intake of sweets, chocolates and sweeter foods.
This approach will cause feelings of isolation and stigmatisation.
These feelings may also be acutely felt when with the child’s peer group, especially in the school surroundings.
The child is often embarrassed to eat snacks when other children are not allowed to, sometimes resulting in hypoglycaemia.
The school timetable should be examined carefully and snacks placed within natural school breaks if possible.
The teachers and lunch supervisors need instructions on the importance of regular carbohydrate and the individual child’s signs and symptoms of hypoglycaemia and action to take if hypoglycaemia occurs.
The ‘School Pack’ designed by Diabetes UK is useful in this context (75).
It is most unfortunate that the trend in the UK is not to eat meals at the family table with parents and siblings.
Good eating habits are therefore not encouraged.
It is important to counsel families, encouraging them back to more traditional eating patterns and to establish better supervision, commu- nication and enjoyment at family meals.
Infants and Toddlers Breast feeding is to be encouraged with infants diagnosed with Type 1 diabetes.
Frequent small meals in infants and toddlers are compatible with good overall glycaemic control, especially when a long-acting insulin is the main insulin prescribed.
In toddlers, eating as a family may help promote greater co- operation at meal times.
Providing suitable foods with a variety of tastes, colours and textures can also improve a toddler’s compliance with their diet.
Of course this age group is renowned for food refusal and food fads, which is extremely anxiety provoking for the parent.
This situation requires delicate handling because the child can hold the parent to ransom by refusing to eat and consequently parents ‘give in’ to the child and a poor dietary intake is established.
Behaviour tactics are necessary; the parent should not get into conflict over these problems or give in to demands.
Insulin analogues are extremely useful in this situation, especially given after the child has eaten.
School Children Advice on prevention of disruptive, confidence-shattering hypoglycaemia is most important.
School staff should be aware that children with diabetes need quick and easy access to food at all times, and this especially includes periods related to physical activity.
Specific holiday and travel advice should be made available.
Unfortunately, some schools continue to exclude children with diabetes from excursions and holidays and this needs to be assisted by health care professionals who can help by providing responsible advice to parents and teachers.
THE NUTRITIONAL MANAGEMENT OF CHILDREN’S DIABETES 75
Young people with diabetes (and dietitians) may learn greatly from the experience of attending either local or nationally organised educational holidays (76,77). They are extremely useful educational events where skills can be developed in adjusting carbohydrate and insulin around different activities.
Adolescents The normal physiological, psychological and metabolic changes of puberty are often associated with poor glycaemic control.
Insulin requirements usually increase greatly with the physiological increase in insulin resistance and rapid growth.
There is a tendency for excessive weight gain, particularly in girls.
Careful review of insulin dosage, energy input and output is advisable throughout adolescence.
Excessive weight gain may result from attempts to obtain excellent glycaemic control by matching insulin requirements with food intake.
Weight monitoring is important for both the early recognition of excessive weight gain and also weight loss, as this can be the first sign of a potential eating disorder.
Delayed puberty and poor linear growth may be an indication of insufficient energy intake, inappropriate insulin and/or poor glycaemic control.
All children must have regular height as well as weight monitoring and be plotted on appropriate growth charts.
While a degree of rebellious behaviour is usual in all adolescents it can be dangerous in diabetes when associated with failure to take insulin and erratic eating behaviour (7,79).
Access to expert psychological support and counselling should be available.
All adolescents should receive advice on the potential dangers of excessive alcohol intake.
Eating Disorders The incidence of eating disorders in adolescent girls with diabetes is higher than that in the non-diabetic population and its incidence is increasing (79).
This may be partly a consequence of intrusive dietetic management of diabetes at an earlier age.
In association with eating disorders, the omission of insulin is a well-described tactic in attempts at weight loss in overweight insulin-treated patients (80,81).
Individuals with eating disorders have higher HbA1c levels and an earlier age of onset of diabetic complications, one study reporting that eating disorders were associated with a threefold increase in risk of diabetic retinopathy (79).
It is not only teenage girls with eating disorders who require additional support but all teenagers are potentially vulnerable as there is some indication that binge eating and misuse of insulin is common among both teenage boys and girls.
Evidence from the Young Diabetes Conference in 1987 indicated that
76 NUTRITIONAL MANAGEMENT OF DIABETES MELLITUS
71% of young people with Type 1 diabetes admit to ‘binge’ eating which is often associated with feelings of extreme guilt (78).
The Acheson Report recommended ‘policies which promote the adoption of healthier lifestyles, particularly in respect of factors which show a strong social gradient in prevalence or consequences’ (82).
Eating disorders have serious consequences for metabolic control and consequent acceleration of the onset of complications.
They are also an indication of mental health problems requiring psychological support (82).
There is a need to research effective methods of tackling these problems; to train health care professionals to deal with eating disorders.
This will inevitably require sufficient resources.
Indicators that could be used to show effective treatment are increased uptake of insulin usage, better glycaemic control and fewer admissions with diabetic ketoacidosis.
Parties, Festivities and Special Events Children with diabetes should be encouraged to attend and participate in all family, social and religious events to which their non-diabetic siblings and friends are included and not to hide behind their diabetes.
Special dispensation is usually given to children with diabetes during fasts such as Ramadan.
Parents are recommended to advise other parents and care givers on their child’s food preferences including low-sugar drinks.
Occasional sugary food treats may not cause hyperglycaemia if physical activity levels are also high.
To prevent or treat hyperglycaemia resulting from social events that include unusual amounts of eating, the use of additional short or rapid-acting insulins may be useful (see extra insulin guidelines above).
As with all age groups, friends and other care givers should know how to recognise and treat hypoglycaemia.
DIABETES IN CHILDREN AND ADOLESCENTS NOT DUE TO TYPE 1 DIABETES
Type 2 Diabetes Non-insulin-dependent, non-immune-mediated Type 2 diabetes has always been considered rare in children.
However, in Japan it is more common than Type 1 diabetes and has increased greatly in incidence in the last two decades (83).
Also in recent years in certain paediatric populations in the USA Type 2 diabetes has accounted for up to 45% of newly diagnosed diabetes (9,10) and there is evidence that this type of diabetes is now on the increase in the UK (11).
The highest risk groups for Type 2 diabetes in youth are obese, physically inactive, female adolescents with a family history of diabetes, particularly from ethnic minority communities (12,13).
THE NUTRITIONAL MANAGEMENT OF CHILDREN’S DIABETES 77
In adults, Type 2 diabetes is difficult to manage and there is a high reported incidence of serious vascular complications.
Its emergence in adolescence is therefore a major public health concern, particularly as in this age group non- adherence in terms of clinic attendance and treatment regimens is common (7).
An essential component of nutritional management is a review of eating habits and lifestyle, and almost always there will need to be both a reduction of energy intake and an increase of physical activity to promote weight loss.
Unfortunately these behavioural changes present major obstacles to effective education.
Close surveillance will be necessary and if weight loss does not occur with simple healthy eating advice more detailed advice should be given on energy reduction.
Nutritional advice will depend on the type of treatment prescribed and advice given on hypoglycaemia if necessary.
Carefully organised multicentre trials of lifestyle management and interven- tions amongst young people are required (84).
DIABETES SECONDARY TO CHRONIC DISEASES OF CHILDHOOD
Cystic Fibrosis (CF)-related Diabetes As life expectancy in CF improves, slowly evolving, non-ketotic, glucose intolerance and diabetes is becoming more frequent (14).
The diabetes is predominantly due to insulin deficiency but there are elements of insulin resistance and, because of co-existing pancreatic exocrine deficiency, there is a need for high-energy, complex carbohydrate and high-fat foods which conflicts with the usual advice for diabetes in terms of cardiovascular risk.
Moreover it is common practice in CF to use overnight gastrostomy feeds to improve nutrition and steroid therapy is often prescribed.
Both of these increase glucose intolerance (and may initially precipitate diabetes).
Alterations of food intake and absorption and constantly changing treatments demand flexibility in both nutrition education and insulin regimens, especially as the diagnosis of diabetes in addition to CF is particularly demoralising.
Haemoglobinopathies Treated b-thalassaemia with chronic iron overload is associated with decreasing tissue sensitivity to insulin, pancreatic insulin deficiency and diabetes (15). Insulin doses may be high and the diabetes difficult to manage as in CF because of the double diagnosis. Chronic glycosuria may be associated with poor weight gain and effective nutritional management becomes important in trying to persuade patients to increase energy intake in association with escalating insulin doses.
78 NUTRITIONAL MANAGEMENT OF DIABETES MELLITUS
Genetic Defects of b-cell Function This group of rare disorders was formerly known as maturity-onset diabetes in the young (MODY) and comprises at least six subtypes of genetically inherited disorders of insulin secretion usually presenting under the age of 25 years and also present in several other family members in different generations (16).
It is important to recognise the small number of this unusual and ‘mild’ type of diabetes in a paediatric clinic (confirmed by special tests in a molecular genetic laboratory) because of the treatment implications.
The two commonest types are: .
Glucokinase deficiency (25% total) , a defect in the glucose-sensing gene resulting in mild persistent hyperglycaemia from birth, but with a very low risk of long-term complications.
The only treatment required is healthy eating advice to improve levels of glycaemia. .
HNF-1a deficiency (55% total) , involves progressive b cell failure from puberty, managed initially by healthy eating advice like Type 2 diabetes but subsequently treated with low dose sulphonylurea tablets and later insulin so that nutritional advice on hypoglycaemia as described elsewhere is required.