Current Issues in the Dietary Management of Children and Adolescents with Type 1 Diabetes Using Intensive Insulin therapy

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Article
Current issues in the dietary management
of children and young people with type 1
diabetes using intensive insulin therapy
Carmel Smart, Prudence Lopez and Bruce King
Citation: Smart C, Lopez P, King
B (2012) Current issues in the
dietary management of children
and young people with type 1
diabetes using intensive insulin
therapy. Diabetes Care for
Children & Young People 1: XXX
Article points
1. Nutrition management is
one of the most fundamental
elements of care and education
for children and young people
with type 1 diabetes.
2. Regular supportive contact
from dietitians is required to
increase dietary knowledge
and adherence.
3. The authors conclude that
randomised controlled trials of
methods to manage postprandial
glycaemia after meals high in
fat and protein are needed,
as well as evaluation of their
acceptability to the families
of those with diabetes.
Key words
- Carbohydrate counting
- Dietary management
- Intensive insulin therapy
- Protein and fat
- Type 1 diabetes
Authors
Carmel Smart, Paediatric Diabetes
Dietitian; Prudence Lopez,
Endocrinology Fellow; Bruce King,
Paediatric Endocrinologist, John
Hunter Childrens Hospital, Hunter
Medical Research Institute, The
University of Newcastle, Australia.
Nutritional management is an important aspect of care for children and young
people with type 1 diabetes using intensive insulin regimens. Research suggests that
medical nutrition therapy should focus on interventions to ensure normal growth and
development, promote lifelong healthy eating habits and maintain glycaemic control,
as well as assisting with prevention of the complications associated with diabetes.
In this article, the authors review the current evidence and issues regarding dietary
management in children with type 1 diabetes using multiple daily injections and
insulin pump therapy, and the future work needed.
The importance of glycaemic control
in preventing the development of
complications in type 1 diabetes was
demonstrated in the Diabetes Control and
Complications Trial (DCCT group, 1993). A key
component of diabetes care is effective nutritional
management (Delahanty et al, 1993). Whilst
optimising glycaemic control is an important
objective of medical nutrition therapy, a major goal
in children is to establish lifelong healthy eating
habits to ensure optimal nutrition for growth and
development and to prevent diabetes complications
(Smart et al, 2009a). It is vital that healthy eating
principles, based on recommendations for all
children and young people, targeting increased
consumption of fruit and vegetables and decreased
saturated fat intake, underlie all education (Rovner
and Nansel, 2009).
Since the late 1990s, intensive insulin regimens
have been utilised in paediatric centres worldwide.
However, gaps remain in the evidence regarding the
dietary management of childhood diabetes using
intensive insulin therapy (IIT).
Carbohydrate amount and type
The International Society for Paediatric and Adolescent
Diabetes (ISPAD) Clinical Practice Consensus
Guidelines recommend that carbohydrate should
account for 50–55% of total daily energy intake
(Smart et al, 2009a). Carbohydrate intake should not
be restricted as it is essential for growth. A key aspect
of nutrition therapy is monitoring carbohydrate
distribution, amount and type in order to balance
carbohydrate intake and insulin action (Sheard et
al, 2004; Wheeler and Pi-Sunyer, 2008). In regard
to IIT, adjusting prandial insulin doses to match
carbohydrate consumption results in more flexible
dietary intakes, whereas consistency in day-to-day
carbohydrate intake remains important for those
on conventional therapy (Wolever et al, 1999). See
Table 1 for recommendations on carbohydrate intake
for different insulin regimens.
Carbohydrate amount
The carbohydrate content of a meal is the main
factor resulting in a rise in postprandial blood glucose
level (ADA, 2004). Increasing carbohydrate content
XXXDiabetes Care for Children & Young People Volume 1 No 2 2012

Current issues in the dietary management of children and young people with type 1 diabetes using intensive insulin therapy
Diabetes Care for Children & Young People Volume 1 No 2 2012
has been shown to linearly increase postprandial
glucose (Halfon et al, 1989). Another study showed
that in adults with well-controlled type 1 diabetes
using multiple daily injections (MDI), changing the
amount of carbohydrate in the diet did not affect
glycaemic control, provided that the level of insulin
is appropriately adjusted (Rabasa-Lhoret et al, 1999).
For children and young people using MDI,
programmes have been developed to utilise
carbohydrate counting and insulin:carbohydrate
ratios (Waller et al, 2008; Anderson, 2009).
In adults, data from the Dose Adjustment for
Normal Eating (DAFNE) study showed that using
insulin:carbohydrate ratios as an integral component
of the intensive self-management program was
associated with improved glycaemic outcomes
(DAFNE Study Group, 2002). Insulin:carbohydrate
ratios are an important tool in IIT to optimise prandial
insulin dosing and allow greater meal flexibility.
However, further randomised studies are needed to
support the findings of improvements in the glycaemic
control and quality of life in children.
Despite universal acceptance of the importance
of managing carbohydrate intake in type 1 diabetes,
the best method of carbohydrate quantification has
been debated. There are three methods available
for quantifying the carbohydrate content of meals:
estimation in exchanges (typically 15 g); estimation
in portions (10 g); and “precise” carbohydrate
counting to grams. Those that advocate carbohydrate
counting to grams believe that this method increases
the accuracy of carbohydrate estimations, allowing
more exact calculations of the prandial insulin dose
(Walsh and Roberts, 2006). However, research has
shown that counting carbohydrates in 1 g increments
does not achieve greater accuracy in carbohydrate
estimations than quantifying in 10 g portions or 15 g
exchanges (Smart et al, 2010).
A study comparing children, young people, and
their care-givers, who used one of the three different
methods of carbohydrate quantification, demonstrated
that the accuracy in carbohydrate estimations was
similar between all groups and that 73% of estimates
were within a 15 g error margin, irrespective of
which method of carbohydrate counting was used
(Smart et al, 2010). Furthermore, as meal size
increased, the accuracy of carbohydrate estimation
decreased, with a trend towards greater inaccuracies
in those counting in gram increments. Additionally,
the study found that children who had been counting
carbohydrate for a longer period of time were less
accurate, highlighting the importance of providing
regular carbohydrate counting updates as children
grow and meal sizes change. Interestingly, in another
study of young people with type 1 diabetes who
were counting carbohydrate in grams, Bishop and
XXX
Table 1. Recommendations for carbohydrate intake for different insulin regimens.
Insulin regimen Meal structure and nutrition considerations
Twice-daily fixed insulin doses Day-to-day consistency in carbohydrate intake
to balance insulin action profiles and to prevent
hypoglycaemia. This is usually achieved by advice
to include three meals and three snacks per day
containing approximately the same amount of
carbohydrate on a daily basis at each meal and
snack. A consistent intake of carbohydrate is
usually encouraged using serves or exchange lists of
measured food quantities.
Prescription of carbohydrate requires regular dietetic
review to ensure total energy needs are met in the
growing child.
Flexible multiple daily
injections
(≥ 4 injections/day) using
rapid-acting insulin pre-meals
and long-acting insulin as basal
dose
Advice to match the meal-time insulin dose to
carbohydrate intake by the use of an individualised
insulin:carbohydrate ratio should be considered.
This allows greater flexibility in meal timing and
carbohydrate intake.
An additional injection may be required
for snacks consisting of larger amounts of
carbohydrate. However, advice regarding the quantity
of carbohydrate that requires additional insulin at a
snack time varies.
Comprehensive education regarding carbohydrate
counting is required for insulin dose adjustment.
Insulin pump therapy using
a continuous subcutaneous
infusion of basal insulin, with
bolus doses given to match the
carbohydrate quantity eaten.
An individualised insulin to carbohydrate ratio
should be used to enable the insulin dose to be
matched to carbohydrate intake at all meals and
snacks.
Matching insulin to carbohydrate requires
comprehensive education in carbohydrate counting.
The bolus type can be adjusted to match meal
composition.
Missed meal boluses are an important contributor
to poor glycaemic outcome.
Note: Individualised advice regarding carbohydrate amount and distribution should consider
the usual appetite, food-intake patterns, exercise and energy requirements of the child or
young person with diabetes.

Current issues in the dietary management of children and young people with type 1 diabetes using intensive insulin therapy
colleagues reported that only 23% of participants were
able to estimate daily carbohydrate within 10 g of the
true amount (Bishop et al, 2009).
This raises the question of how accurate
people with diabetes and families need to be in
estimating meal carbohydrate content. In children
with type 1 diabetes, a 10 g inaccuracy in the
estimation of the meal carbohydrate content was
not found to affect postprandial glycaemia, whereas
a 20 g overestimate resulted in 31% of children
experiencing hypoglycaemia 2–3 hours after the
meal (Smart et al, 2009b; 2012). Therefore, in order
to accurately count carbohydrate intake to maintain
glycaemic control, carbohydrate estimations should be
within 10 g of the meal carbohydrate content.
It is commonly believed that the nutrition
information panel on food labels facilitates accuracy
in carbohydrate counting in gram increments.
However, a variation of up to 45% between the
carbohydrate content reported on the label and the
actual carbohydrate content of the product has
been shown (Smart et al, 2011), in accordance with
national food standards (Food Standards Australia
New Zealand, 2012). This questions the feasibility
of instructing families to count carbohydrate by
1g increments when food labels are not as accurate.
Furthermore, an emphasis on carbohydrate amount,
without consideration of dietary quality, may lead
to increased consumption of packaged food and
unhealthy eating practices (Mehta et al, 2009).
In summary, these studies suggest that the focus
of carbohydrate counting interventions should not
be an attempt to assist individuals to count accurately
to the last gram, but rather ensuring accuracy in
estimations of unlabelled foods, whilst promoting
variety in healthy food choices.
Glycaemic index (GI)
The GI was defined in 1981 by Jenkins et al and
ranks carbohydrate-containing foods based on their
ability to raise blood glucose levels for a standardised
amount of carbohydrate (Jenkins et al, 1981). The
GI values of many foods have now been published
(Brand-Miller et al, 2009). Whilst the importance
of GI in the management of type 1 diabetes in
children has been a subject of much debate, studies
have suggested a benefit for low-GI diets (Gilbertson
et al, 2001; Nansel et al, 2008). Ryan and colleagues
demonstrated that, in children using MDI, when
a low-GI meal was eaten rather than a high-GI
meal, the postprandial blood glucose excursion was
significantly lower at 30–180 minutes (Ryan et al,
2008). However, it is important that GI is not taught
in isolation as monitoring carbohydrate amount is a
key strategy in intensive therapy (ADA, 2004).
Protein and fat
Protein and fat influence postprandial glycaemia in
people with type 1 diabetes (Lodefalk et al, 2008;
Peters and Davidson, 1993). The addition of large
amounts of protein (>50 g) to meals consumed by
adults with type 1 diabetes increased postprandial
glucose levels at 150–300 minutes (Peters and
Davidson, 1993).
Fat results in a delay in gastric emptying and, as a
consequence, delays the peak glucose response and
reduces the postprandial glucose excursion in children
using ITT (Lodefalk et al, 2008).
In pump therapy, the meal-time insulin dose is
typically calculated based on the carbohydrate content
of the meal. More recently, studies have also advocated
the calculation of fat and protein units in order
to cover the postprandial excursions attributed
to high fat and protein meals (Pankowska et al,
2009; 2012). However a recent clinical study using
this algorithm reported hypoglycaemia in 35% of
children (Kordonouri et al, 2012). The question still
remains as to whether there is sufficient evidence to
justify calculating fat and protein units, and whether
families are able to implement it. Further studies are
needed to provide evidence-based recommendations
to optimise postprandial glycaemia when meals
higher in fat and protein content are consumed.
Insulin bolusing for meals
For people using an MDI regimen, studies suggest
that the delivery of insulin prior to meals results
in improved postprandial glycaemia (Strachan and
Fryer, 1998; Jovanovic et al, 2004; Ryan et al, 2008).
Ryan and colleagues reported that, for low-GI meals,
the administration of preprandial insulin resulted in
significantly lower postprandial glucose excursions,
without leading to an increase in hypoglycaemia
(Ryan et al, 2008). Evidence also points to a benefit
of preprandial bolus administration in pump therapy
(Cobry et al, 2010; Scaramuzza et al, 2010; De
Palma et al, 2011). Recent studies suggest that to
diminish postprandial excursions, optimal timing
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Diabetes Care for Children & Young People Volume 1 No 2 2012
Page points
1. A variation of up to 45%
has been observed between
the carbohydrate content
reported on the food label
and the actual carbohydrate
content of the product.
2. Though the importance
of the glycaemic index in
the management of type 1
diabetes in children has been
a subject of much debate,
studies have suggested a
benefit for low-GI diets.
3. Further evidence is needed
to justify the calculation of
the fat and protein content
of meals, and to ascertain
whether families are able to
implement them in daily life.

Current issues in the dietary management of children and young people with type 1 diabetes using intensive insulin therapy
Diabetes Care for Children & Young People Volume 1 No 2 2012
of the meal bolus may be 20 minutes prior, rather
than immediately before, the meal (Cobry, 2010;
De Palma et al, 2011). Further studies are needed
to determine how this recommendation can be
efficaciously implemented in daily clinical practice
with children.
Missed meal boluses have been identified as a
major cause of suboptimal glycaemic control in
young people using insulin pumps (Burdick et al,
2004). Postprandial bolusing, denial of diabetes
or fear of postprandial hypoglycaemia have been
identified as possible contributors to missed mealtime
boluses (Olinder et al, 2011). Therefore, it is advisable
to recommend that boluses are given before the meal.
Care-givers should be reassured that children are
not at risk of hypoglycaemia if they refuse to eat
immediately after insulin delivery. Furthermore, if
the child eats less carbohydrate than the amount the
insulin dose was calculated for, the care-giver can
be reassured that they have time to give the extra
carbohydrate, as hypoglycaemia for over-estimations
in meal carbohydrate quantity is unlikely to occur
until 2–3 hours after the meal (Smart et al, 2012).
An advantage of insulin pump therapy is the
ability to tailor prandial insulin delivery to meal
composition. In clinical practice, alterations to the
insulin bolus distribution are often recommended
for meals high in fat and protein (Chase et al, 2002;
Jones, 2005). Studies of pizza meals, known to cause
prolonged hyperglycaemia, have had conflicting
results. Jones and colleagues found that a dual-wave
bolus resulted in significantly lower blood glucose
levels in the late postprandial period without causing
hypoglycaemia (Jones, 2005). Conversely, De Palma et
al found that, using a lower-fat pizza meal, the 6-hour
blood glucose area under the curve was lower following
a standard bolus delivered 15 minutes preprandially
than the dual-wave bolus (De Palma et al, 2011)
The dual-wave bolus has also been shown to provide
effective control of blood glucose levels for up to
6 hours following meals high in carbohydrate and
fat (Chase et al, 2002; Lee et al, 2004). Furthermore,
a dual-wave bolus prior to a low-GI meal significantly
reduced the postprandial glucose excursion (O’Connell
et al, 2008).
In summary, whilst there is increasing evidence
that meal composition is an important factor in
determining the most effective means of insulin
dosing, there is yet to be consensus on the
management of meals of varying macronutrient
content. The extended bolus is a beneficial option for
insulin distribution in children using pump therapy
with multiple studies finding positive effects. However,
the calculation of the optimal insulin dose for different
meal types remains to be elucidated, as current
algorithms may increase the risk of postprandial
hypoglycaemia.
Dietary behaviours
The key dietary behaviours that have been associated
with improved glycaemic outcomes are adherence to
an individualised meal plan, particularly carbohydrate
intake recommendations (Delahanty, 1993; Patton et
al, 2007; Mehta et al, 2008); avoidance of frequent
snacking episodes or large snacks without adequate
insulin coverage (Delahanty, 1993; Øverby et al,
2007); regular meals and avoidance of skipping
meals, particularly breakfast (Øverby et al, 2007);
and avoidance of over-treatment of hypoglycaemia
(Delahanty, 1993).
Medical nutrition therapy should be provided
upon diagnosis and at regular intervals thereafter,
to meet changes in appetite, insulin regimens
and activity. Nutrition therapy should be directed
towards the whole family, with opportunities such
as family meals used to reinforce healthy eating and
carbohydrate-counting education. Education should
be individualised and part of a self-management
program that is age-appropriate, so that as children
grow and are exposed to new situations regarding
food, advice is tailored and targeted.
In conclusion, nutrition management is one
of the most fundamental elements of care and
education for children with type 1 diabetes. Regular
supportive contacts from dietetic health professionals
are required to increase dietary knowledge and
adherence. Randomised controlled trials of methods
to manage postprandial glycaemia after meals high
in fat and protein are needed, as well as evaluation of
their acceptability to the families of the children and
young people with diabetes. n
Ander son DG (2009) Multiple daily inject ions in young patients
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XXX
Page points
1. The key dietary behaviours
associated with improved
glycaemic outcomes include:
adherence to an individualised
meal plan; avoidance of
frequent snacking episodes or
large snacks without adequate
insulin coverage; regular meals
and avoidance of skipping
meals; and avoidance of over-
treatment of hypoglycaemia.
2. Medical nutrition therapy
should be provided for children
and young people with
diabetes upon diagnosis and
at regular intervals thereafter.
3. Randomised controlled trials of
methods to manage postprandial
glycaemia after high-fat and
high-protein meals are needed.

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Diabetes Care for Children & Young People Volume 1 No 2 2012
“Nutrition therapy
should be directed
towards the
whole family, with
opportunities such as
family meals used to
reinforce healthy eating
and carbohydrate-
counting education.”