Type 1 Diabetes in Children and Adolescents | Paediatrics
Composition of the diet Nutrition recommendations support a diet that meets energy requirements to maintain a healthy body weight and is comprised of: • 50-55% energy from carbohydrate • 30% energy from fat with <10% saturated fat and >10% monounsaturated fat
•
10-15% energy form protein. The contribution of energy from protein should be decrease with age to meet adult guidelines by late adolescence. Food choices which promote a healthy diet
that meet the recommendations for the rest of the population are encouraged. Vitamin and mineral recommendations, along with those for salt intake are the same as the non-diabetic population. Meal planning and education about food
choices is influenced by the choice of diabetes management. CYP using modern flexible regimens will benefit from more flexible eating patterns and greater ability to individualise their eating.
Nutrition and insulin regimens Nutritional management aims:
• Provide sufficient and appropriate energy intake and nutrients for optimal growth and good health
• Prevent and treat acute complications of diabetes
• Reduce the risk of micro and macrovascular complications.
Conventional therapy Twice daily injections of biphasic insulins require consistency of food intake that matches the action of the insulin given. Most conventional insulin regimens require carbohydrate to spread across the day as regular meals and snacks with a supper taken pre bedtime to prevent nocturnal hypoglycaemia. Particular attention needs to be paid to the impact of snack choices on energy and saturated fat intake.
Carbohydrate counting and intensive treatment regimens Management of Type 1 diabetes with either multiple daily injection therapy (MDI) using analogue insulin or continuous subcutaneous insulin infusion (CSII) requires adjustment of insulin according to food intake, activity levels and blood glucose. Carbohydrate counting allows CYP to adjust insulin doses according to the amount and type of carbohydrate consumed. Carbohydrate counting is not a new approach to diabetes management. Modern carbohydrate counting is a tool which allows adjustment of insulin doses and promotes flexibility in lifestyle management. Gillespie et al9 described carbohydrate education in 3 levels and this approach has been adopted by ISPAD. CYP using intensive therapy require level 3 education, using insulin to carbohydrate ratios to match insulin doses to carbohydrate intake. As with many aspects of paediatric diabetes management the
number of clinical studies supporting practice are few. Recent papers have shown that carbohydrate counting can be effective and achievable,10, 11 as supporting the role of nutrition education and
as well
food choices in achieving good glycaemic control.12, 13
Carbohydrate alone is not the only indicator of
glycaemic response and consideration needs to be given to the amount of circulating insulin, the impact of activity and the glycaemic effect of the food also. Carbohydrate counting and insulin adjustment also includes dealing with raised pre- meal blood glucose levels, adjustments for the impact of activity and the expected glycaemic response to a food. Timing of insulin administration impacts on post prandial glycaemia. The currently used fast acting insulin analogues take approximately 15 minutes to begin working, with a peak action one to two hours after injection and duration of action around four hours. There is intra-individual variation in insulin action.
the use of a post-meal injection may be advocated for dealing with younger children who may not eat all the calculated carbohydrate in their meal, this may not give the best glycaemic control. Lugif et al14 demonstrated in small study that administration of analogue insulin 15 minutes prior to a meal results in lower post prandial glucose excursion. Education about carbohydrate counting and insulin adjustment needs to deal with both practical management issues faced by families and the need to achieve good glycaemic control.
It should also
promote understanding of the effects of mixed meals and glycaemic index on post prandial glucose excursions, which is particularly relevant to those using CSII to manage their diabetes. CSII allows the user to make the necessary changes to insulin delivery to deal with the effects of mixed meal composition, glycaemic index, prior insulin administration and exercise. Carbohydrate counting education, therefore, needs to encompass all these aspects to enable patients to make appropriate choices about insulin delivery. An understanding of the glycaemic index can be used to inform bolus choice.15
food choices has been demonstrated to improve glycaemic control in CYP16-18 treatment regimen.
Nutrition & micro and
macrovascular complications It is important to ensure that a focus on carbohydrate education does not compromise the overall quality of the diet. Prevention of micro and macrovascular complications is one of the aims of good nutritional care. Evidence from the USA suggests that CYP and families may make ‘less healthy’ choices as they focus on carbohydrate and achieving good glucose levels.19 Cardiovascular disease is a significant cause
of mortality and morbidity in adults with Type 1 diabetes. In 2004, NICE Guidelines on the Management of Type 1 Diabetes did not include a
Complete Nutrition Vol.10 No.6 December/January 2010/11 | 19
Use of the glycaemic index to influence on all types of
‘ Whilst
Education about carbohydrate counting and insulin adjustment needs to deal with both practical management issues faced by families and the need to achieve good glycaemic control.
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