Carmel Smart

Nutritional management in children and adolescents with diabetes

Carmel Smart, RDa, Ellen Aslander-van Vliet, RDb and Sheridan Waldron, RD, PhDc aSenior Paediatric Diabetes Dietician, John Hunter Children’s Hospital, Newcastle, New South Wales, Australia bPaediatric Diabetes Dietician, Voeding & zo/Diabeter, center for paediatric and adolescent diabetes care and research Rotterdam, The Netherlands cDiabetes Specialist Dietician, Dorset County Hospital, Dorchester, UK

Impact of Fat, Protein, and Glycemic Index on Postprandial Glucose Control in Type 1 Diabetes: Implications for Intensive Diabetes Management in the Continuous Glucose Monitoring Era

BACKGROUND Continuous glucose monitoring highlights the complexity of postprandial glucose patterns present in type 1 diabetes and points to the limitations of current approaches to mealtime insulin dosing based primarily on carbohydrate counting. METHODS A systematic review of all relevant biomedical databases, including MEDLINE, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, was conducted to identify research on the effects of dietary fat, protein, and glycemic index (GI) on acute postprandial glucose control in type 1 diabetes and prandial insulin dosing strategies for these dietary factors. RESULTS All studies examining the effect of fat (n = 7), protein (n = 7), and GI (n = 7) indicated that these dietary factors modify postprandial glycemia. Late postprandial hyperglycemia was the predominant effect of dietary fat; however, in some studies, glucose concentrations were reduced in the first 2–3 h, possibly due to delayed gastric emptying. Ten studies examining insulin bolus dose and delivery patterns required for high-fat and/or high-protein meals were identified. Because of methodological differences and limitations in experimental design, study findings were inconsistent regarding optimal bolus delivery pattern; however, the studies indicated that high-fat/protein meals require more insulin than lower-fat/protein meals with identical carbohydrate content. CONCLUSIONS These studies have important implications for clinical practice and patient education and point to the need for research focused on the development of new insulin dosing algorithms based on meal composition rather than on carbohydrate content alone.

Both Dietary Protein and Fat Increase Postprandial Glucose Excursions in Children With Type 1 Diabetes, and the Effect Is Additive

OBJECTIVE To determine the separate and combined effects of high-protein (HP) and high-fat (HF) meals, with the same carbohydrate content, on postprandial glycemia in children using intensive insulin therapy (IIT). RESEARCH DESIGN AND METHODS Thirty-three subjects aged 8–17 years were given 4 test breakfasts with the same carbohydrate amount but varying protein and fat quantities: low fat (LF)/low protein (LP), LF/HP, HF/LP, and HF/HP. LF and HF meals contained 4 g and 35 g fat. LP and HP meals contained 5 g and 40 g protein. An individually standardized insulin dose was given for each meal. Postprandial glycemia was assessed by 5-h continuous glucose monitoring. RESULTS Compared with the LF/LP meal, mean glucose excursions were greater from 180 min after the LF/HP meal (2.4 mmol/L [95% CI 1.1–3.7] vs. 0.5 mmol/L [−0.8 to 1.8]; P = 0.02) and from 210 min after the HF/LP meal (1.8 mmol/L [0.3–3.2] vs. −0.5 mmol/L [−1.9 to 0.8]; P = 0.01). The HF/HP meal resulted in higher glucose excursions from 180 min to 300 min (P < 0.04) compared with all other meals. There was a reduction in the risk of hypoglycemia after the HP meals (odds ratio 0.16 [95% CI 0.06–0.41]; P < 0.001). CONCLUSIONS Meals high in protein or fat increase glucose excursions in youth using IIT from 3 h to 5 h postmeal. Protein and fat have an additive impact on the delayed postprandial glycemic rise. Protein had a protective effect on the development of hypoglycemia.

Exercise management in type 1 diabetes: A consensus statement

Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week. Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals. However, several additional barriers to exercise can exist for a person with diabetes, including fear of hypoglycaemia, loss of glycaemic control, and inadequate knowledge around exercise management. This Review provides an up-to-date consensus on exercise management for individuals with type 1 diabetes who exercise regularly, including glucose targets for safe and effective exercise, and nutritional and insulin dose adjustments to protect against exercise-related glucose excursions.

Can children with Type 1 diabetes and their caregivers estimate the carbohydrate content of meals and snacks

Diabet. Med. 27, 348–353 (2010)

ISPAD Clinical Practice Consensus Guidelines 2014. Nutritional management in children and adolescents with diabetes.

Carmel E Smarta, Francesca Annanb, Luciana PC Brunoc, Laurie A Higginsd and Carlo L Acerinie aDepartment of Endocrinology, John Hunter Children’s Hospital, Newcastle, Australia; bDepartment of Nutrition and Dietetics, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK; cDepartment of Endocrinology, University Federal of Sao Paulo, Sao Paulo, Brazil; dPediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA and eDepartment of Paediatrics, University of Cambridge, Cambridge, UK

Children and adolescents on intensive insulin therapy maintain postprandial glycaemic control without precise carbohydrate counting

Aims  Carbohydrate (CHO) quantification is used to adjust pre‐meal insulin in intensive insulin regimens. However, the precision in CHO quantification required to maintain postprandial glycaemic control is unknown. We determined the effect of a ±10‐g variation in CHO amount, with an individually calculated insulin dose for 60 g CHO, on postprandial glycaemic control.

Nutritional management in childhood and adolescent diabetes

Voeding & zo/, Diabeter, Center for paediatric and adolescent diabetes care and research, Rotterdam, The Netherlands; Department of Endocrinology and Diabetes, John Hunter Children’s Hospital, Newcastle, New South Wales, Australia; and Dorset County Hospital, Dorchester, UK Corresponding author: Dr Sheridan Waldron, RD, PhD Diabetes Specialist Dietician Dietetic Dept. Dorset County Hospital Dorchester DT1 2JY UK. Tel: 144 1305 255788; fax: 144 1305 255380 e-mail: sheridan.waldron@btinternet.com

A randomized controlled trial of telephone calls to young patients with poorly controlled type 1 diabetes

Objective:  To determine if scheduled telephone calls from a pediatric diabetes educator to children who have type 1 diabetes improve hemoglobin A1c (HbA1c) level, hospital admissions, diabetes knowledge, compliance, and psychological well‐being.

Influence of and Optimal Insulin Therapy for a Low–Glycemic Index Meal in Children With Type 1 Diabetes Receiving Intensive Insulin Therapy

OBJECTIVE—The purpose of this study was to quantify the effects of glycemic index on postprandial glucose excursion (PPGE) in children with type 1 diabetes receiving multiple daily injections and to determine optimal insulin therapy for a low–glycemic index meal. RESEARCH DESIGN AND METHODS—Twenty subjects consumed test breakfasts with equal macronutrient contents on 4 consecutive days; high–and low–glycemic index meals (glycemic index 84 vs. 48) were consumed with preprandial ultra-short-acting insulin, and the low–glycemic index meal was also consumed with preprandial regular insulin and postprandial ultra-short-acting insulin. Each childs insulin dose was standardized. Continuous glucose monitoring was used. RESULTS—The PPGE was significantly lower for the low–glycemic index meal compared with the high–glycemic index meal at 30–180 min (P < 0.02) when preprandial ultra-short-acting insulin was administered. The maximum difference occurred at 60 min (4.2 mmol/l, P < 0.0001). Regular insulin produced a 1.1 mmol/l higher PPGE at 30 min compared with ultra-short-acting insulin (P = 0.015) when the low–glycemic index meal was consumed. Postprandial ultra-short-acting insulin produced a higher PPGE at 30 and 60 min compared with preprandial administration when the low–glycemic index meal was consumed. The maximum difference was 2.5 mmol/l at 60 min (P < 0.0001). CONCLUSIONS—Low–glycemic index meals produce a lower PPGE than high–glycemic index meals. Preprandial ultra-short-acting insulin is the optimal therapy for a low–glycemic index meal.