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Aim: To determine the insulin requirement for a high-fat, high-protein breakfast to optimise postprandial glycaemic excursions in children and young people with type 1 diabetes using insulin pumps. Methods: In all, 27 participants aged 10-23 years, BMI <95 th percentile (2-18 years) or BMI <30 kg/m 2 (19-25 years) and HbA 1c ≤64 mmol/mol (≤8.0%) consumed a high-fat, high-protein breakfast (carbohydrate: 30 g, fat: 40 g and protein: 50 g) for 4 days. In this cross-over trial, insulin was administered, based on the insulin-to-carbohydrate ratio (ICR) of 100% (control), 120%, 140% and 160%, in an order defined by a randomisation sequence and delivered in a combination bolus, 60% ¼ hr premeal and 40% over 3 hr. Postprandial sensor glucose was assessed for 6 hr. Results: Comparing 100% ICR, 140% ICR and 160% ICR resulted in significantly lower 6-hr areas under the glucose curves: mean (95%CI) (822 mmol/L.min [605,1039] and 567 [350,784] vs 1249 [1042,1457], p ≤ 0.001) and peak glucose excursions (4.0 mmol/L [3.0,4.9] and 2.7 [1.7,3.6] vs 6.0 [5.0,6.9],p < 0.001). Rates of hypoglycaemia for 100%-160% ICR were 7.7%, 7.7%, 12% and 19% respectively (p ≥ 0.139). With increasing insulin dose, a step-wise reduction in mean glucose excursion was observed from 1 to 6 hr (p = 0.008). Conclusions: Incrementally increasing the insulin dose for a high-fat, high-protein breakfast resulted in a predictable, dose-dependent reduction in postprandial glycaemia: 140% ICR improved postprandial glycaemic excursions without a statistically significant increase in hypoglycaemia. These findings support a safe, practical method for insulin adjustment for high-fat, high-protein meals that can be readily implemented in practice to improve postprandial glycaemia. K E Y W O R D Schildren and adolescents, endocrinology, insulin therapy, nutrition and diet, self-management 2 of 8 | SMITH eT al.

Background: To manage hyperglycemia following high fat and protein (HFHP) meals, T1D guidelines recommend additional mealtime insulin. However, guidance regarding dosing adjustments for HFHP meals is unclear. Aim: To determine the amount of additional insulin required for a HFHP meal to optimise 6 h postprandial glucose, in young people with T1D using insulin pumps. Method: This was a 4x4 crossover trial conducted at 2 centers in Australia. On 4 days, participants (n=27) with mean age 14.5 ± 3.6 yrs and HbA1c 53 mmol/mol (7.0 ± 0.7%) ate a HFHP meal [carbohydrate (CHO) 30g, fat 40g, protein 50g]. Insulin based on the CHO: insulin ratio (CIR) was given in random order: 100% (control), 120%, 140%, 160% CIR. Postprandial sensor glucose was measured for 6 h. Results: Compared to 100% CIR, 140% and 160% CIR resulted in significantly lower mean glucose excursions from 90- 360 min (p≤ 0.018) and mean peak glucose excursions (4.0 and 2.7 v 6.0 mmol/L, p&lt; 0.001). Hypoglycemia for 100%- 160% CIR was 7.7%, 7.7%, 12.0% and 19.2% respectively (p≥ 0.139). With increasing insulin there was a dose-dependent reduction in mean glucose excursions from 60- 360 min (p&lt; 0.01). Conclusions: Incremental addition of mealtime insulin for fat and protein produces a dose- dependent improvement in postprandial glycemia. For HFHP meals, 140% CIR is advised with titration based on individual glucose response. Disclosure T.A. Smith: None. C.E. Smart: None. M.E. Fuery: None. B. Knight: None. P. Howley: None. B.R. King: Other Relationship; Self; Menarini Group. Funding Australasian Paediatric Endocrine Group