THE ROLE OF DIET IN CHILDREN WITH INSULIN-DEPENDENT DIABETES MELLITUS

OBJECTIF NUTRITION 76 (JUNE 2005)
by Professor Jean-Jacques Robert, Hôpital Necker-Enfants Malades (AP-HP, Paris.)

Diet is an essential component in the treatment of children with diabetes mellitus, who must first have a balanced diet, like the rest of the family.  However, the young diabetic must pay particular attention to the timing of meals and insulin injections. What is the most difficult is finding a balance between insulin, diet, and physical activity. Nutritional education and management of children with diabetes both rely on a multidisciplinary hospital team, and on a network of involved participants: family, associations, and attending physicians.

Diet for children with insulin-dependent diabetes mellitus (IDD or type I diabetes mellitus) is based on a few simple rules:

Based on these few simple rules, the primary objectives for the management of diabetic children can be determined.

A Balanced Diet, for the Whole Family

Children with diabetes must have a balanced diet, just like everyone else. This diet is recommended for the rest of the family: it should not be necessary to make separate meals. Meetings with the dietician will help to evaluate the family’s eating habits. If the eating habits are good, there will not be much to change; if there are dietary mistakes (table 1), then this is a chance to correct them. The rest of the family must participate in this change, so that the young diabetic does not feel isolated. Parents must be convinced that children are able to learn different eating habits, without seeing it as an inconvenience or a punishment.

Carbohydrate-rich foods, the basis of our diet, should provide more than half of the body’s energy needs. Eating enough carbohydrates (250-300 grams per day) does not mean eating just any carbohydrates:

Fats (lipids) should account for 30% of caloric intake. They are often consumed in excess. In order to reduce fat intake, it is recommended to:

Fat intake is best balanced by varying the sources of dietary fats, and by choosing essential poly- and mono-unsaturated fats, or foods rich in vitamins (A, D, E).

Proteins should not account for more than 15% of caloric intake, especially since many high-protein foods contain high quantities of fats. Furthermore, excessive protein intake appears to promote the development of nephropathy.

TABLE 1: THE MOST FREQUENT DIETARY MISTAKES, FOR CHILDREN AND THEIR FAMILIES.
   

Recommendations for Young People with Diabetes

An individual's spontaneous food consumption varies greatly from one day to the next. These variations depend on changes in physical activity. Normally, the pancreas adjusts the quantity of insulin to meet the body's needs. Conversely, in subjects with diabetes mellitus, once insulin is injected, its action cannot be stopped, according to a precise kinetic profile, which requires that food intake be timed according to a precise schedule: eating when insulin activity is high, and abstaining when it is low. In order to be able to adjust the dose, yo-yo dieting should also be avoided.  You cannot eat just anything, at any time.

The timing of meals and injections.

Each injection of rapid-acting insulin must be followed by a meal containing an adequate amount of carbohydrates.  Not eating after an injection is a surefire way to get hypoglycemia.  A light meal is necessary when insulin activity is still high three hours after an injection (rapid-acting insulin or NPH insulin) that is, in practice between 10:00 a.m. and 10:00 p.m; if you do not plan to eat a snack, then the previous dose should be reduced in order to avoid hypoglycemia.

With certain types of insulin (rapid-acting insulin and NPH insulin), the time interval between two injections (and two meals) can only vary within certain limits.  Thus, after injection of rapid-acting insulin and NPH insulin in the morning, if breakfast is eaten late, there is a risk of late-morning hypoglycemia.

Some treatment regimens allow for more flexibility in the timing of injections and meals, and do not generally require the intake of light meals: injections of a rapid-acting analogue insulin before each meal, combined with a long-acting analogue insulin; insulin pump.

In the late afternoon, insulin activity is very low with most treatment regimens: a snack always provokes a “spike” in blood glucose levels.  The following choices are available: either a rapid-acting analogue insulin injection before eating or skipping the snack, or getting the children used to a light snack that does not contain a grain (but this is often not enough to prevent hyperglycemia before dinner).


TABLE 2: LIST OF THE MOST COMMONLY USED INSULINS IN CHILDREN.

Quantities

Quantities ingested must limit too much variations in blood glucose levels, and prevent both hyperglycemia and hypoglycemia. Diet must be fairly regular from one day to the next in order to be able to adjust the insulin doses, and it must also vary with physical activity. Finding the right balance between insulin, diet, and exercise is precisely the key problem in the treatment of diabetes.

It is not enough to take into account the quantity of carbohydrates ingested, but the hyperglycemic effect of food.  On this subject, studies conducted on the hyperglycemic effect of high-carbohydrate foods, or foods with a high glycemic index, were very useful for clearing up numerous preconceived notions.  Thus it was demonstrated that:

Translating the glycemic index into practical terms proves fairly difficult, especially since the differences between high-carbohydrate foods tend to be less pronounced in well-balanced meals. Thus, bread and rice, which have a greater hyperglycemic effect than pasta and dried vegetables, have a lower hyperglycemic effect when they are served by high-fiber foods.

More and more often, we must also tackle the problem of quantity to limit excessive weight gain.  Young people with IDD are also faced with the overall population trend, that is an increased incidence of being overweight and obese.  The problem then is similar to that of type II diabetes mellitus, with the essential objective of treatment being to reduce excess weight through a combination of diet and physical activity.

There are several methods to evaluate the amount of food ingested. Pediatricians and dieticians from the Educational Commission for Aid to Young Diabetics (French Commission Pédagogique de "l’Aide aux Jeunes Diabétiques” (AJD) decided upon a simple rule for stabilizing the quantity of carbohydrates in a meal:

It is also useful to know the equivalences between the main starches, using household measurements (teaspoons, cups, etc.) Other means of evaluating quantities, such as weighing foods or calculating dietary carbohydrates, are not regularly used at the beginning of treatment.

A sweet dessert may be eaten occasionally, after a meal, provided that the meal remains balanced.

For light meals and snacks, the AJD has developed brochures proposing a selection of approximately equivalent foods based on the child’s age and his or her eating habits as evaluated by the dietician.

Educating Children with Diabetes

Caring for children with IDD (and his or her parents) requires a multidisciplinary team comprised of physicians, nurses, dieticians, and social workers trained in the overall management of diabetes mellitus.

This team, exercising most often in a hospital setting, provides the children and his or her parents with essential knowledge on diabetes and the fundamental safety rules, in particular in case of hypoglycemia

This training, which must change with the child’s age, carried out by a network of participants, relies on educational games and media, advice, and individual care (sports, recreation), enabling the child to live an almost normal social life, while complying with the main components of the treatment of his or her diabetes. The attending physician and the family (parents, as well as brothers and sisters) also make up a link in the chain and important support element to help the child to maintain blood glucose control and nutritional balance with reasonable constraints.

Conclusion

Diet is an essential component in the management of insulin-dependent diabetes mellitus, on which blood glucose control is greatly dependent.  Young people very often consider dietary recommendations as the main constraint in their treatment. More than the other aspects of treatment, diet is a matter of education. The daily problems that encounter children and adolescents with diabetes in terms of diet are often very far from the ideal of nutritional principles. Diabetologists and dieticians must take this into account in the educative approach and dietary monitoring if they wish to provide the best possible assistance to young diabetics.

Professor Jean-Jacques Robert
Hôpital Necker-Enfants Malades [Necker-Sick Children’s Hospital], AP-HP, Paris(8,957 characters)

References