Quality statement 3: Intensive insulin therapy and level 3 carbohydrate‑counting education for type 1 diabetes

Quality statement

Children and young people with type 1 diabetes are offered intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis.

Rationale

The aim of intensive insulin therapy is to reach near‑normal blood glucose levels, to reduce the risk of long‑term complications and improve quality of life. Dietary management can also improve control of blood glucose and HbA1c levels. When using intensive insulin therapy it is important to match the insulin dose to carbohydrate intake, in line with individualised insulin‑to‑carbohydrate ratios (level 3 carbohydrate-counting). Children and young people and their family members or carers (as appropriate) should be taught how to do this at diagnosis.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that children and young people with type 1 diabetes are offered intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis.

Data source: Local data collection.

Process

Proportion of children and young people with type 1 diabetes who are offered intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis.

Numerator – the number in the denominator who receive intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis.

Denominator – the number of children and young people with type 1 diabetes.

Data source: Local data collection.

Outcome

a) HbA1c level of 48 mmol/mol or lower.

Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.

b) Quality of life.

Data source: Local data collection and 2013–14 National Paediatric Diabetes Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care diabetes services for children and young people) ensure that systems are in place to offer intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis to children and young people with type 1 diabetes.

Healthcare professionals (those providing diabetes services for children and young people) offer intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis to children and young people with type 1 diabetes.

Commissioners (NHS England regional teams and clinical commissioning groups) commission services that offer intensive insulin therapy and level 3 carbohydrate‑counting education at diagnosis to children and young people with type 1 diabetes.

What the quality statement means for children and young people and their parents and carers

Children and young people with type 1 diabetes are offered intensive insulin therapy (either multiple daily injections or an insulin pump) and level 3 carbohydrate‑counting education at diagnosis.

'Multiple daily injections' means injecting a long-acting (slow) insulin once or twice a day, and a rapid-acting (fast) insulin before eating. An insulin pump is a small machine connected to your body that gives you insulin throughout the day, so you don't need to inject yourself.

'Level 3 carbohydrate counting' means counting the carbohydrates in your food and drink, so you can make sure you are injecting the right amount of insulin.

Source guidance

Definitions of terms used in this quality statement

Intensive insulin therapy

Insulin therapy is aimed at reaching near-normal blood glucose levels. There are 2 types of intensive insulin therapy:

Multiple daily injection basal–bolus insulin regimens

An intermediate or long‑acting insulin that is usually injected once or twice a day (basal), and a rapid‑acting insulin that is injected as needed before each meal and snack.

[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18 (full guideline) and expert opinion]

Continuous subcutaneous insulin infusion (insulin pump therapy)

A programmable pump and insulin storage device that delivers a background or basal supply of insulin (either a rapid‑acting analogue or a short‑acting insulin) and boluses of insulin as needed, through a subcutaneous needle or cannula.

[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18 (full guideline) and expert opinion]

Level 3 carbohydrate counting

Carbohydrate counting for people with type 1 diabetes who are using intensive insulin regimens (multiple daily injections or insulin pump) involves calculating insulin‑to‑carbohydrate ratios that are individualised according to age, sex, pubertal status, duration of diabetes, time of day and activity. Pre‑meal insulin is adjusted according to the estimated carbohydrate content of meals and snacks using the specified insulin‑to‑carbohydrate ratios.

[Adapted from Diabetes (type 1 and type 2) in children and young people: diagnosis and management (2015) NICE guideline NG18 (full guideline) and expert opinion]

Equality and diversity considerations

Particular care should be taken when communicating with children and young people with type 1 diabetes and their family members or carers (as appropriate) if they have, for example:

  • physical, cognitive or sensory disabilities

  • different cultural, ethnic or family traditions to the healthcare professional

  • difficulties speaking or reading English.