
role
of
nutrition
or
 carbohydrate
counting
in
diabetes
management?

 Coding
 Topics
 Frequency
 %
 1
 Carbohydrate
counting
is
critical
 26
 26.8
 2
 Love
the
pump
 5
 5.2
 3
 Importance
of
support
from
DHC
 team
 2
 2.1
 4
 Importance
of
good
nutrition
and
 sensible
eating
 6
 6.2
 5
 Account
for
protein
 1
 1
 6
 Frustration
with
lack
of
 knowledge/support
from
DHC
team
 1
 1
 7
 Frustration
with
lack
of
accuracy
with
 food
labels
 3
 3.1
 8
 Challenge
of
blood
glucose
 management
with
exercise
 2
 2.1
 9
 Other

 5
 5.2
 10
 Response
“No”
 22
 22.7
 11
 Carbohydrate
counting
is
critical
and
 support
from
DHC
team
(1
&
3)
 4
 4.1
 12
 Carbohydrate
counting
is
critical
and
 love
the
pump
(1
&
2)
 6
 6.2
 13
 Carbohydrate
counting
is
critical
and
 good
nutrition
(1
&
4)
 8
 8.2
 14
 Love
the
pump
and
good
 nutrition/sensible
eating
(2
&
4)
 2
 2.1
 15
 Carbohydrate
counting
is
critical
and
 challenge
of
exercise
(1
&
8)
 1
 1
 16
 Carbohydrate
counting
is
critical,
 good
nutrition/sensible
eating,
and
 challenge
of
exercise
(1,
4
&
8)
 1
 1
 17
 Good
nutrition/sensible
eating
and
 challenge
of
exercise
(4
&
7)
 1
 1
 18
 Carbohydrate
counting
is
critical
and
 lack
of
accuracy
with
labels
(1
&
7)

 1
 1
 
 Total
 97
 100
 
 Missing
 200
 
 
 Total
 297
 

 158
 Question
46:

Do
you
have
any
comments
about
this
survey?
 Table
56:
Survey
question
46
–
Do
you
have
any
comments
about
this
survey?

 Coding
 Topics
 Frequency
 %
 1
 Enjoyed
doing
and
praise
for
study
 design
 23
 28.4
 2
 Enjoyed
opportunity
to
think
about
 nutrition
and
carbohydrate
counting
 3
 3.7
 3
 Love
the
pump
 2
 2.5
 4
 Importance
of
support
from
DHC
 team
 3
 3.7
 5
 Suggestions
to
improve
study
design
 6
 7.4
 6
 Enjoyed
doing
and
thinking
about
 nutrition
(1
&
2)
 8
 9.9
 7
 Enjoyed
doing,
thinking
about
 nutrition,
and
support
from
DHC
 team
(1,2
&
4)
 2
 2.5
 8
 Enjoyed
thinking
about
nutrition
and
 love
the
pump
(2
&
3)
 1
 1.2
 9
 Other
 10
 12.3
 10
 Response
“No”
 19
 23.5
 11
 Enjoyed
doing
and
suggestions
to
 improve
study
design
(1
&
5)
 3
 3.7
 12
 Love
the
pump
and
support
from
 DHC
team
(3
&
4)
 1
 1.2
 
 Total
 81
 100
 
 Missing
 216
 
 
 Total
 297
 

 159
 7.2
 MULTIVARIATE
RESPONSES
 This
section
will
describe
how
three
scale
scores
were
constructed
by
recoding
or
grouping
specific
uni‐ variate
survey
question
responses
together
in
a
multivariate
manner.

The
scores
include:
 7.2.1
 Nutrition‐related
diabetes
health
care
team
member
scale
score
 7.2.2
 Nutrition
knowledge
scale
score
 7.2.3
 Glycemic
outcome
score
 7.2.1
 Diabetes
health
care
(DHC)
team
member
scale
score
 The
nutrition‐related
DHC
team
member
scale
score
was
calculated
from
survey
question
3:

 Question
3:
 Who
currently
provides
your
nutrition
support
for
your
diabetes
management?
 (Please
check
all
that
apply)
 The
rationale
behind
this
scale
was
to
explore
the
number
of
DHC
professionals
adult
insulin
pump
users
 rely
upon
for
nutrition
support.

All
DHC
professionals
were
assessed
as
discrete
variables.

Participants
 received
a
score
of
“1”
for
each
DHC
professional
they
selected.

Otherwise
they
received
a
“0”.

The
DHC
 professionals
 included
generalist,
specialist,
nurse,
dietitian
and
Diabetes
Education
Centre.
 
Responses
 for
“Medtronic
Help
Line”,

“I
educate
myself”,
“I
do
not
have
one”
and
“Other”
were
not
included.

The
 scale
can
range
from
0
–
5.
 For
 statistical
 analysis
 where
 respondents
 were
 divided
 into
 dichotomous
 groups
 based
 on
 an
 approximate
50:50
group
split,
a
score
of
<2
was
used.
 Table
57:
Diabetes
health
care
team
member
scale
score
 DHC
Team
Members
 Frequency
 %
 Cumulative
%
 0
 58
 19.5
 19.5
 1
 91
 30.6
 50.1
 2
 69
 23.2
 73.3
 3
 56
 18.9
 92.2
 4
 12
 4
 96.2
 5
 11
 3.7
 100
 Total
 297
 100
 
 Mean
=
1.7,
SD
=
1.3
 160
 7.2.2
 Nutrition
knowledge
scale
score
 The
nutrition
knowledge
scale
score
was
calculated
from
seven
survey
questions:
 16:
 If
eaten
on
its’
own,
which
nutrient
is
fully
converted
to
sugar
2
hours
after
eating?
 17:
 Which
of
the
food
groups
below
DO
NOT
contain
carbohydrates:
(Please
check
all
that
ap‐ ply).
 18:
 How
do
fats,
protein,
and
fibre
affect
the
digestion
of
carbohydrates
when
included
in
the
 same
meal?
 19:
 Are
you
familiar
with
the
concept
of
glycemic
index?
 20:
 What
food
in
the
list
below
has
the
HIGHEST
glycemic
index?
 22:
 When
reading
food
 labels,
 the
gram
count
 for
“carbohydrate”
 is
more
 important
that
the
 gram
count
for
“sugar”.
 23:
 Label
#1:
What
is
the
serving
size
for
this
bread?
 24:
 Label
#1:
How
many
grams
of
available
carbohydrate
should
be
counted
for
1
serving?
 25:
 Label
#1:
How
many
grams
of
available
carbohydrate
should
be
counted
 if
you
eat
only
1
 slice
of
bread?
 26:
 Label
#2:
How
many
grams
of
available
carbohydrate
should
be
counted
for
1
serving?
 27:
 When
a
label
states
“No
Added
Sugar”
that
means
it
will
NOT
raise
blood
glucose
at
all.”
 28:
 What
do
you
USUALLY
do
if
you
have
a
low
blood
glucose?
 The
 rationale
 behind
 this
 scale
 was
 to
 explore
 respondents’
 understanding
 of
 fundamental
 nutrition
 principles
involved
in
diabetes
management.

Each
question
was
recoded
based
on
a
correct
or
incorrect
 answer.

Respondents
received
a
score
of
“1”
when
they
answered
the
question
correctly.

All
other
an‐ swers
 including
“I
do
not
know”
were
given
a
score
of
 
“0”.
 
 If
a
participant
skipped
a
question
the
as‐ sumption
 was
 made
 that
 they
 did
 not
 know
 the
 answer
 and
 they
 received
 a
 score
 of
 “0”
 for
 that
 question.
 
 Each
 food
 group
 option
 for
 question
 17
 (high
 sugar
 foods,
 vegetables,
 fruit
 &
 fruit
 juices,
 grains,
fats,
protein,
starchy
vegetables,
milk
and
yogurt)
was
assessed
as
a
discrete
variable.

However
 due
to
a
lack
of
variance
in
response,
“high
sugar
foods”,
“fruit
&
fruit
juices”,
“grains”
and
“starchy
vege‐ tables”
were
not
included
in
the
final
calculation.

Similarly,
question
23
and
27
were
also
excluded
from
 the
nutrition
knowledge
scale
calculation
due
to
a
lack
of
variance
in
response.

For
label
reading
ques‐ tions
23‐26,
participants
were
asked
 to
 refer
 to
 two
examples
of
 labels
 and
determine
 the
amount
of
 available
 carbohydrate
 based
 on
 different
 serving
 sizes
 and
 the
 presence
 of
 fibre
 and
 sugar
 alcohols.

 Appropriate
 treatment
of
hypoglycemia
 for
question
28,
 included
options
 “eat
 15
grams
of
 fast
acting
 carbohydrate”,
“eat
15
grams
of
fast
acting
carbohydrate
plus
15
grams
of
protein”
and
appropriate
an‐ swers
in
the
“other
(please
specify)”
comment
box.

Scores
on
the
nutrition
knowledge
scale
can
range
 from
0
–
13.
 161
 For
 statistical
 analysis
 where
 respondents
 were
 divided
 into
 dichotomous
 groups
 based
 on
 an
 approximate
 50:50
 group
 split,
 a
 score
 of
 <10
 was
 used
 to
 differentiate
 between
 “high”
 and
 “low”
 nutrition
knowledge
scale
scores.
 Table
58:
Nutrition
knowledge
scale
score
 Nutrition
knowledge
 Frequency
 %
 Cumulative
%
 3
 4
 1.3
 1.3
 4
 3
 1.0
 2.4
 5
 9
 3.0
 5.4
 6
 19
 6.4
 11.8
 7
 25
 8.4
 20.2
 8
 45
 15.2
 35.4
 9
 52
 17.5
 52.9
 10
 38
 12.8
 65.7
 11
 55
 18.5
 84.2
 12
 41
 13.8
 98
 13
 6
 2.0
 100
 Total
 297
 100
 
 Mean
=
9.2,
SD
=
2.2
 7.2.3
 Glycemic
outcome
score
 The
glycemic
outcome
score
was
calculated
from
survey
question
32:
 Question
32:
What
was
the
result
of
your
MOST
RECENT
A1c
test?
 The
rationale
behind
this
scale
was
to
explore
respondents’
diabetes
management
outcomes
based
on
 their
glycemic
control
according
to
the
most
recent
Canadian
Clinical
Practice
Guideline
of
a
desired
A1c
 test
result
of
≤7%.

Participants
received
a
“1”
if
their
last
A1c
was
≤
7%.

If
their
last
A1c
was
greater
than
 7%
participants
received
a
score
of
“0”.

If
a
participant
failed
to
answer
question
32
(i.e.
“missing),
they
 were
not
did
not
receive
a
glycemic
outcome
score
and
ere
not
 included
in
any
analysis
related
to
gly‐ cemic
control.
 Table
59:
Glycemic
outcome
score
 Score
 A1c
 Frequency
 %
 0
 >
7.0%
 132
 52.4
 1
 ≤
7.0%
 120
 47.6
 
 Total
 252
 100
 
 Missing
 45
 
 
 Total
 297
 
 162
 7.3
 RESPONSE
COMMENTS
 • Please
 note
 all
 comments
were
 transcribed
 verbatim;
 errors
 in
 spelling
 or
 grammar
were
 not
 cor‐ rected.
 • This
section
includes
responses
from
the
original
data
set
(n=332)
prior
to
deletion
of
31
respondents
 due
to
insufficient
demographic
or
nutrition
knowledge
.
 Question
3:


 Who
currently
provides
your
nutrition
support
for
your
 diabetes
management?
(please
check
all
that
apply)
 Table
60:
Survey
response
comments
–
Question
3
 Response
 Comment
text
from
“Other
(please
specify)”
response
option
 1.
 Online
diabetes
forums.
 2.
 Currently
I
am
between
Physicians
and
a
health
care
team
I
can
better
speak
to
this
in
a
 few
weeks.
 3.
 I
am
an
executive
chef
and
a
research
chef
(food
science
technology)
as
well
as
an
RD.
 4.
 Only
recently
had
access
to
a
dietician
–
this
coincided
with
pump
therapy
–
until
summer
 of
2007
I
did
not
have
any
access
to
a
dietician
even
though
I
had
been
diabetic
for
15
 years.
 5.
 I
received
nutrition
support
initially
when
I
attended
the
“Pump
School
Program”
at
the
 diabetes
centre
in
March
2005,
but
haven’t
been
back
since.
 6.
 I
am
a
dietitian
working
in
the
Diabetes
Education
Centre.
 7.
 Naturopathic
Physician.
 8.
 Our
Diabetes
Ed.
Centre
does
not
have
a
full
time
dietician.

The
waiting
list
is
long
for
an
 appointment
for
casual
service.
 9.
 I
have
consulted
with
a
dietitian
in
the
past
but
haven’t
found
the
information
 particularly
well‐suited
to
my
needs.

I’m
42
years
old,
have
had
type
1
for
21
years,
am
 extremely
active,
and
am
experiencing
hormone‐related
blood
sugar
fluctuations
that
I
 have
difficulty
managing.

I’ve
consulted
with
fitness
specialists,
but
they’re
not
diabetes
 specialists,
so
overall
I’m
frustrated.
 10.
 Friends
with
diabetes.
 11.
 With
help
from
spouse.
 12.
 I
have
a
spouse
and
daughter
who
both
work
in
health
care
professions.
On
another
 matter,
please
note
that
the
survey
website
would
not
open
by
using
the
“CTRL
and
 Click”
method.

I
had
to
paste
the
address
into
the
internet
connection,
menu
bar.

 Hopefully
others
were
successful
by
clicking
on
the
address.
 163
 Table
60:
Survey
response
comments
–
Question
3
 Response
 Comment
text
from
“Other
(please
specify)”
response
option
 13.
 I
am
married
to
a
dietitian.
 14.
 I
went
to
a
Diabetes
Education
Centre
about
5
years
ago
and
have
not
been
since.
 15.
 Barrie
Ontario
Diabetes
Centre
was
extremely
ill
equipped
to
assist
me
with
carb
 counting
–
I
since
have
moved
to
Mississauga’s
Trillium
Centre
Diabetic
Educations
and
 an
more
than
happy
with
the
information
they
provided
with
carb
counting
in
area
fast
 food
places
and
at
any
meal
I
eat.

This
place
is
top
notch
–
just
wish
Barrie
would
 educate
the
educators!!!

It’s
a
1.5
hour
drive
for
me
to
trillium!!
 16.
 My
daughter
was
recently
diagnosed
with
Type
1
Diabetes,
so
I
just
went
through
the
 nutritional
support
with
her
at
Children’s
Hospital
in
Vancouver.
 17.
 Diabetes
Dialogue
Magazine.
 18.
 Carb
counting
with
the
help
of
my
pump.
 19.
 My
wife
is
a
nurse.
 20.
 From
attending
my
local
Tops
group,
I
learn
very
good
nutritional
information.

In
fact,
I
 am
the
leader
of
my
group
for
the
second
year
in
a
row.
 21.
 Fitness
instructors
at
gym
that
I
attend.
 22.
 Internet
forums.
 23.
 Reading
nutrition
books.
 24.
 Other
is
a
bodybuilding
oriented
nutritionist
 25.
 Above
through
the
Chronic
Renal
Insufficiency
Program
at
the
Regina
general
Hospital
 26.
 Carb
King
Book.
 27.
 I
am
a
dietitian
that
works
in
a
Diabetes
Education
Centre.
 28.
 Diabetes
nurse
educator.
 29.
 Pharmacist
who
is
a
CDE.
 
 164
 Question
8:


 How
do
you
decide
how
much
insulin
to
give
yourself
when
 eating
a
meal/snack?
 Table
61:
Survey
response
comments
–
Question
8
 Response
 Comment
text
from
“Other
(please
specify)”
response
option
 1.
 I
use
both
the
bolus
wizzard
and
I
do
occasionally
count
and
calculate
on
my
own.
 2.
 Combination
of
estimating
and
using
my
own
calculations
and
sometimes
using
the
 wizard.
 3.
 I
am
used
to
using
the
sliding
scale,
but
I
have
also
been
using
the
bolus
wizard.
 4.
 I
tend
to
calculate
myself
and
will
also
check
with
what
the
bolus
wizard
says.

I
find
the
 amount
of
active
insulin
will
dictate
the
exact
amount
of
insulin
that
I
give.
 5.
 I
have
been
diabetic
for
46
years
I
calculate
it
based
on
experience.
 6.
 Medtronic
pump
does
the
math
for
me.

I
count
carbs,
test
and
the
pump
deos
the
math.

 Just
quicker
than
doing
it
myself.
 7.
 Count
the
number
of
carbs
and
bolus
wizard,
but
take
into
consideration
activity/insulin
 sensitivity.
 8.
 I
eyeball
the
food,
check
my
blood
sugar,
and
mentally
calculate
the
appropriate
dose.

My
hgA1c
have
been
in
the
6.2
–
6.7
range
for
many
years.

I
have
been
an
insulin
 dependent
diabetic
for
over
50
years
and
have
used
a
pump
for
13‐14
years.
 9.
 I
guess
a
lot.
 10.
 Use
Bolus
wizard
plus
my
head
to
double
check
ratio
sensitivity
correction
and
plans.
 11.
 Count
CHO
and
use
wizard
but
adjust
significantly
to
correct
for
context
(stress/exercise).
 12.
 30
years
of
trial
and
error!
 13.
 Both
2
&
3.
 14.
 I
use
a
combination
of
the
first
3
depending
on
the
situation.
 
 165
 Question
28:
What
do
you
USUALLY
do
if
you
have
a
low
blood
glucose?
 Table
62:
Survey
response
comments
–
Question
28
 Response
 Comment
text
from
“Other
(please
specify)”
response
option
 1.
 Eat
a
snack
and
track
glucose
values
using
sensor
and
respond
with
either
insulin
or
food
 depending
upon
graph
results
after
20
minutes
and
periodically
thereafter.
 2.
 If
in
daytime
I
eat
15
g
of
fast
acting
carb…if
in
the
evening
after
supper
I
eat
15
g
carb
 and
15g
protein
and
check
my
bg
before
bed.
 3.
 Always
#2
and
often
#3.

It
can
be
difficult
to
take
the
protein
e.g.
in
the
middle
of
a
 business
meeting
or
interview
it
can
be
difficult
to
eat
protein
and
easier
to
take
the
 glucose
tabs
only
and
then
recheck
BG
later.
 4.
 Eat
15
grams
fast
acting
carbohydrate,
check
blood
sugar
levels
when
rising
eat
15
grams
 of
a
long
acting
carbohydrate
to
maintain
blood
sugar
levels.
 5.
 Use
dextrose
tablets,
or
another
tablet
form.
 6.
 2
tsp
honey,
wait
15
min,
if
still
low
another
2
tsp
honey,
when
BS
rises
eat
some
fat
 (cheese)
and
protein
(bread).
 7.
 Eat
4
dex
glucose
tablets.

Recheck
my
blood
sugar,
if
after
10
minutes
it
is
still
below
 3mmol/L,
I
have
another
4
dex
4
tablets.

I
continue
to
recheck
my
serum
glucose
until
it
 normalizes
and
may
have
to
give
a
small
amount
of
insulin
to
compensate
for
the
extra
 carbohydrate
I
consumed.

 8.
 Depends
on
active
insulin,
how
long
its
been
since
I’ve
eaten
and
how
low
my
blood
 sugar
is.

I
sometimes
do
#2,
4,
or
5.
 9.
 I
have
glucose
tabs
and
carb
and
protein
if
a
long
time
before
next
meal.
 10.
 This
all
depends
on
how
low,
what
time
of
day
and
I
have
active
bolus
insulin.

Generally
 speaking
I
would
treat
with
5‐10
grams
of
fast
acting
carbs
ie.
Glucose
tabs,
juice
or
 candies.
 11.
 Between
meals
15
carb
&
15
protein
right
before
a
meals
just
15
carbs.
 12.
 Orange
or
Apple
juice.
 13.
 Take
15g
juice
and
re
check
blood
sugar
then
if
they
are
still
low
eat
15
grams
protein.
 14.
 Eat
somewhere
between
15
and
35
grams
of
carb
depending
on
how
low
I
am,
what
I’ve
 been
doing
exercise‐wise
and
what
I
will
be
doing
immediately
afterward.
 15.
 I
eat
15g
fast
acting
Carbs
and
depending
on
the
activities
I
am
engaged
in,
I
also
have
 some
protein,
or
I
wait
to
see
if
the
15g
will
be
enough.
 16.
 Depends
on
how
llow
and
for
how
long.

Typically
if
below
5.0
I
drink
30
grams
of
juice
 (one
container).

If
above
5.0
I
drink
15
grams
of
juice
and
check
BG
in
30
minutes.
 17.
 10
grams
of
fruit
choices,
test
blood
sugar
after
10
minutes
the
if
in
normal
range
have
a
 small
snack
and
bolus
appropriately.
 18.
 May
lower
basal
rate
if
B.G.
is
not
below
3,0
otherwise
eat
15gm
CHO
and
15G
CHON.
 166
 Table
62:
Survey
response
comments
–
Question
28
 Response
 Comment
text
from
“Other
(please
specify)”
response
option
 19.
 About
10
grams
of
a
carb
like
triscuits
along
with
4
oz.
orange
juice.
 20.
 Eat
15/20
grams
of
fast
cating
carbs
(depends
on
how
low
I
am)
and
then
a
snack
that
 has
at
least
7
grams
protein.
 21.
 Usually
keep
having
fast
acting
carbs
until
I
feel
better
and
in
control
again.
 22.
 Eat
10
grams
of
fast
acting
carbohydrate
the
check
again
in
15
minutes,
If
not
raised
 enough,
then
I
have
the
carb/protein
option.
 23.
 Suspend
my
pump
and
eat
5‐10
CHO
if
mild
low
and
if
significant
low
that
does
not
 respond
quickly
I
will
eat
15
CHO
repeatedly
and
then
protein
snack
or
meal
if
due.
 24.
 I
put
my
pump
on
temporary
basal
0.65‐.7
so
I
am
not
feeding
insulin.

I
also
have
125ml
 of
1%
milk.
 25.
 I
eat
15
grams
of
sugar,
wait
15
minutes
recheck
my
glucose
and
repeat
if
still
not
up
to
 at
least
5.0.

I
also
have
my
pump
suspended
as
soon
as
I
suspect
that
my
sugar
is
low.

If
 I
am
wearing
a
glucose
“Real
Time”
sensor,
an
alarm
will
let
me
know
I
am
on
my
way
to
 a
low.
 
 167
 Question
44:


Which
of
the
following
topics
would
you
like
more
information
 on?
(Please
check
all
that
apply)
 Table
63:
Survey
response
comments
–
Question
44
 Response
 Comment
text
from
“Other
(please
specify)”
response
option
 1.
 How
to
fine
tune
values
in
the
bolus
wizard.
 2.
 How
to
make
insulin
adjustments
during
pregnancy.
 3.
 Carbohydrate
counting
when
not
usings
nutritional
labels
–
getting
better
at
“eyeballing”
 carb
values.
 4.
 Basal
testing.
 5.
 Health
meal
ideas
and
easy
to
prepare
recipes.
 6.
 None
required
at
this
time.
 7.
 Mo9re
information
on
corrective
bolusing.
 8.
 None.
 9.
 I
find
that
very
little
information
is
available
about
exercise
regimes
and
insulin
 adjustments.

This
is
very
important
when
using
rapid
insulin.
 10.
 I
am
up
to
date
on
all
the
above
information
as
I
teach
diabetes
management
as
well
as
 being
a
pump
user.
 11.
 Procedures
for
doing
fasting
basal
checks…how
to
determine
or
confirm
sensitivity
level
 entered
into
pump…how
to
determine
of
confirm
active
insulin
time
entered
into
pump.
 12.
 No
info
required,
I
can
find
info
when
ever
I
need
it.

I
use
trial
and
error
for
different
 bolus
delivery
methods
and
no
meal
seems
to
give
the
same
results
twice!!!!
 13.
 I
have
a
problem
trying
to
regain
lost
weight.

Nothing
that
I
have
tried
has
helped
so
far.
 14.
 Glycemic
index
and
glycemic
load
–
how
to
figure
it
out
or
find
books
that
can
use
to
help
 with
glycemic
indexing.
 15.
 Exercise
–
marathon
training
&
nutrition.
 16.
 Most
of
the
above
choices
have
been
covered
with
me
by
my
my
burse
educator.
 17.
 How
to
cope
with
unpredictable
hormone
effects
on
BG;
how
t
eat
well
when
I
really
 don’t
like
cooking
or
meal
planning!
 18.
 If
my
pump
fails,
what
type
and
how
much
insulin
would
I
use
until
I
could
get
a
 replacement
pump.
 19.
 Due
to
a
recent
bout
with
either
food
poising
or
severe
stomach
flu
I
was
told
to
take
off
 my
pump
entirely
(I
had
turned
it
down
significantly)
at
the
hospital.

What
is
the
correct
 procedure?

I
continued
to
be
ill
for
four
days,
put
my
pump
back
on
and
had
difficulty
 keeping
my
sugars
from
getting
too
high
while
trying
to
take
in
some
easy
post
flu
 nutrition.
 168
 Table
63:
Survey
response
comments
–
Question
44
 Response
 Comment
text
from
“Other
(please
specify)”
response
option
 20.
 Reference
books
for
carbohydrate
information.
“Food
choices
in
the
market
place”.
 21.
 Adjussting
basal
rates
accoeding
to
blood
glucse
levels
too
higfh
or
too
low.
 22.
 How
to
adjust
insulin
when
sick
e.g.
vomiting
and
also
about
how
fats
affect
absorption
 rates.
 23.
 I
believe
that
I
have
all
the
info
I
need.
 24.
 Prevention
tips
dealing
with
extensive
travel
and
failure
of
pump,
etc.
 25.
 How
exactly
does
Bolus
Wizard
factor
:Active
insulin”
when
calculating
boluses?
 26.
 Sick
day
management
 27.
 Understanding
false
highs
and
the
period
of
time
they
last
after
playing
rigorous
sports
 such
as
hockey.
 28.
 I
already
do
almost
all
of
the
above
but
any
additional
information
is
always
helpful.
 29.
 How
to
go
about
carb
counting
with
a
mixed
meal
or
something
one
has
baked
at
home.
 30.
 I
am
always
interested
in
learning
about
new
research
being
done
in
the
area
of
diabetes.

 I
believe
I
work
hard
(most
times)
at
keeing
my
diabetes
under
control.

I
would
be
 interested
to
learn
why
a
reasonably
well
controlled
person
is
experiencing
some
of
the
 problems
associated
with
poor
control.
 31.
 Everything
is
going
fine.

No
needs
at
this
time.
 32.
 None
–
too
much
information.
 33.
 Fine
tuning
basal
rates.
 34.
 What
kinds
of
food
help
or
stimulate
better
brain
function
or
health?
 35.
 More
information
on
the
biological
side
of
diabetes
(such
as
what
happens
in
the
body
of
 a
diabetic
that
is
different
from
a
non
diabetic
and
more
detailed
information
on
side
 effects.

Nothing
I
have
received
from
my
doctors
has
ever
felt
like
100%
of
the
 information
as
I
was
diagnosed
as
a
child.

It
would
be
very
helpful
to
me
as
a
young
 person
who
will
deal
with
this
for
the
rest
of
their
life
to
know
more
about
the
science
 behind
what
is
going
on
my
body.

Too
much
of
the
information
I
receive
tells
me
the
 same
general
rules.
 36.
 I’d
like
more
info
on
high
fat
meals
ie
pizza/pasta
and
how
to
bolus
for
those.
 37.
 Weight
training
and
the
effect
of
heavy
lifting
and
the
release
of
sugar
from
the
liver.

 How
to
manage
elevated
blood
sugars
after
resistance
training.
 38.
 Insulin
adjustments
based
on
hormonal
levels
–
my
insulin
needs
drop
significantly
just
 prior
to
and
during
menstruation.
 
 169
 Question
45:

Do
you
have
any
comments
on
the
role
of
nutrition
or
 carbohydrate
counting
in
diabetes
management?
 Table
64:
Survey
response
comments
–
Question
45
 Response
 Comment
text
in
response
box
 1.
 Have
noted
since
being
on
the
pump
that
regardless
of
how
carefully
I
read
and
bolus
the
 carbohydrate
counts
in
cereals,
i.e.
shredded
wheat,
oatmeal
etc.
my
blood
sugars
still
 raise
dramatically
necessitating
a
further
bolus
later.
 2.
 It
is
the
single
most
important
part
of
diabetes
control.
 3.
 Would
like
to
have
a
electronic
device
that
lists
carbs.
 4.
 This
should
be
a
regular
educational
component
of
any
visit
to
see
the
“team”
at
a
 diabetes
clinic…very
easy
to
have
the
knowledge
but
the
support
is
needed
to
make
it
 part
of
personal
practices.
 5.
 I
am
finding
that
by
simply
reducing
my
carbs,
I’ve
had
much
better
sugars,
lowere
basal
 requirements,
and
have
lost
weight.

Low
carb
is
looking
better
every
day!
 6.
 Love
the
pump.
 7.
 No.
 8.
 I
would
like
to
be
able
to
set
a
bolus
to
give
a
second
bolus
at
a
fixed
period
after
the
 original
bolus.

I
enjoy
Chinese
meals
but
find
my
glucose
spikes
about
3
hours
after
I
 bolus
at
the
beginning
of
the
meal.

The
square
wave
meters
out
insulin
at
a
given
rate
 over
period
of
time,
not
at
a
predetermined
time.
 9.
 I
understand
how
important
this
is
in
regards
to
managing
my
diabetes.
 10.
 For
the
most
part,
I
focus
on
carbs
on
labels
and
do
not
worry
about
the
fat(s).

I
also
rely
 on
my
bolus
wizard
allot.
 11.
 The
most
important
part
of
my
management
since
this
is
the
basis
for
determining
how
 much
insulin
to
take
as
a
bolus
each
day
not
to
mention
determination
of
insulin
 sensitivity,
basal
rates
etc.

The
importance
of
nutrition
is
being
diminished
by
the
CRA
in
 regards
to
the
Disability
Tax
Credit
and
in
terms
of
the
general
health
care
system.

In
 Nova
Scotia
the
only
access
to
a
dietitian
is
through
either
the
Endocrinology
clinic
and
 generally
only
then
if
you
are
on
pump
or
the
Diabetes
Mgmt
Centre.

Access
to
the
 Diabetes
Mgmt
Centre
is
restricted
to
two
visits
throughout
your
life
time
unless
there
is
 a
significant
life
change
that
needs
to
be
addressed.
 12.
 I
have
been
diabetic
for
42
years
and
it
is
an
ongoing
learning
experience.

I
am
pleased
at
 the
amount
of
information
given
on
packages
for
carb
counting.

I
find
some
restaurants
 nutrition
guide
tend
to
be
a
bit
off…I
have
had
some
lows
as
a
result
of
this,
so
I
think
 they
need
to
do
a
bit
more
work
on
them.
 13.
 A
critical
point.
 14.
 Counting
carbohydratehas
significantly
improved
glucose
levels.

Unfortunately
this
 information
is
not
always
readily
available
on
baked
goods
from
specialty
shops
or
 restaurants.

 170
 Table
64:
Survey
response
comments
–
Question
45
 Response
 Comment
text
in
response
box
 15.
 No.
 16.
 Need
more
details
to
be
able
to
troublehsot.
 17.
 It’s
vital
to
control
the
insulin
levels
and
avoid
highs
and
lows.
 18.
 No.
 19.
 No.
 20.
 No.
 21.
 The
bolus
Wizard
function
greatly
facilitates
carb
counting.
 22.
 Carbohydrate
counting
is
extrememly
impornat
for
individuals
with
diabetes.

I
am
a
 dietitian
myself
so
while
I
have
not
used
the
dietitian
services
at
my
DEC,
I
would
if
I
did
 not
have
the
knowledge
myself.
 23.
 Extremely
important
–
essential
for
good
control.

More
patients
should
be
taught
the
 role
of
carbohydrate
countin
in
managing
daily
blood
sugars.
 24.
 For
my
glucose
control,
it
is
crucial
that
I
try
to
stay
within
my
daily
allotment
and
 carefully
count
carbohydrates.

I
speed
skate
and
cycle,
and,
unless
I
am
highly
active,
 competing
or
training,
try
to
consume
between
250
and
300
grams
of
carbohydrates
per
 day.

Staying
within
my
range
at
each
meals
or
snack
also
allows
me
to
better
control
 glucose
levels.

Lastly,
I
have
found
that
avoiding
meals
or
snacks
in
the
evening
keeps
my
 waking
levels
much
more
stable.
 25.
 Carbohydrate
counting
makes
living
with
diabetes
a
lot
easier.
 26.
 I
have
excellent
control
and
do
not
count,
however,
I
am
very
aware
of
how
different
 foods
affect
my
glucose
levels.
 27.
 I
used
to
use
the
exchange
system
and
sometimes
still
rely
on
it.

When
I
first
asked
the
 diabetes
management
team
about
carb
counting
they
said
just
stick
to
that
system.

I
had
 to
insist
and
next
time
I
saw
them
they
were
gung
ho
on
it.

Very
frustrating
from
my
 point.

I
have
friends
in
the
U.S.
and
they
carb
count
with
everything.

Is
is
necessary
to
 carb
count
to
everything
or
what
is
the
leeway??
 28.
 Type
1
for
41
years,
on
pump
since
1981‐
so
far
so
good.

I
just
eat
sensibly.
 29.
 If
nutrition
and
carb
counting
can
be
mastered
while
using
the
pump
its
the
easiest
way
 to
lower
your
A1c.
 30.
 Proper
nutrition
and
carb
counting
are
essential
in
controlling
diabetes.
 31.
 Since
getting
my
insulin
pump,
I
only
then
realized
how
important
carb
counting
is
Back
 when
I
was
diagnosed
back
in
the
70’s
up
until
about
8‐10
yrs
ago
I
NEVERdid
carb
 counting
as
I
was
taught
“exchanges”
and
I
found
it
++hard
to
convert
to
carb
counting.
 32.
 No.
 33.
 Sometimes
protein
counting
makes
a
big
difference
in
control.

I
find
that
if
I’ve
had
extra
 protein
at
an
evening
meal,
my
overnight
blood
sugars
will
be
higher
than
normal.
 171
 Table
64:
Survey
response
comments
–
Question
45
 Response
 Comment
text
in
response
box
 34.
 No.
 35.
 No.
 36.
 I
believe
that
nutrition
and
carb
counting
needs,
need
to
be
reviewed
on
a
yearly
basis
 with
the
client/diabetic
so
any
difficulties
can
be
solved
early.Many
diabetcics
think
that
 one
visit
with
the
dietician
is
all
they
need
&
that
they
know
everything
there
is
to
know
 about
the
diet
etc.
 37.
 Always
count
your
carbs…
 38.
 No.
 39.
 The
most
important
aspect
is
balancing
carbs
/
exercise
/
insulin.

Without
counting
carbs
 you
cannot
properly
dose
insulin.
 40.
 No.
 41.
 I
have
never
needed
to
count
carbs
as
I
have
always
been
able
to
manage
my
blood
 sugars
really
by
rule
of
thumb.

I
realize
I
have
been
lucky
but
at
79
years
of
age
and
after
 50
years
of
diabetes
I
see
no
reason
to
change
now.

I
just
wish
that
pumps
had
been
 available
in
the
1950’s.
 42.
 It
is
time
consuming
but
well
worth
the
effort.
 43.
 I
learned
the
hard
way
how
important
it
is
to
manage
your
diabetes.

Last
July
I
lost
a
 child
due
to
poorly
controlled
sugars
(a1c
of
16.3)
and
since
then
have
taken
control
of
 my
diabetes
and
have
managed
to
have
a
beautiful
healthy
baby
boy
just
3
days
ago
 while
maintaining
an
a1c
between
5.7
and
6.3
throughout
the
entire
pregnancy.

My
 Medtronic
insulin
pump
gave
me
the
confidence
and
the
ability
to
provide
the
best
care
 for
myself
and
my
child
during
my
pregnancy
and
hopefully
for
many
years
to
come.

I
am
 a
very
outspoken
Pump
supporter
and
I
only
wish
more
people
had
the
access
to
this
 amazing
device
that
I
have.
 44.
 Because
of
carb
counting
I
am
making
better
choices.

The
real
problem
occurs
when
 manufacturers
do
not
put
carb
values
on
foodstuffs.
i.e
–
dole
peaches
in
light
syrup
state
 after
fibre
reduction
total
carbs
is
22
gms.
–
when
I
eat
and
bolus
this
amount
it
usually
 tips
the
scale
on
the
high
side
and
I
wind
up
having
to
correct.
–
solution
don’t
eat
fruit
 cups.
 45.
 Fell
myself
and
my
spouse
have
had
to
determine
and
regulate
diet
based
mostly
on
our
 own
information.
 46.
 It
is
extremely
important,
along
with
glucose
testing
7
–
10
times
per
day.
 47.
 I
was
diagnosed
with
Type
1
Diabetes
in
1973
while
living
in
England.

I
was
taught
to
 manage
my
diet
by
counting
carbohydrates
right
from
the
start.

It
has
been
part
of
my
 life
ever
since.

I
have
learned
much
more
about
diet
over
the
years
as
more
research
and
 information
has
become
available.

I
have
done
pretty
well
with
this
method
overall
and
 have
remained
healthy.
 172
 Table
64:
Survey
response
comments
–
Question
45
 Response
 Comment
text
in
response
box
 48.
 I
don’t
know
if
I
am
special
or
just
not
taking
proper
care
but
I’ve
had
erratic
blood
sugar
 levels
my
entire
life.

Most
times
when
I
test
myself
I’m
completely
shocked
no
matter
 what
the
reading
is.

I
can
go
from
15
to
3
after
a
20
minute
walk,
but
the
next
day
after
 eating
the
exact
same
thinks
and
doing
the
exact
same
things
go
from
15
to
20
on
that
 same
walk.

Carbs
seem
to
affect
me
differently
from
one
day
to
the
next
and
Im
not
 good
and
making
adjustments
using
the
pump
(carb
vs
insulin
ratio)
ive
continued
to
use
 the
exact
same
figures
my
doctor
gave
me
when
I
began
over
3
years
ago
because
 nothing
seems
to
be
the
same
from
one
day
to
the
next…there
is
zero
pattern…
 49.
 I
feel
I
have
the
basics
down,
but
still
have
lows
and
highs
from
miscounting
the
carbs.

 Just
one
of
the
problems
with
diabetes.
 50.
 I
have
been
diabetic
for
25
years
and
gastroparesis,
and
my
number
one
issue
with
poor
 control
always
involved
poor
estimating
on
food
digestion
timing.

The
easiest
to
manage
 is
foods
with
high
glycemic
index
so
timing
of
food
hitting
my
bloodstream
is
more
 accurate
to
calculate.

Pizza
and
pasta
are
deadly
because
of
the
slow
absorption
time.
 51.
 I’ve
been
diabetic
for
31
years
and
am
so
glad
to
see
evident
research
that
has
changed
 the
way
we
manage
our
disease.

I
used
to
take
one
needle
a
day
and
check
urine!!

Wow
 –
how
awful
control
was
back
then!!

I
lost
my
brother
to
rRenal
Failure
and
heart
failure
 caused
by
his
pure
control
of
his
diabetes.

I
truly
believe
males
have
a
more
difficult
time
 following
rules
for
good
control.

He
had
better
education
with
it
in
the
beginning
since
 he
was
diagnosed
in
grade
10
was
2.5
years
older
than
me.

He
was
trained
initially
on
2
 shots
per
day..sadly..he
was
a
stubborn
jerk
and
after
losing
his
sight
about
5
years
ago..
 went
downhill
fast!!
 52.
 Since

I
learned
to
use
my
pump,
carb
counting
is
essential.

However,
I
do
encounter
 foods
where
the
packaging
info
is
definitely
wrong.

Eating
out
is
a
nightmare
–
I
generally
 don’t
because
it
takes
me
another
24
hours
to
get
back
on
track.

I
would
also
like
some
 info
on
the
role
that
pre‐menopause
and
menopause
has
on
diabetes.

I
have
been
 diagnosed
diabetic
for
34
years
with
minimal
complications.

I
do
feel
my
metabolism
has
 changed
somewhat
but
it
is
not
consistent
when
I
change
basal
patterns
to
account
for
 exercise
and
quiet
days.

I
would
really
like
to
lose
weight
but
have
not
had
a
lot
of
 success.

Personal
trainers
are
not
tuned
in
the
needs
of
diabetics
on
insulin.

The
 dietitian
was
not
helpful
either!
 53.
 No.
 54.
 After
26
years
of
being
Diabetic,
seeing
a
Dietician
is
almost
useless.

Most
of
the
time
I
 have
a
better
understanding
of
portion
sizes
and
charbohydrate
counting
than
they
do.

 One
thing
that
I
always
find
frustrating
is
that
reference
books
with
Charbohydrate
 information
are
hard
to
find.

When
I
was
a
child
the
“Food
choices
in
the
Marketplace”
 was
the
best
tool
and
now
I
cannot
find
an
updates
version
of
this
book.
 55.
 Figuring
out
how
many
carbs
are
in
my
foods
that
are
not
labeled
is
a
challenge.

Carb
 counting
as
well
as
adjusting
insulin
for
exercise
have
been
two
of
my
biggest
challenges
 as
a
pump
user.
 56.
 NO!
 57.
 You
couldn’t
use
the
pump
effetely
if
you
don’t
card
count.

Protei
does
need
to
be
 counted
for
some
people!
 173
 Table
64:
Survey
response
comments
–
Question
45
 Response
 Comment
text
in
response
box
 58.
 When
eating
away
from
home
at
a
restaurant
(where
there
are
no
labels)
that
is
the
most
 difficult
thing
to
calculate
even
with
a
book.
 59.
 No.
 60.
 No.
 61.
 No
thanks.
 62.
 I
was
diagnosed
with
Celiac
Disease
seven
months
ago.

It
has
been
a
difficult
task
trying
 to
incorporate
the
two
diseases
together
with
respect
to
nutrition
and
proper
glucose
 management.

Proper
management
of
celiac
disease
plays
a
big
part
on
proper
diabetes
 management.

I
have
been
having
trouble
with
my
blood
sugars
for
at
least
six
years.

 Prior
to
that
my
A1C’s
have
always
been
around
6.5
or
less.

Thanks
to
the
pump,
 diabetes
management
along
with
celiac
disease
has
been
a
lot
easier.

I
have
no
idea
how
 I
would
manage
if
I
were
on
needles
again.

I
would
strongly
recommend
any
other
 diabetics
who
have
celiac
disease
to
begin
on
pump
therapy
for
proper
management
of
 the
two
diseases.
 63.
 In
filling
out
this
survey,
I
am
now
realizing
I
don’t
know
as
much
as
I
thought
I
did
and
 want
to
seek
assistance
with
this.
 64.
 I
find
that
carb
counting
is
essential
for
sound
management
of
type
1
diabetes,
and
 greatly
reduces
highs
and
lows.

Since
switching
to
a
pump
and
using
carb.
Counting,
my
 glucose
levels
have
leveled
out
and
I
now
know
that
my
A1c’s
are
a
true
reflection
of
my
 typical
glucose
readings,
rather
the
merely
an
“average”
of
highs
and
lows.
 65.
 I
sometimes
think
that
carbohydrate
count
given
on
food
labels
is
not
quite
accurate.

For
 example,
if
I
bolus
for
30g
of
carbohydrates
for
a
whole
hot
dog
bun,
I
have
a
low
soon
 after
eating.

If
I
want
to
have
a
TV
Dinner
(Swanson’s
Hungry
Man,
for
example),
the
 label
on
the
box
says
there
are
100g
of
carbohydrates
in
a
meal
that
is
mostly
protein.

I
 bolus
for
45g,
which
is
for
the
potatoes,
corn,
and
tiny
dessert.

45g
usually
works
out
just
 fine,
so
where
are
the
other
55g?
 66.
 I
have
learned
over
the
years
that
the
more
knowledge
of
nutrition
I
can
obtain
means
 the
better
I
can
control
my
diabetes.
 67.
 I
think
it
is
very
important
to
use
carb
counting
and
read
packaging
for
that
information,
 and
remembering
to
subtract
fibre.

I
am
finding
that
some
of
the
restaurants
that
have
 nutritional
information
available
are
not
always
accurate…I
sometimes
have
lows
after
 using
those
guides.

I
think
those
restaurants
should
recheck
those
values.
 68.
 No.
 69.
 I
need
to
know
more
about
carb
counting
to
be
effective
with
my
pump.

I’ve
just
been
 on
the
pump
for
6
weeks.
 70.
 No.
 71.
 Vital
skill.
 72.
 Carb
counting
is
an
essential
to
properly
manage
type
1
diabetes
while
using
a
pump.
 174
 Table
64:
Survey
response
comments
–
Question
45
 Response
 Comment
text
in
response
box
 73.
 I
wish
it
were
easier
to
do!
 74.
 I
have
had
type
1
diabetes
for
43
years,
so
I
think
that
a
newly
diagnosed
diabetic
would
 have
gotten
more
in
depth
diet
information
than
I
did.
 75.
 Carbohydrates
are
key
to
managing
my
diabetes.

I
really
watch
what
the
carbs
are
that
I
 am
about
to
eat
and
modify
the
serving
to
fit
my
diabetes
better.
 76.
 Carbohydrate
counting
is
of
the
utmost
importance
when
using
an
insulin
pump.
 77.
 One
of
the
most
important
pieces
in
the
diabetes
management
puzzle.
 78.
 I
think
that
both
are
critical
for
achieving
effective
blood
glucose/sugar
control.
 79.
 I
need
to
gain
waight
but
it
is
hard
when
a
diabetic
i
cant
eat
sugar
to
help
gain
waight
 can
you
recommend
a
diet
for
this
problem
 80.
 Not
at
present.
 81.
 I
got
my
life
back
when
I
went
on
a
pump
and
started
counting
carbohydrates.

That
 being
said
it
is
much
easier
to
“cheat”
on
a
pump.

I
deal
with
depression
and
am
an
 emotional
eater.

I
am
working
hard
at
getting
that
in
check.

I
have
joined
TOPS
and
am
 in
the
process
of
losing
some
weight.

My
endocrinologist
has
asset
a
goal
weigh
for
me
 of
142
pounds.

I
am
confident
that
I
will
get
there
with
sensible
eating
habits
and
making
 the
right
food
choices.

So
far
I
have
lost
15
pounds
this
year.
 82.
 With
working
in
the
nutrition
health
care
field,
I
see
how
important
nutrition/diabetes
 management
is
and
how
many
people
choose
to
not
comply
with
recommendations.

 83.
 CHO
counting
is
just
one
factor
in
insulin
dosing.

Context
is
of
MAJOR
importance
in
my
 diabetes.

All
CHO’s
are
not
alike.

I
also
react
very
differently
to
various
foods.
 84.
 They
are
critical.
 85.
 I
find
managing
glucose
levels
during
strenuous
exercise
and
prolonged
work
periods
of
 moderate
exercise
quite
a
challenge
and
often
very
unpredictable;
i.e.
what
works
one
 day
doesn’t
necessarily
work
the
next.

For
example,
during
a
work
shift
(health
care
 worker),
I
reduce
my
basal
to
about
0.15
U/hr
and
still
experience
frequent
 hypoglycemia.

All
I
can
do
at
present
is
test
frequently
and
eat
accordingly.

Any
insights
 would
be
welcomed.
 86.
 No.
 87.
 I
am
hoping
with
the
carb
counting
and
the
pump
I
will
lose
weight.
 88.
 N/A.
 89.
 No.
 90.
 With
the
new
guidelines
to
subtract
the
number
of
grams
of
fibre
from
the
total
carbs,
I
 find
that
sometimes
it
works,
and
sometimes
it
doesn’t,
so
I
don’t
usually
subtract
unless
 I
have
had
experience
with
the
certain
food
and
know
what
it
does
to
my
glucose.
 175
 Table
64:
Survey
response
comments
–
Question
45
 Response
 Comment
text
in
response
box
 91.
 I
feel
that
carb
counting
is
one
of
the
best
ways
to
control
sugar
levels.

I
actually
weigh
 my
food
using
a
scale
with
a
database
of
foods.

I
can
see
at
a
glance
the
number
of
carbs
 in
my
meal/snack.
 92.
 My
insulin/carbohydrate
ratio
chnages
with
the
seasons.

My
insulin
dosage
goes
up
in
 the
winter
and
down
in
the
summer
especially
on
really
hot
humid
days.

Sometimes
I
 change
the
basal
instead
of
increasing
the
insulin
or
vice
versa.
 93.
 Today’s
fast‐acting
insulin
still
lasts
a
bit
too
long
(Humalog
and
Novolog
for
≈
6
hrs),
so
a
 slow
carb,
and
smaller
meals
seen
to
be
important
in
order
not
too
raise
the
sugar
levels
 too
high
as
little
insulin
should
be
put
in
to
prevent
hypoglycemia
later
on.

I
can’t
do
that
 as
I
eat
a
lot
in
each
meal.
 94.
 What
I
would
like
to
see
is
Manufacturers
of
products
take
responsibility
for
the
products
 they
make
and
also
give
appropriate
nutritional
guidelines
based
on
a
real
full
serving
 based
on
packaging
sizes.

An
example
of
this
would
be
Campbells
Chunky
Soup.

The
 package
size
is
420ml,
however,
the
Nutritional
Facts
label
serving
size
is
for
250ml
=
 Carbs
of
20g.

250ml
does
not
divide
into
420ml
evenly.

If
manufacturers
are
doing
this
 deliberately
to
so
that
they
only
have
to
send
in
1
test
profile
so
they
can
have
their
 labeling
accurate,
then
they
should
make
packaging
sizes
in
equal
amounts
related
to
 whatever
the
portion
size
is.

Using
the
above
example,
the
soup
container
should
be
in
a
 500ml
container,
not
a
420ml.
 95.
 Diabetes
management
for
adults
with
Type
2
would
be
much
easier
if
physicians
were
 better
educated
(general
practitioners,
specifically).

I
have
come
across
a
few
individuals
 who
are
surprised
at
the
steps
I
take
to
ensure
my
blod
sugars
are
in
a
normal
range.

I
 am
even
more
surprised
at
the
comments
these
individuals
have
received
from
their
 physicians.

Specifically
comments
like:
“My
doctor
saya
my
blood
sugars
are
ok
at
14.”

 “My
doctor
told
me
that
checking
my
blood
sugar
twice
a
week
is
ok.”

My
doctor
say
 that
I
can
eat
what
I
want.”
 96.
 I
believe
it
is
hugely
important.

That
said
I
will
not
say
that
I
ALWAYS
eat
the
absolute
 best
way
possible.

I
do,
however,
carefully
choose
those
tims
when
I
feel
it
is
relatively
 safe
to
indulge
based
upon
my
current
vlood
glucose
and
recent
level
of
control.
 97.
 No.
 98.
 It’s
critical
to
manage
any
instance
of
diabetes,
and
even
more
so
when
using
a
pump.
 99.
 Becoming
very
difficult
to
trust
carb
values
suggested
when
dining
out.
 100.
 As
a
Type
1
Diabetic,
it
is
vital
for
me
to
carb
count.

The
pump
has
simplified
the
process
 immensely.

My
meal
time
insulin
doses
depend
on
carb
counting.
 
 176
 Question
46:

Do
you
have
any
comments
about
this
survey?
 Table
65:
Survey
response
comments
–
Question
46
 Response
 Comment
text
from
response
option
 1.
 Excellent
survey.

Well
designed.

I
am
very
interested
in
reading
the
final
summary
of
the
 research
results
and/or
thesis.

Please
email
results
to
…
 2.
 Thank
you.

The
survey
has
reminded
me
of
the
importance
of
food
awareness

in
my
 diabetes
management.
 3.
 This
survey
made
me
think
about
some
of
the
questions
that
I
could
not
answer.

It
was
an
 interesting
survey.
 4.
 I
am
happy
to
be
able
to
assist
in
any
way
that
I
can.
 5.
 I’ve
enjoyed
this
survey,
it
has
allowed
me
to
see
where
I
need
more
education.
 6.
 Yes,
not
all
screens
gave
the
purple
bar
to
allow
answering
the
questions,
tried
2X,
had
to
 skip
some.
 7.
 A
very
well
put
together
survey,
and
I
was
very
happy
to
do
it.

I
realize
there
are
some
 things
I
need
to
learn
yet.

Thank
you.
 8.
 Pleased
to
participate.

Hope
that
it
is
helpful.
 9.
 What
does
my
level
of
education
have
to
do
with
this
survey?
 10.
 No.
 11.
 None.
 12.
 I
think
I
answered
he
questions
correctly,
do
I
get
a
copy
of
the
correct
answers
?
 13.
 No
but
I’m
sure
I’ve
taken
it
before.

Sorry
if
this
is
a
duplicate.

I’ve
been
on
the
pump
just
 two
months
but
there
was
no
option
for
that
so
I
chose
0.5.
 14.
 No.
 15.
 No,
but
I
have
filled
this
survey
out
before.
 16.
 Thank
you.
 17.
 Ask
more
questions
per
page.

Keep
being
bounced
out.
 18.
 This
is
a
very
comprehensive
survey.

It
is
definitely
one
of
the
best
I
have
taken
part
in.

Well
 done!
 19.
 I
hope
it
helps
others.
 20.
 
Good
enjoyed
it.
 21.
 Sometimes,
circumstances
make
you
respond
in
a
certain
way
and
I
am
not
sure
if
the
 answers
are
totally
honest
in
the
sense
that
perhaps
they
were
asked??

More
explanatory
 areas
needed,
 22.
 Questions
5,
6
&
7
regarding
dietitian,
I
see
the
dietitian
at
a
Diabetes
Education
Centre
 Question
11
regarding
range
of
carbs
per
meal
and
snacks
I
usually
aim
for
around
200
 grams
carb
for
the
day,
some
days
more
some
days
less.


 177
 Table
65:
Survey
response
comments
–
Question
46
 Response
 Comment
text
from
response
option
 23.
 Education
on
nutrition
and
carb
counting
are
the
keys
to
success
for
pump
users.
–
will
the
 results
of
this
survey
be
available
after
all
info
gathered?
 24.
 This
is
a
very
indepth
survey,
very
interesting,
hopefully
it
will
help
in
this
study.
 25.
 No.
 26.
 No.
 27.
 No.
 28.
 No.
 29.
 This
was
very
good.

It
tells
me
that
I
need
to
learn
more
about
my
diabetes.

I
have
been
a
 diabetic
for
more
than
36
years
&
am
still
learning.

I
hope
this
survey
will
identify
that
there
 is
a
need
for
more
dietiticans/nutritionists.
 30.
 I
hope
you
can
make
a
difference.

As
prevelant
as
Diabetes
is,
I
still
find
a
lot
of
people
who
 have
a
lot
of
preconceived
ideas
about
what
it
is
all
about.

Education
is
a
huge
issue
for
 those
with
diabeties
and
their
families.
 31.
 Thank
you….
 32.
 Question
21
is
confusing.

If
my
BG
drops
on
its
own
overnight
for
several
days
I
would
 adjust
the
basal
rate.

If
I
skip
a
meal
there
should
be
no
adjustment
needed,
when
using
an
 insulin
pump.

The
basal
rate
should
hold
my
BG
steady
through
fasting
period
(unless
 increasing
activity
level).

I
would
just
not
administer
a
bolus
until
eating
again.
 33.
 No.
 34.
 No.
 35.
 No.
 36.
 Will
you
tell
us
the
correct
answers
for
the
carb
counting
section?

Should
those
7
g
of
 dietary
fibre
have
been
subtracted
from
the
total
33
gr.
Of
carbohydrate
for
the
2
slices
 example??
 37.
 Very
thorough.
 38.
 Keep
up
the
good
work
the
pump
changed
my
life,
I
know
a
business
and
it
makes
being
 busy
a
lot
easyer.

Thanks
marlo
graves.
 39.
 If
it
results
in
some
useful
information
or
assistance,
that
would
be
great.
 40.
 Well
thought
out.
 41.
 In
Qusetion
21,
I
would
have
to
adjust
my
basal
rate
if
my
blood
sugar
suddenly
dropped
at
 night,
but
if
I
skip
a
meal,
my
basal
rate
stays
the
same.
 42.
 
 Thank
you
for
inviting
my
participation
and
for
carrying
out
this
important
research.
 43.
 Good
luck
I
hope
that
you
pass
your
thesis
defense.
 44.
 Pretty
good
survey.

The
only
trouble
I
had
was
I
didn’t
answer
question
16
at
first,
went
 back
to
15
to
change
my
answer
and
then
the
survey
bi‐passed
16
and
I
couldn’t
answer
it.
 178
 Table
65:
Survey
response
comments
–
Question
46
 Response
 Comment
text
from
response
option
 45.
 Keep
up
the
great
work
on
research
and
information
sharing.

It
has
changed
my
life
for
the
 better.

Before
the
pump
my
HA1C
was
10.9
so
I
chose
to
try
this
method
of
control
since
 injections
seemed
to
unable
to
help
me.

I
believe
the
long
acting
insulin
was
the
culrprit
as
I
 had
daily
crashes
at
supper
then
extreme
highs
in
the
middle
of
the
night.

My
HA1C
is
now
 under
7%
and
has
remained
this
way
for
the
past
2
years
on
the
pump!
 46.
 I
hope
you
can
continue
to
educate
more
diabetics
about
the
need
to
pay
attention
to
what
 they
put
in
their
mouths
and
their
lifestyle
choices.

I
know
more
than
a
few
that
focus
on
 food
so
much
that
their
lives
revolve
around
it.

They
are
constantly
looking
for
another
way
 to
eat
more
without
exercising.

I
was
disgusted
at
the
last
Diabetes
Symposium
I
went
to
in
 2007.

I
have
never
seen
so
many
morbidly
obese
individuals.

Every
day
is
another
chance
to
 improve
my
care.

I
want
to
be
around
to
see
my
little
grandson
grow
up
and
be
good
health
 while
I
am
at
it.

The
insulin
pump
has
revolutionized
my
care
and
improved
my
health
 overall.

I
tried
using
a
Glucose
Sensor
but
abandoned
it
because
it
because
I
was
so
stressed
 with
it.

I
doubled
my
use
of
testing
sticks
for
my
glucometer
while
on
the
Sensor
because
I
 was
told
to
check
any
readings
that
were
odd.

So,
now
I
am
back
to
the
usual
 regime……Good
Luck
with
this
survey.
 47.
 No.
 48.
 It
is
great
to
be
able
to
participate.

Thank
you.
 49.
 This
was
great,
Thank
you.
 50.
 OK.
 51.
 Simple
and
easy
to
answer.
 52.
 No.
 53.
 Thanks
for
including
me
and
it
would
be
great
to
receive
more
information.
 54.
 I
don’t
think
it
should
make
a
difference
as
to
what
type
of
education
you
have.
 55.
 I
found
this
to
be
quite
helpful
in
realizing
where
I
am
at
with
my
diabetes
control.

I
am
very
 glad
you
have
sent
this
information
out.

The
local
Diabetes
Clinic
does
not
have
staff
that
 know
about
the
insulin
pump
so
find
it
very
hard
with
my
work
place
to
travel
the
extra
 distance
to
seek
help
during
their
office
hours.
 56.
 No.
 57.
 You
should
have
asked
how
long
I
have
had
diabetes.

I
am
sure
the
answers
given
on
this
 survey
would
be
different
from
a
newly
diagnosed
diabetic
than
someone
like
me,
who
has
 had
diabetes
40
years
(back
when
vial
of
insulin
only
cost
$1.50.

Also,
the
dark
purple
drag
 line
is
hard
on
the
eyes,
and
makes
the
answers
hard
to
read.
 58.
 I
found
the
survey
very
interesting,
and
I
also
found
out
a
few
things
I
need
to
check
into
the
 next
time
I
go
to
the
Diabetic
Education
Centre.

Thank
you
very
much
for
doing
this
survey.

 I
have
had
diabetes
for
41
years
and
there
are
still
things
I
need
to
learn.

Things
are
always
 changing…therefore
you
need
to
keep
learning
to
stay
on
top
of
everything.
 59.
 This
survey
is
just
fine.
 60.
 It
was
easy
to
do.
 179
 Table
65:
Survey
response
comments
–
Question
46
 Response
 Comment
text
from
response
option
 61.
 No.
 62.
 No.
 63.
 This
survey
was
fun
to
take.

I
enjoyed
it.

Hope
you
find
my
answers
useful
to
your
study.
 64.
 I
hope
that
the
answers
that
get
to
this
survey
help
you
to
advance
the
use
of
insulin
pumps
 for
those
of
us
that
require
them.
 65.
 Good
job!
 66.
 Brings
it
back
to
mind
that
I
am
the
one
who
should
be
doing
this
better!
 67.
 The
pump
is
new
to
me
only
3weeks.
 68.
 I
found
the
survey
interesting
and
felt
I
had
a
good
handle
on
most
of
the
questions.

One
 question
I
found
confusing
was
the
one
what
I
would
adjust
if
I
had
a
low
night
time
sugar
or
 skipped
a
meal.

To
me,
those
two
things
have
two
different
solutions.

I
read
the
question
 several
times
and
got
the
same
from
it
each
time.

In
typing
this
I
may
have
a
clearer
 understanding
of
what
you
were
getting
at‐that
is
night
time
as
opposed
to
over
night
blood
 sugars.

I
stick
by
my
answer
of
adjusting
my
bolus.
 69.
 Research
is
good.

Keep
up
the
good
work!
 70.
 No.
 71.
 Am
interested
in
my
results,
where
I
may
benefit
from
more
education.

I
am
always
open
to
 suggestions
where
I
may
improve
my
health
with
diabetes.
 72.
 I
enjoyed
completing
this
survey.

It
made
me
think
of
some
of
my
answers..
 73.
 N/A.
 74.
 I
really
enjoyed
this—made
me
think
about
counting
on
a
regular
routine‐sometimes
with
a
 pump
I
forget
I
am
diabetic==I
let
it
do
all
the
work—then
when
I
read
my
magazines
on
 diabetics—I
come
back
to
the
real
worl==but
it
is
fun
to
forget.
 75.
 The
survey
is
great.

I
enjoyed
doing
it.

However,
you
may
want
to
number
of
months
 instead
of
years
for
the
length
of
a
pump
use.

I
have
been
using
it
for
just
over
1.5
years
but
 had
to
check
off
2.
 76.
 I
think
this
is
a
very
important
topic.

I
wish
my
siblings
had
an
understanding
of
this
concept
 when
I
travel
and
visit
them.
 77.
 Why
not
survey
physicians
who
look
after
diabetics?
;‐)
 78.
 I
feel
it
is
a
great
way
for
people
to
reassess
their
working
knowledge
of
their
diabetes.

It
 can
give
us
a
heads
up
warning
on
where
we
need
to
pull
up
our
socks.

I
feel
this
especially
 important
for
newer
pumpers.

It
can
take
a
long
time
to
know
how
to
react
in
many
 different
situations.
 79.
 Good
Luck
with
your
Thesis
(‐:
 80.
 I
think
it
is
really
great
to
ask
the
folks
who
do
this
on
a
daily
basis,
these
questions.

As
for
 the
survey,
it
is
clearly
written
out,
the
questions
simple
and
was
not
difficult
to
do.
 81.
 Easy
to
complete.
 180
 Table
65:
Survey
response
comments
–
Question
46
 Response
 Comment
text
from
response
option
 82.
 Interesting
questions,
I
think
Medtronic
needs
to
provide
more
information
about
the
 decisions
made
for
the
program
running
the
pump.

Specifically,
the
decision
to
not
consider
 active
insulin
when
asking
for
a
meal
or
snack
bolus.
 83.
 I
do
hope
this
survey
helps
both
Type
1
and
Type
2
diabetics
realize
the
importance
of
carb
 counting
and
label
reading.

Proper
management
of
carb
and
insulin
helps
control
glucose.
 
 


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