Paediatrics | Type 1 Diabetes in Children and Adolescents ‘
Between one and 10 per cent of children with Type 1 diabetes also have coeliac disease, necessitating treatment with a gluten-free diet.
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recommendation for screening of lipid levels due to lack of evidence, therefore, cholesterol is not routinely measured in many clinics. Since 2004, a number of publications have identified early atherosclerotic changes and raised lipid levels in CYP with Type 1 diabetes.20, 21
are included in the ISPAD guidelines.22
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References: 1. Aslander-van Vliet E, Smart C, Waldron S.(2007) Nutritional management in childhood and adolescent diabetes. Pediatric Diabetes; 8(5): 323-39. 2. Anon (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. The New England Journal Of Medicine; 329(14): 977-86. 3. Anon (1994). Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. Diabetes Control and Complications Trial Research Group. The Journal Of Pediatrics; 125(2): 177-88. 4. Anderson EJ, et al (1993). Nutrition interventions for intensive therapy in the Diabetes Control and Complications Trial. The DCCT Research Group. Journal Of The American Dietetic Association; 93(7): 768-72. 5. Delahanty L, Simkins SW, Camelon K (1993). Expanded role of the dietitian in the Diabetes Control and Complications Trial: implications for clinical practice. The DCCT Research Group. Journal Of The American Dietetic Association; 93(7): 758. 6. Delahanty LM, Halford BN (1993). The role of diet behaviors in achieving improved glycemic control in intensively treated patients in the Diabetes Control and Complications Trial. Diabetes Care; 16(11): 1453-8. 7. Waller H, et al (2008). Pilot study of a novel educational programme for 11-16 year olds with type 1 diabetes mellitus: the KICk-OFF course. Archives Of Disease In Childhood; 93(11): 927-31. 8. Christie D, et al (2009). Maximising engagement, motivation and long term change in a Structured Intensive Education Programme in Diabetes for children, young people and their families: Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE). BMC Pediatrics; 9: 57. 9. Gillespie SJ, Kulkarni KD, Daly AE (1998). Using carbohydrate counting in diabetes clinical practice. Journal Of The American Dietetic Association; 98(8): 897-905. 10. Mehta SN, et al, (2009). Impact of carbohydrate counting on glycemic control in children with type 1 diabetes. Diabetes Care;32(6):1014-6. 11. Smart CE, et al (2010). Can children with Type 1 diabetes and their caregivers estimate the carbohydrate content of meals and snacks? Diabetic Medicine: A Journal Of The British Diabetic Association; 27(3): 348-53. 12. Patton SR, Dolan LM, Powers SW (2007). Dietary adherence and associated glycemic control in families of young children with type 1 diabetes. Journal Of The American Dietetic Association;107(1):46-52. 13. Mehta SN, et al.(2008) Dietary behaviors predict glycemic control in youth with type 1 diabetes. Diabetes Care; 31(7): 1318-20. 14. Luijf YM, et al (2010). Premeal injection of rapid-acting insulin reduces postprandial glycemic excursions in type 1 diabetes. Diabetes Care; 33(10): 2152-5. 15. O'Connell MA,et al (2008). Optimizing postprandial glycemia in pediatric patients with type 1 diabetes using insulin pump therapy: impact of glycemic index and prandial bolus type. Diabetes Care; 31(8): 1491-5. 16. Ryan RL,et al (2008). Influence of and optimal insulin therapy for a low- glycemic index meal in children with type 1 diabetes receiving intensive insulin therapy. Diabetes Care; 31(8): 1485-90. 17. Gilbertson HR,et al (2001). The effect of flexible low glycemic index dietary advice versus measured carbohydrate exchange diets on glycemic control in children with type 1 diabetes. Diabetes Care; 24(7): 1137-43. 18. Rovner AJ, Nansel TR, Gellar L (2009). The effect of a low-glycemic diet vs a standard diet on blood glucose levels and macronutrient intake in children with type 1 diabetes. Journal Of The American Dietetic Association; 109(2): 303-7. 19. Mehta SN, et al (2009). Emphasis on carbohydrates may negatively influence dietary patterns in youth with type 1 diabetes. Diabetes Care; 32(12): 2174-6. 20. Guy J, et al (2009). Lipid and lipoprotein profiles in youth with and without type 1 diabetes: the SEARCH for Diabetes in Youth case-control study. Diabetes Care.;32(3):416-20. 21. Edge JA, James T, Shine B (2008). Longitudinal screening of serum lipids in children and adolescents with Type 1 diabetes in a UK clinic population. Diabetic Medicine: A Journal Of The British Diabetic Association; 25(8): 942-8. 22. Donaghue KC,et al (2009) Microvascular and macrovascular complications associated with diabetes in children and adolescents. Pediatric Diabetes; 10 Suppl 12: 195-203. 23. Laffel L.(2010) Exercise: it isn't just child's play when it comes to managing type 1 diabetes. The Journal Of Pediatrics;157(5):701-3. 24. Riddell MC, Iscoe KE (2006). Physical activity, sport, and pediatric diabetes. Pediatric Diabetes; 7(1): 60-70.
Targets for lipid levels Nutrition
advice for CYP needs to ensure they develop appropriate healthy diets that meet the targets for saturated fat and protein intake. There is little information available about protein intake and complications in CYP. Where microalbuminuria is present it is prudent to ensure that protein intake is appropriate for growth and not excessive. Food choices must promote health particularly heart health. This includes eating more whole grains, making low fat and low GI food choices, along with eating appropriate amounts of fruit and vegetables.
Nutrition and associated
conditions Type 1 diabetes is an autoimmune condition associated with an increased risk of coeliac disease. Between one and 10 per cent of children with Type 1 diabetes also have coeliac disease, necessitating treatment with a gluten-free diet. Coeliac disease is often asymptomatic and this makes nutritional management challenging. Those with both conditions will require additional support from the dietitian.1
Nutrition and exercise Exercise is a common cause of both hypo and hyperglycaemia. Appropriate advice to CYP can prevent blood glucose fluctuations both during and after exercise.23 The current recommendations for exercise in
the UK, encourages 60 minutes of moderate intensity exercise daily. For CYP with diabetes, exercise has not been shown to improve metabolic control, though it does have the same overall health benefits in terms of cardiovascular function and bone health. CYP need to understand how to adjust food
intake and/or insulin to prevent exercise induced hypo and hyperglycaemia. Hypoglycaemia is usually associated with exercise of moderate intensity performed for longer than 60 minutes or exercise performed during the peak insulin activity. Exercise performed in the afternoons is associated with an increased risk of nocturnal hypoglycaemia. Education to prevent hypoglycaemia needs to encompass appropriate insulin adjustment and guidance on the type and amount of carbohydrate needed.1
Advice should include the management of
post exercise hypoglycaemia, which may occur 12 to 24 hours after exercise, particularly if activity lasts longer than one hour or is strenuous. Carbohydrate requirements during exercise are of the magnitude of 1g/kg body weight per hour of activity. Carbohydrate consumed during exercise needs to produce glucose during the activity. The
20 | Complete Nutrition Vol.10 No.6 December/January 2010/11
glycaemic index of a food can be used to advice suitable exercise snack choices.
Suitable exercise snack choices:
• Isotonic sports drinks • Jaffa cakes • Raisins • Jelly sweets • Breakfast cereal bars
Hyperglycaemia is associated with exercise
when the activity performed is anaerobic or competition or the CYP is lacking insulin. Exercise with inadequate levels of insulin promotes an exaggerated counter regulatory hormonal response that results in excess glucose production from the liver. If blood glucose levels are raised (greater than 14mmol/L) exercise should be avoided until the blood glucose is corrected if ketones are present.24
In situations where blood
glucose levels are raised before anaerobic activity, or competition, additional fast acting insulin may be required. Increased activity levels in CYP can result in
increased energy requirements. As well as considering blood glucose control, nutrition advice need to ensure that appropriate amounts of food are consumed to meet the energy demands for growth and activity.
Nutrition & acute complications The two main acute complications of diabetes are hypo and hyperglycaemia. Appropriate nutrition education for the treatment regimen forms part of their prevention. Exercise management strategies also link to the management of these acute complications. Manipulation of food choices at bedtime may also be considered to prevent nocturnal hypoglycaemia both in relation to insulin regimen and activity management. Illness is another cause of high or low blood
glucose levels and, whilst the major management strategies will revolve around insulin adjustment, advice to ensure appropriate carbohydrate intake is needed.
Summary Nutritional care of CYP with Type 1 diabetes is complex. Good nutritional management is an important part of achieving glycaemic control that will promote a healthy future. Achieving nutritional guidelines requires the paediatric diabetes dietitian to have an in depth knowledge understanding of the relationships between treatment
regimens, physiological
requirements, nutritional requirements and physical activity. They need to use this understanding to educate CYP and their families within a relationship that supports individualised
education and enables
understanding of food choices and their impact on daily glycaemic control as well as long term health and wellbeing.
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