Nutritional management of children and adolescents with insulin-dependent diabetes mellitus.

1. All foods should be labeled to indicate the calories, sources of the calories, the mineral and vitamin content, the types and amounts of carbohydrates, the amount of cholesterol and amounts and types of fatty acids, and the amount and type of artificial sweetener, if any. 2. A long-term evaluation of the exchange system in the dietary instruction of patients with insulin-depedent diabetes mellitus and their families should be carried out. 3. General guidelines for meal plans for youngsters with diabetes should allow for flexibility and variety in food selection so that they account for individual differences as well as being applicable to different socio-economic, cultural, and ethnic groups. 4. The distribution of calories in the diet should be: 50% to 60% carbohydrate, 15% to 20% protein, and 20% to 25% fat. 5. Nutrition education of the patient with insulin-dependent diabetes mellitus and of the patient's family about the principles of good nutrition, the importance of a balanced meal plan, and the rationale for food prohibitions should be a critical part of diabetes care. 6. Nutritional assessment should include plotting height and weight measurements on standard growth grids at regular intervals. 7. Scientifically sound cross-over studies of the differences between "simple" and "complex" carbohydrates need to be carried out on children with insulin-dependent diabetes mellitus. 8. Before optimal and safe use of fiber in therapy of children is possible, further studies are needed of the convenience and palatability of meals with currently available fiber, the use of "medicated foods" to which specific types of fiber have been added, and the extent of trace element and mineral binding by various fibers. 9. More studies are needed concerning the effects of food form, nutrient-nutrient interactions, and non-nutritive constituents of food on the glycemic effect of a given food. 10. Fructose and sorbitol may be used in limited amounts as parts of an otherwise nutritious and well-balanced meal plan, but the usefulness of their chronic ingestion has not been established. 11. Fructose and sorbitol are not substitutes for artificial noncaloric sweeteners and should not be used in the belief that they are of use in weight control. 12. Aspartame contains no calories and has no apparent risks. However, consumption of large amounts of granulated aspartame, which contains a lactose or dextrose carrier, could affect blood glucose levels. The use of cyclamate and saccharin by children with insulin-dependent diabetes mellitus should be limited pending further review. 13. The use of combinations of artificial sweeteners is reasonable to limit the risks associated with any one sweetener. 14. The medical profession and patients with insulin-dependent diabetes mellitus should be made aware that the disease is a disorder of lipid metabolism as well as carbohydrate metabolism. 15. Cholesterol and saturated fat intake should be limited and the total calories from fat should be reduced to 20% to 25% of the caloric intake. 16. Patients with insulin-dependent diabetes mellitus should have at least yearly monitoring of their fasting serum total and high-density lipoprotein cholesterol levels and the triglyceride levels. 17. The patient with insulin-dependent diabetes mellitus should be taught that, in addition to control of the dietary lipid intake, limitation of the high rate of cardiovascular complications associated with insulin-dependent diabetes mellitus depends on excellent control of blood glucose levels, age-appropriate aerobic exercise, and avoidance of the use of tobacco in any form. 18. Blood pressure should be monitored every 6 to 12 months. It is critical that hypertension be diagnosed and treated early. 19. Young patients with insulin-dependent diabetes mellitus, and their families, should be educated in a prudent approach to the use of dietary salt, with little use of added salt and a choice of foods without excessive sodium content. However, supplemental sodium chloride may be warranted when there is glycosuria in a newly diagnosed or poorly controlled patient. 20. Insulin-dependent diabetes mellitus does not result in increased dietary requirements for iron, magnesium, zinc, selenium, chromium, or other trace minerals or vitamins and, therefore, should not be an indication per se for mineral or vitamin supplements. 21. Nutritionists and dietitians with expertise in the treatment of childhood and adolescent diabetes should be recognized as valuable members of a multidisciplinary diabetes health care team. The role of such a nutritionist or dietitian includes an initial assessment and then later adjustment of meal plans to be consistent with the patient's growth, development, changes in activity level, and appearance of complications. 22. Families should be advised to follow principles of good nutrition in their own meal planning as a way to increase dietary compliance by their children with insulin-dependent diabetes mellitus. Flexibility in meal plans should be encouraged as a way to maximize dietary compliance.