Nutritional management

Guidelines on food components

Carbohydrates

The proportion of carbohydrate as a percentage of total energy intake varies enormously around the world but there is agreement that carbohydrate should not be restricted
In some countries where carbohydrate forms 60–70% of intake, excellent glycemic control is achievable

Meals containing complex carbohydrate from sources such as whole grains (wheat, corn, maize), potatoes, rice or pasta are particularly recommended
Carbohydrate sources containing soluble fiber should be strongly encouraged (see below)

Quantitation of carbohydrate

Many methods of counting carbohydrate have been used and many are still commonly used in pediatric practice

e.g. Exchanges
- Portions/servings
- Grams
- Glycemic index
- Carbohydrate : insulin ratio

Although exchanges and gram counting would appear to have an educational value, there is little evidence that parents (and particularly young people) can understand or implement such diets in the long term. Unless rigorously reviewed, there is a danger that such dietary ‘prescriptions’ will lead to carbohydrate constraint as the child grows, and may lead to disordered eating behavior (including eating disorders).

However, some practical quantification of carbohydrate is necessary as part of intensification of management. Parents and young people should be able to visualize amounts and types of carbohydrate using educational tools such as the “plate model”or “size of hand model”. In this way it may be possible to estimate the glycemic impact of various types of food.

The insulin dose and action profile needs to be balanced against the expected carbohydrate intake

For example

twice-daily insulin regimens of short and longer acting insulins require regular and frequent carbohydrate intake (often as ‘snacks’) to prevent hypoglycemia during inevitable periods of hyperinsulinemia
multiple injection regimens of pre-meal short or rapid-acting insulins enable a more flexible or dynamic approach
most insulin regimens require carbohydrate intake before bed to prevent nocturnal hypoglycemia
increased exercise and sport require extra complex carbohydrate before, during and after exercise to balance increased energy needs and prevent hypoglycemia

Fiber

Soluble fiber found mainly in vegetables, legumes, oats and fruits may be particularly useful because it reduces the speed of carbohydrate absorption and may improve lipid metabolism
Insoluble fiber found in grains and cereals promotes healthy bowel function
A reasonable target for total fiber intake for children above 2 years is an amount equal (in grams) to the child’s age plus 5 g/day
Increased fiber intake should be introduced slowly to prevent abdominal discomfort
Increased fiber intake should be accompanied by an increase in fluid intake

Sucrose

Can provide up to 10% of total energy intake (no more than that advised for the general population)
Moderate amounts can be included as part of mixed meals without causing hyperglycemia
Sucrose-sweetened drinks or sweets eaten at inappropriate times may cause significant hyperglycemia and should be avoided
May be used to prevent or treat hypoglycemia before and during physical exercise
Denial of sucrose-containing foods may have important psychological implications

Fructose

The major fruit sugar, does not greatly elevate blood glucose
In excess may elevate triglyceride levels
As a sweetening agent is not recommended
Naturally occurring sources, fruits and vegetables, are recommended

Fats

Are the most energy-dense food substance and are important components of lipid membranes
Serum cholesterol is a predictor of macrovascular risk. Although dietary cholesterol is not the most important determinant of serum cholesterol, a diet low in total fat with emphasis on decreasing saturated and transunsaturated fatty acids is recommended. Saturated fats are found in animal produce such as whole milk, cheese, butter and red meats. Transunsaturated fatty acids are found in manufactured confectionary such as biscuits, cakes and chocolates
Polyunsaturated fatty acids derived from vegetable origins such as corn, sunflowers, safflower, soybean, seeds and oils, or from oily marine fish may reduce lipid cardiovascular risk factors. Unsaturated fatty acids of the n-3 variety found in oily fish and certain vegetable oils are thought to be particularly beneficial
Monounsaturated fatty acids (particularly cis-configuration) found in olive, sesame, rapeseed and some nut oils may be beneficial in controlling lipid levels and convey some protection against cardiovascular disease. They are recommended replacements for saturated fats

In societies where total energy intake is compromised or where there is a predominant vegetable/fish diet, the intake of fat may be greater than the recommended 35%. However, this higher fat intake may be composed of low saturated fat and high levels of n-3 polyunsaturated fats. In South-East Asia the traditionally high carbohydrate, low fat diet comprises only 20–30% fat. In contrast, South Asian cooking methods of deep fat frying with ghee, a saturated form of fat, increase the total fat intake significantly and in addition to local high fat milk may increase cardiovascular risk especially when in association with diabetes

Protein

Worldwide intake of protein varies greatly depending on economy and availability
Is an essential source of nitrogen
Intake decreases during childhood from approximately 2 g/kg per day in early infancy to 1 g/kg per day for a 10 year old, and to 0.8–0.9 g/kg per day in later adolescence
Can only be used for growth if the total energy intake is sufficient
Sources of vegetable protein such as beans, legumes and lentils, which are lower in saturated fat and higher in fiber and complex carbohydrate, should be encouraged but are difficult to incorporate when not part of the indigenous diet
When persistent microalbuminuria, raised blood pressure or established nephropathy occurs, excessive protein intake may be detrimental and therefore intake should be at the lower end of the scale. Protein restriction in adolescence should not be allowed to interfere with normal growth and requires expert management by a dietician

Vitamins, minerals and antioxidants

Supplements of vitamins, minerals or trace elements are not usually recommended unless nutritional assessment confirms significant deficiencies

Optimum vitamin status should be maintained for cardiovascular protection
Many fresh fruits and vegetables are naturally rich in antioxidants (tocopherols, carotenoids, vitamin C, flavonoids) and should be strongly encouraged in young people with diabetes

Salt

Sodium chloride is added to many processed and ‘fast foods’
In many countries, salt intake is in excess of recommendations
In adults, less than 6 g/day is recommended (except in very hot countries) but evidence is not available for children

Alcohol

Alcohol is dangerous in children and prohibited in many cultures
Excess alcohol intake may induce a prolonged hypoglycemic effect
Carbohydrate should be eaten before, during and after alcohol intake
Special care should be taken to prevent nocturnal hypoglycemia

Special labeled ‘diabetic’ foods

Are not recommended or necessary because they are expensive, calorie-dense, high in fat and may contain sweeteners with laxative effects
Lower sugar or sugar-free products are more suitable

’Bulk’ sweeteners

Added sweeteners such as dextrins or sugar alcohols (e.g. sorbitol, mannitol) are added to commercial foods to improve sweetness and palatability
They are all energy-containing, and affect the level of BG. They may also produce a laxative effect and are not recommended as sweeteners

Artificial or intense sweeteners

Saccharin, aspartame, acesulfame K, cyclamates, alitame and sucralose are used in low sugar or sugar-free products to improve sweetness and palatability
Acceptable daily intakes have been established in some countries

Meal planning and review