Pediatric, Adolescent, and Young-Adult Nutrition Issues in IDDM

Stuart J. Brink, MD Pediatric, Adolescent, and Young-Adult Nutrition Issues in IDDM Although insulin is life sustaining for patients with insulin-dependent diabetes mellitus (IDDM), the meal plan is of critical importance for avoiding hyperglycemia, preventing hypoglycemia, and maintaining metabolic balance. Consistency, timing, composition, and caloric content of food intake and physical activity, age, sex, growth, and pubertal status alter meal-plan needs. Self-monitoring of blood glucose should be used to individualize the meal plan. The general American Diabetes Association recommendations suggest that 5065% of total calories be from carbohydrates from foods with a lower glycemic index and/or high fiber content. Protein should contribute 12-20% of total calories and fat <30%, with <10% saturated fat and <300 mg/day cholesterol. More severe fat restriction should be considered in individuals with persistent lipid abnormalities when compared with sex- and ageadjusted values. Calories should be sufficient for growth and development, with growth data obtained several times a year and plotted on standardized weight, height, and velocity charts. Blood pressure should be similarly plotted on age- and sex-standardized curves. All meal plans should be individualized, but certain circumstances require special attention in IDDM patients: 1) lack of minerals or vitamins in a youngster who is a picky eater; 2) eating disorders (i.e., obesity, bulimia, anorexia nervosa); 3) specific gastrointestinal diseases (i.e., Crohn's disease, celiac disease, giardiasis, or IgA deficiency); 4) low iron stores because of associated achlorhydria and positive gastroparietal antibodies; 5) alternative sweeteners, especially in pregnant women and very young children; 6) mineral balance changes that may occur with increased soluble fiber intake and episodes of hyperglycemia with or without ketosis/ketoacidosis; 7) changes in physical From the New England Diabetes and Endocrinology Center, Chestnut Hill, Massachusetts. Address correspondence and reprint requests to Stuart J. Brink, MD, New England Diabetes and Endocrinology Center (NEDEC), 25 Boylston Street, Suite 211, Chestnut Hill, MA 02167. 192 activity that require nutritional counterbalancing; and 8) intensified insulin therapy (including multidose insulin and continuous subcutaneous insulin infusion) associated with more frequent hypoglycemia and increased risk of obesity—both conditions potentially amenable to appropriate nutrition counseling. Diabetes Care 11:192-200, 1988 N utrition considerations in the treatment of insulin-dependent diabetes mellitus (IDDM) are under review by many investigators and by organizations such as the American, British, and Canadian Diabetes Associations. Recommendations for dietary management in patients with IDDM are being reexamined to help improve compliance and ultimately to improve blood glucose control. Rollo (1) was perhaps the first to write about the difficulties of adherence to prescribed dietary restrictions. This is as true now as it was almost 200 years ago. Patients and their family members should be taught general principles of nutrition, including content of food expressed as carbohydrate, protein, or fat. Many are sufficiently interested and motivated to learn about source of fat (high or low cholesterol, saturated or unsaturated fats) as well as mineral (especially sodium), vitamin, and fiber content. Labeling of foods has become more commonplace as commercial vendors have learned of the interest of modern society in how food is processed and what calorie sources, sweeteners, and preservatives are used. Meal plan and exchange concept. In the preinsulin era, rigid restriction of carbohydrate was prescribed to reduce the acute symptoms of young patients. After insulin therapy was introduced in the 1920s and control of glycemia was partially achieved, less emphasis was DIABETES CARE, VOL. 11, NO. 2, FEBRUARY 1988 S.J. BRINK placed on acute symptomatology and more on providing overall nutritional adequacy (2-4). Since the introduction of the exchange concept 35 years ago, there have been few rigorous and well-constructed studies to assess the short- or long-term effectiveness of this approach or to compare the exchange system (5) with other ways of teaching nutrition management to patients with diabetes. A classic study by Knowles et al. (6) maintained that patients with IDDM fare as well on unmeasured diets as did comparable groups treated with a measured diet that allegedly followed the exchange routine. Before the current era of stringent criteria for diabetes control, Abraira et al. (7) reported that normalweight young adults spontaneously regulate their intake to maintain constant weight regardless of precise degree of glycemic control or insulin dosage. Food cognition. Analysis of thought concerning food and eating must consider a developmental approach to utilizing the exchange concepts for teaching patients about meal planning. Piaget and Inhelder (8,9) proposed that younger children lack the ability to use causal reasoning but progress to concrete operational thought and formal thought as they develop the use of logical reasoning. In an elegant study by Contento (10), conceptualizations of foods, snacks, and nutrients were analyzed in children. Cognitive developmental theory was able to predict and explain difficulties that young people had understanding what happens to food as it is eaten, digested, and used by the body. Even though the children who participated in this study, who did not have diabetes, preferred less nutritious snacks, some showed conflict in making decisions about which type of snack to eat. Candy, snack foods, and ice cream were often thought not to be "foods" because they were perceived as "not for routine use at the dinner table." Nutrition education should, therefore, include information and experiences that help distinguish between which foods and snacks to eat and which to avoid. Development of curricula about food groupings for patients with diabetes need not rely only on fancy computer graphics but rather may require more specific input from developmental psychologists and teachers who understand the differences in the child's thought processes as well as the peer pressures of the older child and adolescent. Meal plans. Physicians, dietitians, and nurses responsible for the care of children with diabetes have adopted their own approach to use of the exchange concept. For example, Jackson (2) recommended a gradual approach in which the parents and/or children are taught about high-quality common foods in the initial session and about one or two substitutions from each group in subsequent sessions. Gradually, the patient and family are familiarized with the entire exchange concept at a rate compatible with the educational capacity of the youngster and his/her family members. Brink (11-13) emphasizes parent-supervised age-appropriate limit setting co (...truncated)