Modeling carbohydrate counting error in type 1 diabetes management

Background: The error in estimating meal carbohydrates (CHO) amount is a critical mistake committed by type 1 diabetes (T1D) subjects. The aim of this study is both to investigate which factors, related to meals and subjects, affect the CHO-counting error most and, to develop a mathematical model of CHO-counting error embeddable in T1D patient decision simulators to do in silico clinical trials. Methods: A published dataset of 50 T1D adults is used, which includes patient’s CHO-count of 692 meals, dietitian’s estimates of meal composition (used as reference), and several potential explanatory factors. The CHO-counting error is modeled by multiple linear regression with stepwise variable selection starting from 10 candidate predictors, i.e. education level, insulin treatment duration, age, body weight, meal type, CHO, lipid, energy, protein and fiber content. Inclusion of quadratic and interaction terms is also evaluated. Results: Larger errors correspond to larger meals, most of the large meals are underestimated. The linear model selects CHO (p<0.00001), meal type (p<0.00001) and body weight (p=0.047), while its extended version embeds a quadratic term of CHO (p<0.00001) and interaction terms of meal type with CHO (p=0.0001) and fiber amount (p=0.001). The extended model explains 34.9% of the CHO-counting error variance. Comparison with the CHO-counting error description previously used in the T1D patient decision simulator shows that the proposed models return more credible realizations. Conclusions: The most important predictors of CHO-counting errors are CHO and meal type. The mathematical models proposed improve the description of patients’ behavior in the T1D patient decision simulator.