The care of children with diabetes is complex.
It involves not only the child but also the family and multiple carers.
It requires a deep understanding of the relationship between treatment regimens and constantly changing physiologi- cal requirements, including growth, fluctuations in appetite associated with changes in growth velocity, varying nutritional requirements and sporadic episodes of physical activity.
In addition diabetes management is set within the current context of frequently dysfunctional family dynamics, deteriorating national dietary characteristics, issues of non-compliance, peer pressure, emerging independence and the ultimate aim of maintaining quality of life.
However evidence suggests it is possible to improve diabetes outcomes through meticulous attention to nutritional management.
This requires a clear focus of the dietetic targets in relation to glycaemic control and the reduction in cardiovascular risk.
The fundamental premise of success for the paediatric diabetes specialist dietitian is the development of a trusting relationship between the child and family, which will facilitate behaviour change during the challenges and turbulence of childhood and adolescent development.
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LOOKING TO THE FUTURE
The management of childhood diabetes will continue to present special challenges to all members of the paediatric diabetes team.
These challenges are perhaps greatest for the dietitian whose success depends so much on trying to promote significant changes of behaviour related to food, eating and weight control.
All of these areas of human behaviour are notoriously resistant to change, particularly in adolescents and family groups.
Despite these difficulties there will be developments in management that should improve the prospects for the dietitian.
Specialist paediatric diabetes dietitians will have more specific and extensive training and will become a more effective member of the multi-disciplinary diabetes team.
With better training the knowledge base in both paediatrics and diabetes will increase and be more practical.
Also the skills to effect behaviour change, which include counselling, motivational interviewing and the ability to be flexible by using various education tools to suit different families, will be far more extensive than at present.
Better communication between team members will be seen as essential in providing comprehensive, co-ordinated professional support and optimal care of the child and family.
Nutritional management will have targets more clearly linked to the two major diabetes outcomes of maintaining much tighter glycaemic control associated with a substantial reduction in microvascular complications and far better prevention of cardiovascular disease.
The highly trained and experienced dietitian will have an extended role in the team and will be confident not only to advise on food changes but also to help adjust insulins to reduce post-prandial blood glucose excursions.
These adjustments will become more flexible and appropriate because of more frequent use of rapid-acting insulin analogues, continuous insulin infusions and perhaps other modes of insulin delivery such as inhaled insulin.
Methods of continuous monitoring of blood glucose will become easier and more sophisticated so that the glycaemic effects of certain types of carbohydrate intake will become more readily apparent to the child and family.
Thus the devolution back towards carbohydrate assessment or measurement in some form will continue so that a more precise balance between food and insulin can be achieved.
It has become clear that the specialist paediatric diabetes dietitian must also focus attention on reducing cardiovascular risk factors.
Evidence is accumulat- ing that increases in anti-oxidants and modifications in fatty acid intake may induce beneficial changes in cell membranes and these changes must be initiated in childhood to minimise the progression of atherosclerosis.
These are exciting innovations but unfortunately they are set against a nutritional environment in the UK which encourages unhealthy eating
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practices with increasing reliance on high-fat, high-salt fast foods, disorganised family eating patterns and even a reluctance by many influential agencies to promote healthier eating along the lines of those in some other areas and countries such as around the Mediterranean and Scandinavia.
To counterbalance this the dietetic community must improve the scientific evaluation of dietary practices by more extensive and better research.
In paediatric practice where numbers are relatively small this can only be achieved by well-structured, multi-centre projects similar to DCCT and DAFNE (see above).
To enable all these exciting changes in practice to come to fruition there will need to be a recognition by health authorities that specialist paediatric diabetes dietitians are an important investment in the future of children with diabetes.
It is then essential that there is more adequate resourcing for paediatric centres of excellence to be established as specialist training centres.