M

Choose lower fat alternatives whenever you can

Figure 5.2 Plate model. Modified from: ©Diabetes UK. This figure has been reproduced with the kind permission of Diabetes UK. Adapted February 2001, from the Balance of Good Health: Food Standards Agency

Fatty and sugary foods

Try not to eat these too often, and when you do, have small amounts you can

Fatty and sugary foods

Try not to eat these too often, and when you do, have small amounts you can with adjustment of insulin doses on a meal-to-meal and day-to-day basis, improved glycaemic control. This requires motivation, recording blood glucose results and altering insulin doses according to experience and often using an insulin adjustment algorithm. Moreover, the evaluation of intensified nutrition education programmes using carbohydrate assessment techniques in adults (43,44) has produced very good glycaemic outcomes.

Carbohydrate Assessment

The necessity and efficacy of using some form of carbohydrate assessment to achieve optimal glycaemic control is still hotly debated and questioned (4,45). In the past, exchange diets or carbohydrate portion systems were used rigidly, the person with diabetes was expected to eat the same amount of carbohydrate per meal or snack to balance their prescription of insulin and the patient was not encouraged to adjust their own insulin doses (46). Understandably, dietary adherence to such a system was poor (47-49) and made no allowances for diversity of energy expenditure (50) and growth. Also unless rigorously reviewed there was the danger that such dietary 'prescriptions' would lead to carbohydrate constraint as the child was growing, resulting in restricted growth and creating abnormal eating practices that are detrimental to normal family functioning (51). These dysfunctional approaches to eating may also contribute to disordered eating behaviours or eating disorders (52,53).

Most traditional teaching methods include some form of estimating or counting of carbohydrate. This may place misguided emphasis on quantifying carbohydrate and may alter the nutritional balance of the diet compared with non-diabetic peers. The subsequent suppression of carbohydrate then causes an increase in total fat (48,49,54,55) and potentially increases cardiovascular risk factors. Therefore whatever the educational method used there must also be a consideration of the balance of all the major nutrients.

The fundamental paradigm for carbohydrate education is the development of an understanding of the relationship between food and the post-prandial meal effect. This has to involve pre- and post-prandial blood glucose testing. The child and parents then need to be taught the skills to interpret the blood glucose tests and adjust insulin accordingly if optimal glycaemic control and a reduction in complications is to be achieved.

Optimal metabolic control as assessed by the level of glycated haemoglobin (HbAlc) is the gold standard of monitoring treatment of diabetes and the only evidence-based risk factor for future microvascular complications (17). However the DCCT (56) also suggests that post prandial glycaemic excursions play a significant role in increasing the risk of complications. This evidence supports a symbiotic link between the nutritional management of diabetes, blood glucose monitoring and insulin adjustment. Thus all three elements must be considered together.

Carbohydrate Assessment Methods

The following are descriptions of methods used to assess carbohydrate and their application will depend upon the preference of the child and family and their changing needs.

Carbohydrate Counting

Modern carbohydrate counting is a meal planning approach that focuses on improving glycaemic control and allowing maximum flexibility of food choices, so is especially suitable for children and young adults. Three levels of carbohydrate counting have been identified by the American Dietetic Association and can be considered as a stepwise approach (57,58).

• Level 1 - basic, and introduces the concept of carbohydrate as the food component that raises blood glucose. A consistent intake of carbohydrate is encouraged using exchange or portion lists of measured quantities of food that contain all types of sugars and starches. Allowing a greater variety of carbohydrate foods (based on knowledge of the glycaemic index) than was previously accepted. With a regular carbohydrate intake and the results of blood glucose monitoring it is then possible for the dietitian, diabetes specialist nurse or doctor to advise on the appropriate insulin dose.

• Level 2 - the intermediate step, in which the individual continues to eat regular carbohydrate and frequently monitors blood glucose levels, but learns to recognise patterns of blood glucose response to carbohydrate intake modified by insulin and exercise. They learn to make their own adjustments to insulin doses, or alter carbohydrate intake or timing of exercise to achieve blood glucose goals. Alterations of insulin should be made in response to a pattern of blood glucose results over a few days not based on a single high or low blood glucose.

• Level 3 - for people on multiple injections or insulin pumps, requires a good understanding of the first two levels and motivation to closely monitor blood glucose levels. Once the appropriate insulin doses have been established on a regular intake of carbohydrate, an insulin/carbohydrate ratio can be calculated, e.g. 1.5 units rapid-acting insulin = 15 g carbohydrate exchange for additional carbohydrate. With this insulin/carbohydrate ratio the patient can begin to vary the amount of carbohydrate eaten at any particular meal and increase or decrease the insulin dose keeping the same ratio. This provides greater dietary flexibility than a traditional exchange diet and helps reduce the frequency of hypoglycaemia as well as high blood glucose levels after large meals.

The carbohydrate counting system at level 3 requires intensive education, extensive reassessment by an experienced dietitian and highly motivated patients. However levels 1 and 2 may assist in achieving better compliance and improved blood glucose control when not using multiple injection regimens (59).

Glycaemic Index (GI) See Chapter 11.

Qualita tive A dvice

The evidence base behind using the exchange system has been questioned as above and some studies have recommended a less prescriptive qualitative approach (48,49). This dietary education method is distinctly different from the 'free' diet. It has all the qualities of healthy eating principles plus a clearly defined carbohydrate structure to the meal plan. Studies have shown that children who follow this type of advice have comparable glycaemic control to children who follow exchanges (48,49), although in these studies glycaemic control was far from optimal and the DCCT has shown the significant benefits of intensive management. A recent study also showed reasonable glycaemic control in a group of children that had received qualitative advice from diagnosis (23). Although it appears reasonable glycaemic control can be achieved using this method the negative aspect is there is no mechanism to prevent post-prandial blood glucose excursions.

Intensive Nutrition Education

A programme of intensive nutrition and insulin management has not been widely used in the UK up to the present time but it has been positively evaluated in some European centres in adults with Type 1 diabetes (43,44). It encourages self-management and is based upon changing insulin doses according to blood glucose monitoring and assessment of carbohydrate at each meal and snack. A recent pilot study has taken place in the UK in adults with Type 1 diabetes, called the DAFNE (Dose Adjustment For Normal Eating) Study (60). It involves a five-day outpatient skills-based training and treatment programme. The feasibility of this programme in children and adolescents with diabetes is being considered at the present time and the results will be crucial in finding out whether it is possible with this regimen to improve glycaemic control in children and adolescents with diabetes in the UK.

One of the concerns of this approach is the potential increase in hypoglycaemia as demonstrated by the DCCT where the intensive group had a threefold increase in the rate of hypoglycaemia (17). However, later paediatric studies have shown that good glycaemic control can be achieved without adversely affecting hypoglycaemia rates (59,61). The careful balancing of nutritional intake to insulin therapy was one of the important conclusions of the DCCT analysis and it seems clear that regular dietary re-education is essential when intensified management is introduced.

InsulinTypes, Regimens and Action Profiles

General advice on balancing carbohydrate intake against the insulin action profile:

• Regular and frequent carbohydrate intake is advisable to prevent hypoglycaemia during inevitable periods of hyperinsulinaemia when the insulin regimen is twice daily mixtures of quick- and slower-acting insulins.

• A more flexible carbohydrate intake is possible when the insulin regimen is of multiple pre-prandial doses of quick or rapid-acting insulin.

• Carbohydrate intake is required before bedtime to prevent nocturnal hypoglycaemia in most insulin regimens.

• Extra carbohydrate is required before, during and after increased exercise and sport to balance increased energy needs and prevent hypoglycaemia.

• A 'grazing' or 'little and often' style of eating, often seen in younger children, may be suited to an insulin regimen consisting mainly of longer acting insulins.

• Flexible carbohydrate intake is possible when prandial boosts of insulin are given on multiple injection regimens or during continuous subcutaneous insulin infusions (CSSI 'pump treatment').

Insulin Analogues

Advice on balancing the insulin against an estimated carbohydrate intake has become more relevant and precise since the introduction of insulin analogues and CSSI management. The two rapid-acting insulin analogues currently available, lispro and aspart, have benefits over conventional soluble insulin:

• Very rapid onset of action within 10-15 min of subcutaneous injection

• A time action profile reducing the post-prandial blood glucose excursion

• Shorter duration of action reducing later hypoglycaemia several hours after insulin injection, including a reduction in nocturnal hypoglycaemia

However, it has become clear that to improve overall glycaemic control by the use of rapid-acting analogues, the slower-acting insulins also have to be carefully adjusted, and this may be made easier with the introduction of the newer longer acting analogue insulins.

In children the rapid-acting analogues are proving useful when:

• Injected after a meal when a young child's food intake is unpredictable

• Given as opportunistic extra doses when a child binges to satisfy hunger

• Injected as a calculated dose for particular levels of hyperglycaemia (it is useful to give specific guidelines on extra doses for particular levels of hyperglycaemia in relation to the age of the child - see below)

• Used in the evening instead of conventional soluble insulin to avoid nocturnal hypoglycaemia

• Used as a regular third injection after school to accommodate large volumes of food eaten at this time

• Used to reduce hyperglycaemia and ketosis in the management of intercurrent illnesses

Physical Activity

Physical activity in young people with or without diabetes is erratic and unpredictable: it is often spontaneous, usually unplanned and varies enormously in duration, type and intensity. Although regular physical activity and sports are highly recommended in all children and especially those with diabetes, the effects on glycaemic control are highly variable and difficult to manage. There are also great inter-individual differences with regard to physical activity and adjustments of both insulin and carbohydrate intake will be necessary to prevent hypoglycaemia which is a common complication (50,62). Intensive blood glucose testing is strongly advised at the beginning and after each new activity to develop some understanding of the relationship between the required insulin and the amount and type of food to sustain reasonable blood sugar levels.

The blood glucose-lowering effect of heavy exercise may occur several hours after the cessation of physical activity. The possibility of such late post-exercise hypoglycaemia should be remembered when planning meals and snacks. Insulin may need to be reduced and/or carbohydrate increased.

'PREVENTHYPO- AND/OR HYPERGLYCAEMIA DUE TO INSULIN, ILLNESS AND EXERCISE'

Hypoglycaemia

There seems little doubt from personal experience and studies such as the DCCT and others (59,61) that repeated expert dietetic advice as part of comprehensive diabetes management can reduce the incidence of hypoglycaemia. In contrast if diet is ignored as a major determinant of control and especially in extreme activity, hypoglycaemia rates can be worryingly high (50,64).

Guidelines (verbal and written) both for prevention and treatment of hypoglycaemia should be available soon after diagnosis with particular emphasis on regular carbohydrate intake. Hypoglycaemia should be discussed frequently at clinic appointments and investigated with respect to poor dietary management. Moreover if parents and other carers are given clear guidelines on how to treat with urgency episodes of severe hypoglycaemia, the frequency of hospital admissions may decrease to very low levels.

The dietitian should be able to supply useful information in relation to sport, exercise and travelling with diabetes, all of which require careful planning and organisation. Increased blood glucose monitoring (before and 2h after) is advised for new activities. Nocturnal hypoglycaemia in relation to new activities, long duration and intense exercise should be discussed and changes in treatment may be necessary. The options for change may be either a reduction in insulin or increasing carbohydrate intake, and often both are necessary (50). Educational holidays (76,77) such as those organised by Diabetes UK are a rich source of education for dietitians with respect to planning outings, travel, preventing and treating hypoglycaemia, and arranging meal times to suit a variety of activities.

Hyperglycaemia

One of the most significant diet behaviours in the DCCT that reduced HbAlc was 'adjusting food and/or insulin in response to hyperglycaemia' (40). Dietetic advice should include an appraisal of the usual carbohydrate intake of the day in relation to blood glucose monitoring (BGM). Advice on timings of BGM will be necessary with the aim of developing the child's and parents' understanding of the glycaemic effect of different carbohydrates. The availability of rapid-acting insulin analogues has improved the management of isolated episodes of hyperglycaemia. Due to its short action profile parents feel confident about using these analogues, especially later in the evening. Also these insulins can be used prior to foods known to have a hyperglycaemic effect in the individual child.

Guidelines for extra rapid-acting insulin given for isolated high blood glucose levels or prior to extra carbohydrate loads are as follows:

Age

BG >15 mmol/l

BG >17 mmol/l

BG >20 mmol/l

<6 years

0.5-1.0 units

1-2 units

2-4 units

6-12 years

1-2 units

2-4 units

3-6 units

>12 years

2-4 units

3-6 units

5-10 units

These doses may be repeated after 2 h if the BG shows no significant decrease. Illness

The dietitian along with the diabetes care team should provide clear guidelines on managing diabetes during intercurrent illnesses. Normal food intake may be dramatically reduced and easily digested carbohydrate foods should be offered. It may be necessary to substitute food completely with sweet liquids during complete food refusal. Frequent BGM is essential during this period and adjustment of insulin may be necessary. Insulin should never be stopped but may be increased or decreased depending upon the type of illness and the results of BGM. It is important to recognise the childhood illness that is most likely to cause hypoglycaemia is gastroenteritis with vomiting and diarrhoea. Most other infections with fever cause hyperglycaemia. Written guidelines for 'sick days' are helpful and reassurance is often necessary during these troublesome episodes, especially when a young child will not eat. Adequate fluid intake is essential during hyperglycaemia and fever to prevent dehydration.

'REDUCE THE RISK OF LONG TERM MICRO- AND MACROVASCULAR COMPLICATIONS THROUGH OPTIMUM GLYCAEMIC CONTROL'

The most significant contribution to proving that a reduction in glycated haemoglobin is associated with a reduced risk of microvascular complications in adolescents with Type 1 diabetes was the DCCT (17). The DCCT enrolled 195 adolescents (13 to 17 years at entry) into the trial, 14% of the total participants: 125 with no retinopathy at baseline were recruited (primary prevention cohort) and 70 subjects with mild retinopathy (secondary intervention cohort). In the primary prevention cohort, intensive therapy decreased the risk of retinopathy by 53% in comparison with the conventional group. In the secondary intervention cohort, intensive therapy decreased the risk of retinopathy progression by 70% and the occurrence of microalbumi-nuria by 55%.

Dietary analysis of the DCCT confirmed the value of regular dietary advice and education (63).

'REDUCING THE RISK OF MACROVASCULAR COMPLICATIONS'

High Morbidity and Mortality in Young People with Diabetes

Young people with Type 1 diabetes diagnosed under the age of 30 years have an increased risk of cardiovascular disease. They suffer two to four times higher mortality compared with their peer group and cardiovascular disease is responsible for the majority of deaths above the age of 30 years (5). There is also increasing evidence that macrovascular changes may be present in young people with Type 1 diabetes (65,85). Promoting cardiovascular health is essential from the day of diagnosis.

Achieving Diabetes Nutritional Recommendations

The aetiology of cardiovascular disease is multi-factorial and nutritional intake is only one component. Dietary fats, especially saturated fats, play a key role and the importance of cardio-protective factors such as antioxidants is emerging. The combination and balance between other nutrients and all components of the dietary recommendations are important (1-3,31).

Although the total fat intake of children in the UK has decreased over the last decade (22) children with diabetes still appear to find it difficult to achieve diabetes recommendations (23) and total fat intake remains above recommendations. The indigenous diet of the UK and the unhealthy snack choices made by children may be responsible for this (32). Dorchy and Bourguet (66) also report the difficulty in reducing total fat even with intense dietary education. In comparison other countries report low fat intakes in children with diabetes, (67-72). However even with low fat intakes the fatty acid composition of the diet may not be ideal. Pinelli et al. (67) reported the ideal profile, saturated fat 8%, monounsaturated fat 21% and polyunsaturated fat 4% of total energy. The study by Donaghue et al. (31) shows how a diet rich in monounsaturates changes the lipid profile, and cell membrane characteristics would appear to be important. Children in the general population in the UK have a very poor profile with high saturated fat levels of 14% (22), and studies in children with diabetes also reflect this pattern (68,69,71,72,73). The importance of saturated fat in relation to cholesterol and LDL as cardiovascular risk factors suggests nutrition education should focus not only on total fat but also on the fatty acid profile. Due to the eating style of the average UK child this may be difficult to achieve. It is helpful therefore to give parents practical advice on identifying those foods with a high saturated fat content and to suggest lower fat (and palatable) alternatives.

Careful evaluation of the efficacy of education programmes along with prospective, randomised controlled trials in relation to dietary modification and cardiovascular risks are urgently needed.

PRESERVE SOCIAL AND PSYCHOLOGICAL WELL-BEING Psychosocial Aspects of Meals and Food Intake

Food is often seen as the major issue for parents. The child has a great opportunity for aggravating and manipulating parents through food refusal. It is important that the family is encouraged to treat the child with diabetes and siblings the same from the first days after diagnosis. Virtanen et al. (74) have shown positive dietary changes can occur throughout the whole family due to the presence of a child with diabetes and therefore recommend that advice should be directed at the whole family from the beginning. Some parents will resist this because they do not want to deny siblings previous (often excessive)

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, communication 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 cooperation 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.

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

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.

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