Nutritional management in children and adolescents with diabetes (2009)

Nutritional management is one of the cornerstones of diabetes care and education. Different countries and regions have widely varying cultures and socio-economic status that influence and dominate dietary habits. Although there is strong evidence for nutritional requirements in young people the scientific evidence base for many aspects of diabetes dietary management is weak and often anecdotal. Thus, sensitivity to individual needs, and pragmatism rather than dogmatism are most helpful for effective dietary counseling. These consensus guidelines reflect national and international pediatric position/consensus statements (1, 2–5) and evidence derived from recommendations for adults with diabetes (6–8). Further research is required in many areas of pediatric diabetes management and education particularly in effective dietary interventions and long term outcomes. Dietary recommendations for children with diabetes are based on healthy eating recommendations suitable for all children and adults (E) (4, 7, 9) and therefore the whole family. Nutritional advice must be adapted to cultural, ethnic and family traditions and the psychosocial needs of the individual child. Likewise the choice of insulin regimen should take into account the dietary habits and lifestyle of the child. A specialist pediatric dietician with experience in childhood diabetes should be available as part of a pediatric interdisciplinary diabetes care team to provide education, monitoring and support to the child, parents, carers, extended family, nursery, school teachers, and babysitters (E). Regularity in meal times and routines where the child and family sit down and eat together, helping to establish better eating practices and monitoring of food intake has been shown to be associated with better glycemic outcomes (A,C) (9–13). Nutrition therapy, when used in combination with other components of diabetes care, can further improve clinical and metabolic outcomes (E) (5, 6). The dietician should advise on planning, content and the timing of snacks/meals in the context of each child's individual circumstances, lifestyle and the insulin action profiles. It is important that the whole family is involved in making appropriate changes based on healthy eating principles. The impact of diabetes on eating behavior must not be underestimated and may cause psychological disturbance. Therefore, dietary and lifestyle changes should be assisted by experienced professionals. Education should include behavior change approaches, motivational interviewing and/or counseling and should be regularly reviewed to meet the constantly changing needs and requirements of the developing child. In order to be most effective, the dietician needs to develop a consistent, trusting and supportive relationship with the families concerned (14–16) and also have clear agreed goals with the interdisciplinary team (17). Nutrition education and lifestyle counseling should be adapted to individual needs and delivered in a patient-centered manner. Education can be delivered both to the individual child and family and in small group settings (4, 5). These recommendations target healthy eating principles, optimum glycemic control, the reduction of cardiovascular risk factors, the maintenance of psychosocial well-being and family dynamics. Encourage appropriate eating behavior and healthy lifelong eating habits whilst preserving social, cultural and psychological well-being Three balanced meals a day, with appropriate healthy snacks (if necessary), will supply all essential nutrients, maintain a healthy weight, prevent bingeing and provides a framework for regular monitoring of blood glucose levels Provide sufficient and appropriate energy intake and nutrients for optimal growth, development and good health Achieve and maintain an appropriate Body Mass Index and waist circumference. This includes the strong recommendation for children and young people to undertake regular physical activity Achieve a balance between food intake, metabolic requirements, energy expenditure and insulin action profiles to attain optimum glycemic control Prevent and treat acute complications of diabetes such as hypoglycemia, hyperglycemic crises, illness and exercise-related problems Reduce the risk of micro- and macro-vascular complications Maintain and preserve quality of life Develop an enabling, trusting, empathic, supportive relationship to facilitate behavior change and consequent positive dietary modifications. At diagnosis, appetite and energy intake are often high to restore preceding catabolic weight loss. Energy intake should be reduced when appropriate weight is restored (E) (3). Regular monitoring by the team should assess appropriate weight gain. Energy intake varies greatly within subjects on a daily basis due to age, growth rate, energy expenditure and other important environmental factors such as the type and availability of food Energy intake should be sufficient to achieve optimal growth and maintain an ideal body weight Flexibility in the advice about the amount of food to meet varying energy needs (day by day and year by year) is necessary Dietary advice/meal planning should be revised regularly to meet changes in appetite and insulin regimens and to ensure optimal growth (1, 2) The insulin (amount and type) should be adapted where possible to the child's appetite and eating pattern. 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