Sanjeev N. Mehta

Impact of Carbohydrate Counting on Glycemic Control in Children With Type 1 Diabetes

OBJECTIVE To study the association between parent carbohydrate counting knowledge and glycemic control in youth with type 1 diabetes. RESEARCH DESIGN AND METHODS We assessed 67 youth ages 4–12 years with type 1 diabetes (duration ≥1 year). Parents estimated carbohydrate content of childrens meals in diet recalls. Ratios of parent estimates to computer analysis defined carbohydrate counting knowledge; the mean and SD of these ratios defined accuracy and precision, respectively. A1C defined glycemic control. RESULTS Greater accuracy and precision were associated with lower A1C in bivariate analyses (P < 0.05). In a multivariate analysis (R2= 0.25, P = 0.007) adjusting for child age, sex, and type 1 diabetes duration, precision (P = 0.02) and more frequent blood glucose monitoring (P = 0.04), but not accuracy (P = 0.9), were associated with lower A1C. A1C was 0.8% lower (95% CI −0.1 to −1.4) among youth whose parents demonstrated precision. CONCLUSIONS Precision with carbohydrate counting and increased blood glucose monitoring were associated with lower A1C in children with type 1 diabetes.

Emphasis on Carbohydrates May Negatively Influence Dietary Patterns in Youth With Type 1 Diabetes

OBJECTIVE To assess perceptions of healthful eating and the influence of diabetes management on dietary behaviors among youth with type 1 diabetes and parents. RESEARCH DESIGN AND METHODS Youth with type 1 diabetes (n = 35), ages 8–21 years, and parents participated in focus groups. Focus group recordings were transcribed and coded into themes. Clinical data were abstracted from the electronic medical record. RESULTS Central topics were perceptions of healthful eating and the impact of diabetes management on diet. An emphasis on limiting postprandial glycemic excursions occasionally contradicted the traditional perception of healthful eating, which emphasized consumption of nutrient-dense whole foods in favor of prepackaged choices. Whereas fixed regimens required more rigid diets, basal-bolus regimens provided more opportunities for unhealthful eating. Most youth perceived “refined” grains as more healthful grains. CONCLUSIONS For youth with type 1 diabetes and parents, an emphasis on carbohydrate quantity over quality may distort beliefs and behaviors regarding healthful eating.

Dietary Behaviors Predict Glycemic Control in Youth With Type 1 Diabetes

OBJECTIVE—To investigate the association between dietary adherence and glycemic control among youth with type 1 diabetes. RESEARCH DESIGN AND METHODS—We conducted a cross-sectional analysis of 119 youth aged 9–14 years (mean ± SD 12.1 ± 1.6 years) with diabetes duration ≥1 year (5.4 ± 3.1 years). Dietary adherence was assessed using the Diabetes Self-Management Profile diet domain. Higher score defined greater dietary adherence. Glycemic control was determined by A1C. RESULTS—Dietary adherence score was inversely correlated with A1C (r = −0.36, P < 0.0001). In a multivariate model (R2 = 0.34, P < 0.0001), dietary adherence (P = 0.004), pump use (P = 0.03), and caregiver education (P = 0.01) were associated with A1C. A1C of youth in the lowest (9.0%) tertile of diet score was higher than A1C of youth in the middle (8.1%, P = 0.004) and upper (8.4%, P = 0.06) tertiles. Dietary adherence uniquely explained 8% of the variance in A1C in the model. CONCLUSIONS—Greater dietary adherence was associated with lower A1C among youth with type 1 diabetes.

Contemporary Management of Patients with Type 1 Diabetes

The current standard of care for patients with type 1 diabetes (T1D) employs a system of intensive diabetes management aimed at near-normal glycemia, which reduces the risk of micro- and macrovascular complications. Optimal management is an ongoing process based on a patient-centered collaboration with a primary care clinician and a multidisciplinary diabetes team that provides diabetes management, including education and psychosocial support. Intensive diabetes therapy attempts to mimic physiologic insulin replacement. Over the past 15 years, there has been widespread use of multiple-dose insulin regimens using a variety of insulin analogs, administered either by injection or insulin pump therapy, together with medical nutrition therapy, frequent self-monitoring of blood glucose and, more recently, continuous logo glucose monitoring. It is now possible to achieve previously unattainable levels of glycemic control with less risk of severe hypoglycemia, and yet only a minority of patients achieves target hemoglobin A1c values. This review discusses contemporary management of T1D with a focus on health outcomes.

Disordered Eating Behaviors Are Associated with Poorer Diet Quality in Adolescents with Type 1 Diabetes

Disordered eating behaviors may pose a risk for poor long-term health outcomes in patients with type 1 diabetes. This cross-sectional study examined associations of disordered eating behaviors with diet quality, diet-related attitudes, and diabetes management in adolescents with type 1 diabetes (N=151, 48% female). Participants, recruited July 2008 through February 2009, completed 3-day diet records and survey measures, including the Diabetes Eating Problem Survey (DEPS) and measures of eating-related attitudes. Biomedical data were obtained from medical records. Participants scoring more than 1 standard deviation above the mean DEPS were classified as at risk for disordered eating. The Healthy Eating Index-2005 was calculated to assess diet quality. Analysis of covariance was used to test for differences between risk groups in diet quality, eating attitudes, and diabetes management, controlling for age, sex, and body mass index (BMI) percentile. Youth at risk for disordered eating were more likely to be overweight/obese than those at low risk (59.1% vs 31.8%, P=0.01). The at-risk group had poorer diet quality (P=0.003) as well as higher intake of total fat (P=0.01) and saturated fat (P=0.007) compared with the low-risk group. The at-risk group reported lower self-efficacy (P=0.005), greater barriers (P<0.001), and more negative outcome expectations (P<0.001) for healthful eating, as well as worse dietary satisfaction (P=0.004). The at-risk group had lower diabetes adherence (P<0.01), less-frequent blood glucose monitoring (P<0.002), and higher hemoglobin A1c (P<0.001). The constellation of excess weight, poorer dietary intake, and poorer diabetes management associated with youth at risk for disordered eating suggests potential risk of future poor health outcomes. Attention should be given to healthful weight management, especially among overweight youth with type 1 diabetes.

Approach to management of malignant hyperthermia-like syndrome in pediatric diabetes mellitus.

Background: Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is usually associated with type 2 diabetes mellitus and is rare in children. However, a fatal malignant hyperthermia-like syndrome (MHLS) with rhabdomyolysis associated with new-onset diabetes mellitus and HHNS in adolescents has been described. Design/Methods: Case series. Results: A 16-yr-old obese male (case A) and a 10-yr-old mid-pubertal nonobese female (case B) presented within a 6-month period with emesis, altered mental status, blood glucose >1600 mg/dL, and laboratory evidence of rhabdomyolysis. Case A developed fever after initiation of insulin therapy, along with refractory hypotension and multiorgan failure. He died 14 hrs after admission. Case B developed fever before insulin therapy, was treated with dantrolene, and made a full recovery. Metabolic workup showed evidence of short-chain acyl-CoA dehydrogenase (SCAD) deficiency. Conclusions: We report two cases of malignant hyperthermia-like syndrome associated with HHNS in adolescents. Their respective fluid management and clinical courses are described. Dantrolene therapy should be initiated immediately after this syndrome is recognized. We believe it is unlikely insulin is the sole trigger for MHLS. Case B is unique in that there was evidence of SCAD deficiency, a metabolic defect that we propose could lead to MHLS. We recommend that all patients with HHNS and MHLS be evaluated for an underlying metabolic disorder.

Associations of nutrient intake with glycemic control in youth with type 1 diabetes: differences by insulin regimen.

BACKGROUND Type 1 diabetes management has evolved from meal plans towards flexible eating with carbohydrate counting. With this shift, youth with type 1 diabetes may consume excess fat and insufficient fiber, which may impact glycemic control. Few studies consider whether insulin regimen influences associations between dietary intake and hemoglobin A1c. PATIENTS AND METHODS In this cross-sectional study, 252 youth (52% male; age, 13.2 ± 2.8 years; body mass index z-score [z-BMI], 0.7 ± 0.8) with type 1 diabetes completed 3-day food records. Dietary intake was compared with published guidelines. Logistic regression predicted the odds of suboptimal glycemic control (an A1c level of ≥ 8.5%) related to fat and protein intake or fiber intake according to insulin regimen (pump vs. injection) adjusting for age, sex, diabetes duration, z-BMI, insulin dose, glucose monitoring frequency, and total energy intake (TEI). RESULTS Youth had a mean TEI of 40.9 ± 15.4 kcal/kg/day and excess fat and insufficient fiber intake compared against published guidelines. Pump-treated youth consuming the highest quartile of fat intake (as percentage TEI) had 3.6 (95% confidence interval, 1.3-9.7) times the odds of a suboptimal A1c than those in the lowest quartile. No such association was found in injection-treated youth. In the total sample, youth with the lowest quartile of fiber intake had 3.6 (95% confidence interval, 1.4-9.0) times the odds of a suboptimal A1c, but this association did not differ by insulin regimen. There was no association between protein intake and A1c. CONCLUSIONS Higher fat intake in pump-treated youth and lower fiber intake in all youth were associated with an A1c level of ≥ 8.5%. Improving dietary quality may help improve A1c.

Perceived Benefits, Barriers, and Strategies of Family Meals among Children with Type 1 Diabetes Mellitus and Their Parents: Focus- Group Findings

Dietary management of type 1 diabetes mellitus has become much less restrictive and more flexible in recent years due to contemporary insulin regimens, which may afford families of children with type 1 diabetes mellitus greater ease in sharing family meals. Although these treatment advancements might facilitate family meals, overall demands of diabetes management can influence familys perceived or actual ability to do so. Youths with type 1 diabetes mellitus (ages 8 to 20 years) and parents participated in separate focus groups. Thirty-five youths with type 1 diabetes mellitus (mean age=15.1+/-3.6 years) and their parents participated in 21 focus groups (12 youth groups, nine parent groups). Although there was substantial variability in how often family meals occurred, both parents and youths consistently perceived family meals as valuable and enjoyable. The major barrier to family meals discussed by both youths and parents was busy schedules. Strategies for having family meals that were discussed by parents included shopping to ensure availability of the foods needed to prepare meals, planning, and cooking meals in advance, and using simplified cooking methods. These findings suggest that a family-focused approach to nutrition interventions in this population, as opposed to one targeting the child with diabetes only, can improve the chance for successful dietary change.

Small pituitary size in children with Fanconi anemia.

Fanconi anemia (FA) is a genetic disorder associated with multiple congenital anomalies, bone marrow failure, and pituitary hypofunction including hypogonadism, thyroid dysfunction, and growth hormone (GH) deficiency.

Development and Validation of the Type 1 Diabetes Nutrition Knowledge Survey

OBJECTIVE The purpose of this study was to develop a survey of general and diabetes-specific nutrition knowledge for youth with type 1 diabetes and their parents and to assess the survey’s psychometric properties. RESEARCH DESIGN AND METHODS A multidisciplinary pediatric team developed the Nutrition Knowledge Survey (NKS) and administered it to youth with type 1 diabetes (n = 282, 49% females, 13.3 ± 2.9 years) and their parents (82% mothers). The NKS content domains included healthful eating, carbohydrate counting, blood glucose response to foods, and nutrition label reading. Higher NKS scores reflect greater nutrition knowledge (score range is 0–100%). In youths, glycemic control was assessed by A1C, and dietary quality was determined by the Healthy Eating Index-2005 (HEI-2005) derived from 3-day diet records. Validity was based on associations of NKS scores with A1C and dietary quality. Reliability was assessed using the Kuder-Richardson Formula 20 (KR-20) and correlations of domain scores to total score. RESULTS Mean NKS scores (23 items) were 56.9 ± 16.4% for youth and 73.4 ± 12.5% for parents. The KR-20 was 0.70 for youth and 0.59 for parents, representing acceptable internal consistency of the measure. In multivariate analysis, controlling for youth age, family income, parent education, diabetes duration, and insulin regimen, parent NKS scores were associated with corresponding youth A1C (β = −0.13, P = 0.03). Both parent (β = 0.20, P = 0.002) and youth (β = 0.25, P < 0.001) NKS scores were positively associated with youth HEI-2005 scores. CONCLUSIONS The NKS appears to be a useful measure of general and diabetes-specific nutrition knowledge for youth with type 1 diabetes and their parents.