Caloric Intake

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Energy intake is generally episodic, varying in carbohydrate, protein, and fat intake from meal to meal and day to day. Daily caloric or energy requirement is determined by daily energy expenditure. This is represented by the sum of calories required to meet the needs for resting metabolic rate (RMR), the thermic effect of food (TEF), and the thermic effect of physical activity or exercise (TEE). Resting metabolic rate comprises 60-75% of daily caloric needs and is dependent on age, gender, body composition, and genetics. An approximate 2-3% drop in RMR occurs for every decade, accounting for the greater caloric needs per kilogram body weight in infants, children, and adolescents. Men have a higher RMR and require more calories than women because of their larger size and greater muscle mass. The TEF (i.e., the amount of calories required to absorb, metabolize, and store nutrients) is fairly stable at 10% of daily need. Physical activity, however, varies considerably from individual to individual and from day to day and can influence caloric needs in the range of 150-3000 kcal/d. A very active athletic 16-yr-old could require up to 6000 kcal each day, whereas his/her sedentary counterpart may need less than the recommended caloric level, which is based on light to moderate physical activity (see Table 2).

Estimating caloric requirements is not easy or precise, yet guidelines have been recommended based on WHO calculations and modified for US populations (see Table 2). These should be used only as guidelines and are subject to variability resulting from genetic and ethnic differences as well as concurrent medical conditions. The recommendations for adults, for example, are the same for all individuals over 51 yr of age despite the fact that a 51-yr-old is very different than an 85-yr-old, with or without a medical condition such as heart failure.

A dietary assessment to evaluate usual intake can be combined with the caloric recommendations to arrive at a personalized meal plan. The meal plan is then evaluated by monitoring desired outcomes in terms of blood sugar and lipid levels but also growth and body weight. Infants and small children may need specific caloric prescriptions to achieve normal growth and development, however, in general, most individuals with type 1 diabetes inherently adjust their food intake to meet energy needs. As a result, carbohydrate may be the only nutrient requiring modification and monitoring. For example, a carbohydrate-counting plan outlining specific carbohydrate goals may be accompanied by general guidelines for reducing SFA and consuming moderate amounts of protein.

The increasing incidence of obesity in children and adults in the United States, coupled with the definite tendency to experience weight gain with intensive glucose management, may require greater attention to caloric intake. An analysis of weight gain in DCCT subjects identified that, on average, adult subjects achieving a mean HbA1c of 7.2% gained 4.8 kg more during a 6-yr follow-up than their conventionally controlled counterparts (65). The rate of increase was greatest in the first year of intensive therapy and slowed thereafter and only age was consistently associated with major weight gain. Despite the benefits of improved glycemic control, care should be taken to reduce weight gain and maintain a healthy weight because the physical and health consequences of excessive weight gain remain to be quantified. Caloric requirements can be influenced by factors that are specific to stages in the life span of an individual (see Table 3), and although it is not known how these may be altered by diabetes, they should be considered when evaluating caloric needs.

Table 3

Specific Nutrition Considerations Through the Life Span

Concern

Infant

Low birth weight Children

Adolescents

Elderly

Support growth and development.

Requires approx 120 kcal/kg to continue intrauterine growth rate.

Finicky eating is natural but can be used to exert control over parents/caregivers.

• Recognize individual meals and single-day intake may not be balanced, but over several days, intake will balance.

• Provide items from major food groups at meals and snacks.

• Limit between-meal intake.

• Monitor eating away from home.

Use food to experiment, gain control, and establish themselves as individuals.

• Strict vegetarianism increases risk of poor quality and quantity of protein and inadequate calcium, iron, zinc, vitamin D, and B12.

• Obesity from overeating and underactivity.

• Girls peak caloric need at menarche (approx 12-yr-old).

• Boys peak caloric need during growth spurt until 16-yr-old.

Eating disorders if dissatisfied with body weight, fear of weight gain; leads to obsessive dieting and omitting insulin doses.

Dehydration risk increases accounting for 7% of hospitalizations.

• Increased need for water and liquids, particularly with hyperglycemia.

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