Carmel Smart
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care team. However, every team member should have an understanding of the principles of nutri- tional management.
Advice on carbohydrate quantity, type and distribution is important as carbohydrate is the main determinant of postprandial glucose re- sponse. Education should take into account an individual’s energy needs, eating and physical ac- tivity patterns and insulin regimen. Matching in- sulin to carbohydrate intake for those on inten- sive insulin therapy requires comprehensive edu- cation in carbohydrate counting. It is vital that healthy eating principles targeting an increased consumption of fruit and vegetables and a de- creased saturated fat intake underlie education.
Goals of Nutrition Therapy
The main aims of nutritional management in pe- diatric diabetes are to
• encourage healthy lifelong eating habits;
• achieve and maintain blood glucose levels in the normal range by a balance between food intake, energy expenditure and insulin action profiles;
• provide appropriate energy intake and nutri- ents for optimal growth, development and good health;
• consider personal and cultural food preferenc- es to preserve social, cultural and psychologi- cal well-being;
• achieve and maintain an appropriate body mass index and waist circumference through healthy eating and regular physical activity;
• optimize lipid and lipoprotein profiles to re- duce cardiovascular disease risk, and
• maintain the pleasure of eating by encourag- ing a wide variety in food choices.
Dietetic advice is required at the initial diag- nosis of diabetes, with follow-up 2–4 weeks later and regular (at least annual) review to meet changes in appetite and to provide ongoing age- appropriate education [3] . Circumstances such as
changes in the insulin regimen, dyslipidemia, ex- cessive weight gain or loss as well as the diagnosis of a comorbidity such as celiac disease require ad- ditional dietary intervention with more frequent review.
Eating Patterns
The key dietary behaviors that have been associ- ated with improved glycemic outcomes in people with T1DM are adherence to an individualized meal plan, particularly carbohydrate intake rec- ommendations [4] , avoidance of frequent snack- ing episodes or large snacks without adequate in- sulin coverage, regular meals and avoidance of skipping meals [5] , avoidance of overtreatment of hypoglycemia and insulin boluses before meals [6] . Regularity in mealtimes and routines where the child and family sit down and eat together – helping to establish better eating practices and monitoring of food intake – has been shown to be associated with better glycemic outcomes across all insulin regimens.
The recommended meal plan should consider usual appetite, food intake and exercise patterns (including at school or preschool), activity level and insulin regimen. A key aspect of nutrition therapy is advice on the amount, type and distri- bution of carbohydrate over the day. Nutritional advice regarding carbohydrate distribution, in- cluding the need for snacks, differs according to the insulin regimen [7] . Recommendations for dif- ferent insulin regimens are presented in table 1 .
Energy Balance
At diagnosis, appetite and energy intake are often high to compensate for catabolic weight loss. En- ergy intake should be reduced when an appropri- ate healthy weight is restored. Regular monitor- ing by the diabetes team should assess appropri- ate weight gain.
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The prevention or treatment of overweight or obesity is a key strategy of care, and guidance on appropriate serving sizes, frequency of snacking and appropriate hypoglycemia treatment is im- portant. Additionally, advice should be provided on food and insulin adjustment for exercise.
The total daily energy intake should be distrib- uted as follows: 45–65% carbohydrate, 30–35% fat and 15–25% protein [8] . Carbohydrate should not
be restricted, as it is essential for growth. Carbo- hydrate intake should come predominantly from wholegrain breads and cereals, legumes, fruit, vegetables and low-fat dairy foods (except for children <2 years). Food models such as the plate food model ( fig. 1 ) are useful in providing basic nutritional information and healthy eating con- cepts [9] . They also illustrate carbohydrate-con- taining foods in relation to other foods visually.
Table 1. Nutritional recommendations for different insulin regimens
Insulin regimen Meal structure
Twice daily mixed insulin doses Three meals and 3 snacks per day at regular times to balance the insulin action profile
Consistent carbohydrate quantities at each meal and snack on a daily basis
Treat hypoglycemia with short-acting carbohydrate followed by long-acting carbohydrate
Multiple daily injections using rapid-acting insulin premeals and long-acting insulin as the basal dose; greater flexibility in meal timing and food quantity as one is able to change the mealtime insulin dose and timing
Snacks between meals should not exceed 1–2 carbohydrate serves (e.g. 15–30 g of carbohydrate) unless an additional injection is given
Requires knowledge of carbohydrate counting for insulin dose adjustment at mealtimes
Treat hypoglycemia with short-acting carbohydrate only Insulin pump therapy provides a continuous
subcutaneous infusion of basal insulin, with bolus doses given to match the carbohydrate amount to be eaten
Offers the greatest flexibility in meal timing and quantities; hence, it is particularly helpful for toddlers to decrease parental anxiety at mealtimes
Good knowledge of carbohydrate counting is essential as bolus insulin is matched to the carbohydrate eaten at all meals and snacks
Insulin for food must be given prior to eating for the best glycemic outcome
A missed mealtime insulin bolus is the biggest contributor to poor glycemic outcome
Basal rates, insulin-to-carbohydrate ratios and correction factors are individually calculated
The bolus type and dose can be adjusted to match the meal composition and, hence, better mimics the physiological absorption profile
Treat hypoglycemia with short-acting carbohydrate only
With all insulin regimens, individualized advice regarding carbohydrate amount and distribution should consider usual appetite, food intake patterns, exercise and energy requirements of the person with diabetes.
© 2013 Adapted from Australian Family Physician. Reproduced in part with permission from the Royal Australian College of General Practitioners from Barclay et al. [7].
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 218–225 DOI: 10.1159/000367863
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Carbohydrate Assessment
Children and adolescents with T1DM require ed- ucation regarding the amount, type and distribu- tion of carbohydrate over the day, taking into ac- count their age, food intake patterns and insulin regimens ( table 1 ). Day-to-day consistency in carbohydrate intake using serves or 15-gram car- bohydrate exchanges is encouraged for those re- ceiving fixed mealtime insulin doses. A more flex- ible carbohydrate intake can be achieved using an insulin-to-carbohydrate ratio for those on inten- sive insulin therapy.
Carbohydrate counting is a key nutritional in- tervention for young people using insulin pump or multiple daily injection therapy. It enables ad- justment of the prandial insulin dose according to carbohydrate consumption, thus permitting carbohydrate intake to be varied. Multiple bene- fits have been reported when carbohydrate count- ing is used as an intervention, including improve- ments in glycemic control, diabetes-specific quality of life and coping ability [10] . Advice on carbohydrate quantification should be given
within the context of a healthy diet as focusing only on the amount of carbohydrate can lead to unhealthy food choices.
In clinical practice, a number of methods for carbohydrate quantification are commonly taught, including 1-gram increments, 10-gram carbohydrate portions and 15-gram carbohy- drate exchanges. Research has demonstrated that carbohydrate counting is difficult, and repeated age-appropriate education by experienced health professionals is necessary to maintain accuracy in estimations [11] . Inaccurate carbohydrate counting has been associated with higher daily blood glucose variability.
It is becoming increasingly recognized that fat and protein also contribute to postprandial hy- perglycemia. Fat and protein have been found to increase the delayed postprandial glucose rise ( fig. 2 ) [12] . Consideration of the impact of fat and protein on glucose levels involves the application of advanced nutritional concepts that are best taught after basic carbohydrate counting skills are established. Alterations to the insulin dose and distribution at a mealtime may be necessary
4
2
0
–2 6
–4
Mean glucose excursion (mmol/l)
270 240 210 180 150 120 90 60 30
0 300
Time from meal (min)
Fig. 1. Australian guide to healthy eating. Canberra, National Health and Medical Research Council, 2013 [9] .
Fig. 2. Mean postprandial glucose excursions from 0 to 300 min for 33 subjects after test meals of low fat/
low protein (⚫), low fat/high protein ( ◆ ), high fat/low protein ( ▲ ) and high fat/high protein (◻) content.
The carbohydrate amount was the same in all meals. There were signifi- cant differences in glucose excur- sions between meal types from 150 to 300 min (p < 0.03). © American Diabetes Association. Reproduced
from Smart et al. [12] . 2
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 218–225 DOI: 10.1159/000367863
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for meals very rich in fat and protein. An advan- tage of insulin pump therapy is that it is possible to tailor prandial insulin delivery to meal compo- sition. Combination boluses have been recom- mended for high-fat, high-protein meals and low- glycemic index (GI) meals.
Glycemic Index
Nutrition therapy for young people with T1DM should include education regarding the GI. This is a ranking of foods based on their acute glycemic impact. The GI has been shown to provide addi-
Table 2. Common issues to consider for each age group Age group Issues to consider
Toddlers Encourage them to eat the usual family diet; offer finger foods to encourage self-feeding;
discourage offering a bottle for ‘easy’ carbohydrate intake
Decreased appetite, food refusal and food fads are common; it is important to avoid ‘grazing’ and excessive milk consumption
Regular carbohydrate intake is required to prevent hypoglycemia on twice-daily insulin doses;
offer routine meals and 2 small snacks over the day
Insulin pump therapy is beneficial in managing toddler eating behaviors; it is preferable that preprandial insulin doses are given, but the dose can be split to some before and some during the meal when eating is erratic or new foods are offered; it is important that carbohydrate quantities as small as 7 g are covered by insulin
School-aged children
They become more independent and take on aspects of own care but always with parental supervision and support
Blood testing during the school day is recommended for all children
The meal and snack routine is ideally incorporated into the usual school timetable They need to have an understanding of carbohydrate quantities in foods to ensure an
appropriate distribution over the school day; labelling the carbohydrate quantities of foods in the lunch box is recommended
Avoid excessive eating at afternoon tea contributing to predinner hyperglycemia by either eating more during the day to spread carbohydrate more evenly or considering an additional dose of insulin in the afternoon to cover the extra carbohydrate
Extra carbohydrate food is required only for additional strenuous activity and not needed for the child’s usual active play
Teenagers Challenging behaviors including smoking, drinking, staying out late, sleeping in, skipping insulin and missing meals
Emphasis should be placed on the importance of routine meals and snacks, particularly during periods of rapid growth, to prevent excessive afternoon or evening snacking
Disordered eating habits can be an issue that clashes with diabetes management, and they may require specialist dietetic support
Parental supervision and support continues to be essential, particularly at mealtimes, to ensure insulin boluses are not missed
Alcohol can cause delayed hypoglycemia, and advice needs to be given about moderate alcohol consumption and regular carbohydrate intake during drinking
Participation in competitive sports requires appropriate insulin adjustment as well as an appropriate timing and quantity of carbohydrate intake and adequate fluid to optimize performance
© 2013 Adapted from Australian Family Physician. Reproduced in part with permission from the Royal Australian Col- lege of General Practitioners from Barclay et al. [7].
224 Smart
tional benefit to glycemic control over that ob- served when carbohydrate amount is considered alone [13] . Low-GI foods lower the postprandial glucose excursion compared to carbohydrates with a higher GI. If possible, high-GI food choic- es should be substituted with lower-GI foods. Ex- amples of low-GI food choices include who- legrain breads, pasta, many fruits, milk and yo- ghurt. It is important that the GI is not taught in isolation, as monitoring the amount of carbohy- drate is a key strategy of care.
Specific Advice for Different Age Groups At all ages, advice should focus on decreasing the intake of sweetened drinks and saturated fat [7] . Specially labeled ‘diabetic foods’ are not necessary and may contain sweeteners with laxative effects.
Missed meal boluses are a major cause of subop- timal glycemic control at all ages, and it is advis- able to always give insulin before meals. Common dietary issues to consider at specific ages are out- lined in table 2 .
Nutritional Management of Type 2 Diabetes in Children
Most children with type 2 diabetes are overweight or obese; therefore, nutritional advice should be focused on dietary changes and lifestyle interven- tions to prevent further weight gain or to achieve weight loss. The entire family should be included in the education, since caregivers influence the child’s food intake and physical activity. Families should be counseled to decrease energy intake by focusing on healthy eating and strategies to de- crease portion sizes of foods as well as by lowering the intake of high-energy-, high-fat- and high- sugar-containing foods. Snacks should be limit- ed. Those on medication or insulin therapy re- quire more in-depth teaching on carbohydrate management. Regular follow-up is essential to
monitor weight and glycemic control and to pre- vent the development of diabetes-related compli- cations.
Conclusions
• Nutrition therapy is one of the fundamental elements of care and education for children and adolescents with diabetes
• Individualized nutritional education should be provided at diagnosis by a dietitian with experience in childhood diabetes. Regular supportive contacts with dietetic health pro- fessionals are required to increase dietary knowledge and adherence across the life span
• Dietary recommendations should be based on healthy eating guidelines suitable for all chil- dren and families with the aim of improving diabetes outcomes and reducing cardiovascu- lar risks
• Nutritional interventions should aim to main- tain an ideal body weight, optimal growth as well as health and development. Growth mon- itoring is an important part of diabetes man- agement
• The optimal macronutrient distribution varies depending on the individualized assessment of a young person. As a guide, carbohydrate should approximate 45–55%, fat <30–35%
(saturated fat <10%) and protein 15–20% of the energy intake
• The use of an insulin-to-carbohydrate ratio on intensive insulin regimens allows greater flex- ibility in carbohydrate intake and mealtimes, with potential for improvements in glycemic control and quality of life
• Regularity in mealtimes and eating routines are important for optimal glycemic outcomes on all insulin regimens
• Fixed insulin regimens require consistency in the amount and timing of carbohydrate intake over the day
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 218–225 DOI: 10.1159/000367863
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• Low-GI foods should be substituted for high- GI foods in the diets of children with diabetes to improve glycemic control
• The prevention of overweight and obesity in pediatric T1DM is a key strategy of care and should involve a family-based approach
• Individualized nutritional advice should be provided on how to manage physical activity, exercise and competitive sports
• Nutritional management of type 2 diabetes re- quires a family and community approach to manage issues of excessive weight gain, lack of physical activity and the increased risk of car- diovascular disease
of carbohydrate counting on glucose control and quality of life over 24 weeks in adult patients with type 1 diabetes on continuous subcutaneous insulin infu- sion: a randomized, prospective clinical trial (GIOCAR). Diabetes Care 2011; 34:
823–827.
11 Smart CE, Ross K, Edge JA, King BR, McElduff P, Collins CE: Can children with type 1 diabetes and their caregivers estimate the carbohydrate content of meals and snacks? Diabet Med 2010; 27:
348–353.
12 Smart C, Evans M, O’Connell S, McEl- duff P, Lopez P, Jones T, et al: Both dietary protein and fat increase post- prandial glucose excursions in children with type 1 diabetes, and the effect is additive. Diabetes Care 2013; 36: 3897–
3902.
13 Thomas D, Elliott E: Low glycaemic in- dex, or low glycaemic load, diets for dia- betes mellitus. Cochrane Database Syst Rev 2009; 1:CD006296.
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1 Craig ME, Hattersley A, Donaghue K:
ISPAD clinical consensus guidelines 2009 compendium. Definition, epidemi- ology and classification of diabetes. Pe- diatr Diabetes 2009; 10(suppl 12):3–12.
2 American Diabetes Association: Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care 2005; 28: 186–212.
3 Smart CE, Aslander-van de Vliet E, Wal- dron S: ISPAD clinical practice consen- sus guidelines 2009 compendium. Nu- tritional management in children and adolescents with diabetes. Pediatr Dia- betes 2009; 10(suppl 12):100–117.
4 Mehta S, Volkening L, Anderson B, Nansel T, Weissberg-Benchell J, Wysoc- ki T, et al: Dietary behaviors predict glycemic control in youth with type 1 diabetes. Diabetes Care 2008; 31: 1318–
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5 ỉverby N, Margeirsdottir H, Brunborg C, Andersen L, Dahl-Jứrgensen K: The
influence of dietary intake and meal pattern on blood glucose control in chil- dren and adolescents using intensive insulin treatment. Diabetologia 2007; 50:
2044–2051.
6 Scaramuzza AE, Iafusco D, Santoro L, Bosetti A, De Palma A, Spiri D, et al:
Timing of bolus in children with type 1 diabetes using continuous subcutaneous insulin infusion (TiBoDi Study). Diabe- tes Technol Ther 2010; 12: 149–152.
7 Barclay A, Gilbertson H, Marsh K, Smart CE: Dietary management in diabetes.
Aust Fam Physician 2010; 39: 579–583.
8 National Health and Medical Research Council: Australian dietary guidelines.
Canberra, National Health and Medical Research Council, 2013.
9 National Health and Medical Research Council: Australian guide to healthy eating. Canberra, National Health and Medical Research Council, 2013.
10 Laurenzi A, Bolla A, Panigoni G, Doria V, Uccellatore A, Peretti E, et al: Effects
3 Nutritional Challenges in Special Conditions and Diseases
Key Words
Phenylketonuria ã Maple syrup urine disease ã Urea cycle disorders ã Organic acidaemias ã
Galactosaemia ã Glycogen storage disease ã Protein ã Amino acids ã Galactose ã Fructose ã Glucose
Key Messages
• Common inborn errors of metabolism (IEM) treated by life-long dietary management are responsible for a collection of diverse clinical conditions • It is essential to diagnose conditions before neuro-
logical or other toxicological damage occurs • Treatment strategies involve avoidance or con-
trolled intake of dietary precursors of toxic meta- bolites in amino acid disorders, organic acidaemias, urea cycle disorders, galactosaemia and hereditary fructose intolerance
• Other disorders need to avoid prolonged fasting (e.g. fatty acid oxidation disorders) or a regular glu- cose supply (e.g. glycogen storage disorders) • In IEM where acute metabolic decompensation oc-
curs, the use of an emergency regimen is impera- tive
• Attentive nutritional support with the provision of macronutrients and micronutrients to meet dietary reference values/requirements is essential • Frequent monitoring of growth, nutritional intake,
development and biochemical control is necessary
© 2015 S. Karger AG, Basel
Introduction
Common inborn errors of metabolism (IEM) treated by life-long dietary management are re- sponsible for a collection of diverse clinical con- ditions. Each condition may present at different ages with variable severity and outcome. Disor- ders requiring avoidance of/reduction in dietary precursors of toxic metabolites include phenyl- ketonuria (PKU), maple syrup urine disease (MSUD), organic acidurias, urea cycle disorders (UCD) and galactosaemia. Disorders requiring glucose stabilisation include fatty acid oxidation defects and glycogen storage diseases (GSD). It is essential to diagnose conditions before neuro- logical or other toxicological damage occurs.
Many IEM are now recognised by newborn screening programmes. In some conditions, neonates may require emergency treatment such as dialysis to remove toxic organic acids or ammonia.
In IEM where acute metabolic decompensa- tion occurs (precipitated by infections/surgery/
trauma combined with poor oral intake and fast- ing), with risk of further irreversible damage, particularly neurological, the use of an emergen- cy regimen is imperative. An emergency regimen provides an exogenous energy source (either
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 226–233 DOI: 10.1159/000360344