Fat and protein units: A parent’s perspective

When my daughter was diagnosed with type 1 diabetes, I did not realise what was happening. I thought there would be a few days in hospital and then she would be “better”. That was not the case. I also thought that I would never do another exam in my life. However, the most difficult exam was yet to come – “carbohydrate counting”.

Learning carbohydrate counting is a complex journey and it took around 6 months for me to be able to understand the technique of weighing and calculating carbohydrates. Once on the journey, you realise that insulin and food do not always match, and your maths skills need to be extremely good! I started to talk to other families to see how they dealt with food and I also began to question why my daughter’s blood sugars reacted differently to different foods, such as pizza. I read the pump instruction manual and I started to experiment with dual and square boluses, building up a matrix of meals and insulin deliveries to match.

There were still “awkward meals”, for example macaroni cheese and fish and chips. These were meals that I could never find the right pattern of insulin delivery to fit. I could not find anyone who could give me the right answer and I started to ponder the question, “if my daughter’s plate was only 50% carbohydrate, what effect would the rest of the plate have on her processing of carbohydrate?” I also started to question the impact of fats and proteins in her diet and discussed it with my daughter’s dietitian. I was given an example of “fat and protein units” (FPUs) and how to count them, which is estimated by counting kilocalories (see Box 1).

The calculations looked complex and scary and I thought counting FPUs would never work. I was not sure how to use it in practical terms, so I wrote the calculation for every meal down and found they became quicker each time. After the first meal I monitored my daughter’s blood sugars and they were perfect all evening and on waking the next morning. This was highly unusual for the “awkward” meal she had. Using the same calculations I tried counting FPUs over most evening meals and, once I had established a routine, I found it was no more difficult than just counting carbohydrates.

The calculation did not always work (e.g. when eating low-fat meals) so, in these cases, we reverted to using a different method of insulin delivery. I have found benefit in using the FPU approach for higher-fat and -protein meals, and will continue to use it. It has given me the opportunity to add another tool into the bag that will help my daughter manage and improve her life with diabetes. My daughter’s HbA_1c usually ranges from 52 mmol/mol (6.9%) to 60 mmol/mol (7.6%) and understanding food more has helped maintain these levels, without extra hypoglycaemia.

Conclusions
If I went on this journey again, I would ask for clear teaching in simple, practical terms. An incremental learning approach would ensure that I developed my understanding of foods, starting with basic carbohydrate counting, weighing and measuring, and understanding the maths, followed by understanding the impact of glycaemic index (that is, how different foods affect blood glucose levels) and fat and protein counting. I am sure there is more to add to this list. I would say these are essential tools that families need to understand in order to improve their children’s lives and maintain good control of their type 1 diabetes.