V|tamins and Antioxidant Micronutrients Foods naturally rich in vitamins and dietary antioxidants (tocopherols, carotenoids, vitamin C and possibly flavonoids) should be strongly encour- aged.
Highly reactive oxygen free radicals are increasingly implicated in the pathogenesis of atherosclerosis and foods rich in antioxidants, such as fresh fruit and vegetables, may provide a means of protecting against long-term cardiovascular disease in populations at increased risk.
Unfortunately the intake of vitamins and dietary antioxidants in the UK is low among young children (22).
Scientific evidence on their benefits is still evolving and further research is required in children before firm recommenda- tions can be made.
In the meantime it is appropriate to achieve at least the DRVs for vitamins and to promote foods that naturally contain significant quantities of dietary vitamins and antioxidants (33).
Present evidence does not support the use of dietary supplementation with vitamins or minerals.
Non-starch Polysaccharide (Previously Known as Fibre) Non-starch polysaccharides may be classified into two broad categories , soluble (including gums, gels, pectin) and insoluble (including cellulose and lignin).
Intakes are recommended to the level suggested for the general population.
However intakes may be low in European countries and meeting desired targets may involve considerable change for some children and their families (34).
A reasonable first target would be 1 g/100 kcal/day (similar to non-diabetic children), rising to 2 g/100 kcal/day, with emphasis on soluble fibre (20).
Soluble fibre can benefit both glycaemic control and lipid metabolism, reducing both fasting and post-prandial glucose values.
An improvement in insulin sensitivity is postulated as the mechanism by which soluble fibre can improve fasting hyperglycaemia.
The benefits of increasing soluble fibre are supported by studies in children (19).
Fruit and vegetables are good sources of soluble fibre and emphasis should be placed on increasing intake, as most children with diabetes, like non-diabetic children in the UK, eat considerably less than the daily five portions of fruit and vegetables recommended (22).
Salt Salt intake is in general too high and in Western countries difficult to decrease as it is added to many processed foods (only 20% of intake is added at the table and in cooking). Two-thirds of the children in the National Diet and Nutrition Survey had salt added to their cooking and salt was added to food at the table,
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either usually or occasionally, by about half of the young people (22). Dietary habits are learned in childhood and difficult to change. Therefore these practices should be discouraged for the whole family and practical advice to develop cooking skills to reduce the intake of processed foods would help to reduce salt consumption. Reduction is recommended to that of the general adult population. In most European countries this constitutes a reduction of 50%, to less than 6 g of salt daily.
Alcohol Alcohol has no place in the normal nutrition of young people with or without diabetes, and in many countries alcohol ingestion in children and young teenagers is either illegal or culturally unacceptable.
However, since most UK adolescents do experience and experiment with alcoholic drinks the effect of alcohol on their diabetes requires discussion.
It is important to explain the risks of alcohol-induced hypoglycaemia and stress the dangers of nocturnal hypoglycaemia induced by inhibition of gluconeogenesis.
The benefits of taking complex carbohydrates before, during and after drinking alcohol to reduce the risk of hypoglycaemia need to be explained.
Nutritive Sweeteners These include glucose, sucrose, fructose and sugar alcohols such as sorbitol. All contain energy and should be considered if weight is a problem. The sugar alcohols have a lower glycaemic response than sucrose and have a slightly lower energy value. Large quantities may cause osmotic diarrhoea and some children are particularly sensitive.
Non-nutritive Sweeteners These include saccharin, aspartame, acesulfame K, cyclamates, alitame and sucralase and may be used in low-sugar products to improve variety and compliance. Acceptable daily intakes have been established. Fears that these sweeteners may contribute to hyperactivity in children have not been substantiated.
‘ACHIEVE AND MAINTAIN IDEAL BODY WEIGHT’ The diagnosis of Type 1 diabetes in a child is usually preceded by weight loss and initially extra energy is required to re-establish optimal weight. The appetite and food intake may double in the first 2, 3 weeks after diagnosis and parents need to be reassured that this is a healthy physiological reaction that will settle. This increased appetite is a good opportunity to establish a regular carbohydrate intake and introduce new healthy foods that may become
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established in the future diet.
This is a critical time to ensure that there is not an overshoot towards excessive weight gain.
Weight management during puberty is an important issue.
Paradoxically (particularly in girls) energy requirements may actually decrease due to an unfortunate decline in the frequency and intensity of exercise, and when this occurs weight gain can become a problem.
Puberty is also associated with insulin resistance and insulin doses need to increase to prevent hyperglycaemia but weight gain may accompany this increase in insulin administration.
Regular monitoring of weight and height will help to identify potential weight problems in puberty, too much or too little, and allow insulin, food and weight management advice to be given promptly.
Prevention of weight gain is a major priority because it is difficult to lose once gained and often the problem is transferred into adulthood.
All aspects of diabetic control are compromised when the body mass index (BMI) rises; insulin sensitivity decreases, glycaemic control deteriorates and dyslipidaemias and hypertension can manifest themselves (35).
Intensive Insulin Management Intensified insulin therapy to improve glycaemic control may have the negative effect of increasing weight, as demonstrated in the Diabetes Control and Complications Trial (17).
Close nutritional supervision and weight manage- ment should accompany intensive therapy to prevent weight gain (17,36).
The intensive therapy group in the DCCT also experienced a threefold increase in hypoglycaemia (17).
The need to carefully balance nutritional intake to insulin therapy was one of the important conclusions of the DCCT and stressed the importance of dietary re-education when intensified insulin management is introduced.
Advice is difficult, as it needs to be directed simultaneously to reducing total energy and the fat/carbohydrate ratio, avoiding hypoglycaemia with regular carbohydrate while improving or maintaining good glycaemic control.
‘ACHIEVE AND MAINTAIN OPTIMAL GLYCAEMIC CONTROL ON AN INDIVIDUAL BASIS, BALANCING FOOD INTAKE WITH METABOLIC REQUIREMENTS, PHYSICAL ACTIVITY AND INSULIN TREATMENT’
Initial Consultations The newly diagnosed child and parent have an enormous volume of information to assimilate. This ranges from factual issues, such as what is diabetes, to technical issues, such as how to inject and adjust insulin and monitor blood sugars. In addition they are given information on what they can eat and how all these factors affect each other. This deluge of information is
THE NUTRITIONAL MANAGEMENT OF CHILDREN’S DIABETES 63
often overwhelming and frightening.
Additional issues that health care professionals may feel important should be considered carefully and where possible delivered later.
Initial consultations should be used to develop a trusting relationship with the child and parent establishing rapport, confidence and understanding.
This time should be spent on how the child feels, and is coping with the initial tasks of diabetes.
The focus should be on their immediate questions and real concerns.
Usually the first question parents ask is ‘What can we eat?’ Useful prompts at these times include: . ‘How do you feel about the diabetes?’ . ‘What are your worries about food and diabetes?’ . ‘How will your eating habits at home affect diabetes?’ . ‘Do you think you will have to change the way you and the family eat?’ It is particularly important to establish if other family members have diabetes and the influence this already has on the family eating pattern.
The interplay of insulin with food, eating habits, the timing of meals and snacks and even a wider discussion of insulin effects on metabolism in general should take place, if appropriate to the individual’s level of understanding and perception of diabetes management.
A diet history should be taken to support any changes suggested, although this need not occur at the first appointment, if the parent or child has raised a number of emotional issues and concerns that need addressing.
Completion of a food diary for review at a future appointment is often a more productive use of time.
All information should be provided at a level appropriate to assist the child to achieve their immediate goals while addressing any concerns.
Appropriate information at this stage may be very practical advice for the next supermarket shop or how to read food labels.
Events during the early days and weeks after diagnosis undoubtedly have a lasting impact on long-term control (see Chapter 3) and there is some evidence that if glycaemic control is good in the first 5 years long-term diabetic outcomes are improved (37, 39).
It is essential that the dietitian is perceived at this important time as being an ally and not prescriptive or dogmatic, taking little notice of immediate fears, crucial cultural and behavioural aspects of the family and their eating pattern.
The DCCT showed conclusively that dietitians need to develop skills in communication, counselling and motivational interviewing to facilitate necessary effective changes (36).
Education Methods The DCCT also showed that meticulous attention to both diet (36,40) and insulin management (17) produced better glycaemic control and reduced complication rates. Dietary education tools need to be selected carefully for each child and family to achieve maximum understanding and compliance.
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Educational tools should be varied, appropriate to the needs of the family and staged at a pace with which the family is comfortable.
As families become more confident with managing diabetes, education may become more complex and as children grow and take more responsibility, regular re-education is essential.
The dietitian should have developed the skills to deliver any of the following methods and in this way the needs of the individual child and family can be met.
The mode of transfer of the information should also be appropriate to the child’s age and developmental level.
Food pyramids, Figure 5.1, and plate models, Figure 5.2, are useful in providing basic nutritional information and healthy eating concepts.
They also illustrate visually carbohydrate in relation to the other food components and should be attractive visual aids for children.
Carbohydrate Management Many methods of counting or estimating carbohydrate intake are used in paediatric practice, for example, intensive nutritional management with
Figure 5.1 Food pyramid. Reproduced from US Department of Agriculture: Food and Nutrition Information Center, USA