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ADA/JDRF Type 1 Diabetes Sourcebook, Excerpt #6: Nutrition, Part 2

Anne Peters, MD, and Lori Laffel, MD, MPH, Editors
Jane Lee Chiang, MD, Managing Editor

ADA-JDRF-Type-1-Diabetes-Sourcebook-image

Marion J. Franz, MS, RD, CDE; Alison B. Evert, MS, RD, CDE; Gail Spiegel, MS, RD, CDE; Carol Brunzell, RD, CDE; Joyce Green Pastors, MS, RD, CDE; Joshua J. Neumiller, PharmD, CDE, CGP, FASCP; Laurie A. Higgins, MS, RD, LDN, CDE; and Mary Ziotas Zacharatos, RD, CDE, LD

PEDIATRICS

Normal Growth and Development

Children and adolescents require adequate calories for normal growth and development. Thus, growth must be monitored and recorded every 3 months.17,18 Table 10.2 lists approximate caloric requirements for children and adolescents based on sex, age, and activity level.19 Children need guidance to select appropriate amounts and types of food to sustain normal growth. Nutrition assessment tools such as 24-h recall, 3-day food records, and food frequency questionnaires can be used in conjunction with a computer nutrient analysis program to determine usual nutrient intake. Once calorie and nutrient needs are established, they can be adjusted to accommodate growth or prevent accelerated weight gain.10

At diagnosis, many children and adolescents have T1D-associated weight loss, which must be restored with insulin, hydration, and adequate caloric intake. In youth, weight loss or insufficient weight gain at diagnosis usually requires additional calories to promote catch-up growth. Because energy requirements change with age, physical activity, and growth rate, an evaluation of height, weight, BMI, and nutrition plan should be constantly monitored.10

Chronic under treatment with insulin and long-standing poor diabetes control often leads to poor growth and weight loss. Overtreatment with insulin can lead to excessive weight gain. Impaired linear growth or poor weight gain should raise suspicion for other related autoimmune diseases such as hypothyroidism and celiac disease, and behaviors such as disordered eating behaviors or insulin omission. Height and weight evaluations at each clinic visit will allow for early recognition of any deviations from the norm, which then can be promptly evaluated and treated.10,18

Medical Nutrition Therapy

When young children and adolescents are diagnosed with T1D, their lives are profoundly impacted by diabetes and require consideration when devising a diabetes medical management plan and providing nutrition recommendations. The following checklist (Table 10.2) can help when designing an appropriate nutrition plan. Nutrition guidance should be individualized for the patient and family’s needs and taught in such a way that considers learning theory, behavior change, patient engagement, and other factors that impact understanding and implementing the recommendations.

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Nutrition education and counseling. Nutrition therapy for children and adolescents should be initiated at diagnosis and continued regularly. One model for educating families at diagnosis is to begin with survival skills. An RD with expertise in both pediatric nutrition and T1D should educate the family. Nutrition therapy should be part of the team’s initial education, with close and frequent follow-up after diagnosis. The child or adolescent should be seen by an RD at least annually to evaluate height, weight, BMI, and the food plan. Young children require more frequent evaluations.10,18

Age components of nutrition education and counseling. The challenges of nutrition education for children and adolescents are often age related and require consideration of the child’s specific nutrition and developmental needs. Below is a summary of the specific characteristics to consider when working with different age groups:10

Toddlers

  • Variable appetites
  • Eat small, frequent meals
  • Prone to food jags/selective eating, resulting in food battles with parents
  • Daycare providers need instruction on diabetes management
Preschool/school age 
  • More consistent growth and nutrition intake
  • Usually eat three meals and snacks between meals
  • Begin to be involved in organized sports and physical education class
  • School personnel need understanding and training in diabetes management
Adolescents
  • Variable schedules/more inconsistency/sleeping in on weekends
  • Often working and going to school
  • Peer influence on food choices
  • More responsible for food choices and diabetes self-care
  • More likely to miss shots or boluses
  • Alcohol use needs to be discussed
  • School personnel need understanding and training in diabetes management
  • Skipping meals
  • Potential eating disorders
Nutrition therapy goals and recommendations for youth. Nutrition therapy goals for children and adolescents with T1D include achievement and maintenance of glucose, lipid, and blood pressure goals to prevent or slow chronic complications from arising and to prevent and treat acute complications.13,18 These goals and recommendations apply specifically to youth and their unique needs. Nutrient recommendations are based on requirements for all healthy children and adolescents because there is no research on the nutrient requirements for children and adolescents with diabetes.18 Therefore, youth and their families should be encouraged to follow the Dietary Guidelines for Americans, 2010, which out-line general nutrition recommendations for all youth ≥2 years of age.19 Depending on age, sex, and activity level, those recommendations include a daily intake of:10
  • 3–10 oz of grains
  • 1–2.5 cups of fruit
  • 1.5–4 cups of vegetables
  • 3–7 oz protein foods
  • 2–3 cups of dairy

Youth with diabetes fail to meet their nutrition goals (see Table 10.1).20–23 They consume more total and saturated fat than recommended and inadequate amounts of fruits, vegetables, and grains.20,21,24 The SEARCH for Diabetes in Youth study, the largest study conducted on youth, found that only 6.5% of the cohort (1,697 youth) met ADA recommendations of <10% of energy for saturated fat, and <50% met recommendations for total fat, vitamin E, fiber, fruits, vegetables, and grains.10,21