Nutrition for Children with T1 Diabetes. Gail Spiegel, MS RD CDE Senior Instructor

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1 Nutrition for Children with T1 Diabetes Gail Spiegel, MS RD CDE Senior Instructor

2 2018 ATDC Conference: Conflict of Interest I have no conflicts of Interest. I will not be speaking on off-label topics.

3 Outline Current ADA/ISPAD Guidelines for Nutrition Therapy Nutrition Intake of youth with Type 1 Research on Diet and Glycemic control Low Carb/Ketogenic Diets and potential risks Paleo Diet and potential risks Tips for Improving Postprandial BGs

4 Current Nutrition Guidelines: ADA Achieve blood glucose goals without excessive hypoglycemia Prevent long term complications Meet blood pressure and lipid goals Nutrient recommendations are the same as for all healthy children Follow Dietary Guidelines for Americans Provide adequate calories for growth and the maintenance of a healthy body weight Individualization of meal plans: Fit diabetes into each child s lifestyle ADA Guide to Nutrition Therapy, 3 rd Edition 2017

5 Current Nutrition Guidelines: ADA Match insulin to carbs using intensive insulin regimens to provide flexibility and to accommodate irregular schedules, varying appetites and activity levels Those on fixed insulin doses are taught to keep carbs consistent from day to day The food plan takes into consideration the patient s numeracy, literacy, engagement and ability to adjust insulin For selected individuals who have mastered carb counting, education on impact of protein and fat on glucose excursions should be incorporated into diabetes management ADA Guide to Nutrition Therapy, 3 rd Edition 2017

6 Current Nutrition Guidelines: ISPAD Optimal macronutrient distribution varies depending on individualized assessment As a guide: CHO= 50-55% of calories, Fat <35% of calories and PRO= 15-20% of calories The use of glycemic index provides additional benefit to glycemic control over that observed when total CHO is considered alone. Smart et al, Pediatric Diabetes 2014, 15(Suppl, 20):

7 What Are They Eating? Youth with type 1 diabetes are eating more total and saturated fat than recommended Youth eat inadequate amounts of fiber, fruits, vegetables, and whole grains Bortsov et al Nutr Educ Behav 2011; 43: Nansel, J et al Acad of Nutr Diet 2012;112: Mayer-Davis, et al.. JADA 2006; 106: Mehta, et al Nut Res 2014; 34: Dubose SN, et. al. Journal of Pediatrics, 2015 Katz, et al Diab Tech and Ther 2014

8 Research on Diet and Glycemic Control 532 DCCT Patients- 13 to 39 yo in Intensively Treated Group Diets higher in fat and sat fat and lower in carbohydrate were associated with worse glycemic control independent of exercise, TG concentration and BMI 252 T1 Youth > 8 to 18 years of age Higher fat intake in pump patients and lower fiber intake in all patients was associated with A1c level of > 8.5% 136 T1 Youth 8 to 16.9 years of age Higher unsaturated fat intake was associated with poorer glycemic control. Higher intake of carbohydrate, fiber, natural sugar and HEI-2005 scores were associated with better glycemic control Delahanty, et al Am J Clin Nutr 2009 Katz, et al Diab Tech and Ther 2014 Nansel, et al, Am J Clin Nutr 2016

9 What Do Families Hear and Read About?

10 Some Current Diet Fads Very Low Carb or Ketogenic Diets Paleolithic Diet

11 More patients are asking questions about low carbohydrate diets

12 Very Low Carbohydrate and Ketogenic Diets VLCD = 20 to 50 gm carb or 5-10% of calories from carbohydrate per day Ketogenic= High Fat, Very low carb (< 50 g) 75% of calories = Fat 20% of calories= Protein 5% of calories= Carb

13 Online survey of adults and parents of children with type 1 who are consuming a VLCD for at least 3 months (Dr. Bernstein protocol, TypeOneGrit Facebook group) Mean CHO intake was 36 gm Mean HbA1c= 5.67±.66% Low rates (1-2%) of reported adverse events (severe hypo, hospitalization, DKA) Mixed lipid profiles- high total and LDL cholesterol, Low TG, High HDL

14 Reported high levels of health and satisfaction with diabetes management but not with their professional diabetes care 27% did not discuss VLCD with their diabetes providers Only 49% felt that providers were supportive Didn t discuss diet with provider for various reasons: Disagreement on treatment goals and approach Perceived provider disinterest or unfamiliarity with VLCD Desire to avoid conflict Fear of being accused of child abuse

15 Risks of ketogenic diet Diabetic Ketoacidosis Higher risk because closer to ketotic/acidemic threshold Harder to monitor for DKA Complicated sick day management May result in more ED visits DKA is life threatening! Aguirre Castaneda, et al. Pediatrics 2012

16 Risks of ketogenic diet Poor Growth Patient on VLCD over 8 years Patient on VLCD for 2 years debock et al. Pediatric Diabetes, 2017

17 Risks of ketogenic diet High Risk Lipid Profile Nutritional Deficiencies Hypoglycemia Insulin doses change Hypoglycemia unawareness more common Glucagon doesn t work as well Kwiterovich, et al JAMA 2003 Nordmann, et al Arch Intern Med 2006 debock, et al Pediatric Diabetes 2017

18 Risks of ketogenic diet Bone disease Decreased bone mineral density T1D and celiac already predisposed to decreased bone mineral density! Increased risk for poor bone formation and fractures Bergqvist, AG Am J Clin Nutr, 2008 Simm et al, Epilepsy Res 2017

19 Risks of ketogenic diet Gastrointestinal Problems Nausea Vomiting Diarrhea Constipation Increased GER In >50% of kids! Kossoff, et al Epilepsia 2009

20 Psychological Burden Restricted eating behavior can contribute to social isolation and add to psycho-social burden Increased anxiety Potential source of conflict between family and adolescent Potential source of conflict with diabetes providers/loss to f/u de Bock, et al, Pediatric Diabetes, 2017

21 How Do We Keep Patients Safe? Provide education Have guidelines for when to escalate medical management

22 Protocol for Families Trying Low Carbohydrate or Ketogenic Diets At BDC Peds Clinic RD team is keeping a database of families who enter protocol so that we can track these patients and create data

23 Protocol for Families Trying Low Carbohydrate or Ketogenic Diets

24 Protocol for Families Trying Low Carbohydrate or Ketogenic Diets

25 Educational Materials/ What Does the BDC RD Team Tell Patients?

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28 Premise: Paleo Diet Cut out processed foods with refined sugar, refined grains, refined vegetable oils, trans fats, salt and added chemicals Return to foods that our ancestors, the hunter-gatherers ate Following the diet will help prevent or control chronic diseases like diabetes, heart disease, cancer

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30 Risks of Paleo Diet Missing out on nutrients from grains, legumes, dairy May increase intake of unhealthy fats Restrictive eating = more psychosocial burden Limited evidence for benefit

31 Balanced Diet! Added Sugar gm/day Bell KJ, et al Diabetes Care 2015

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34 Thank You! Kimber Simmons, MD, MS Brigitte Frohnert, MD, PhD Loise Gilmer, MS, RD, CDE Anne Kaess, RD, CDE Lauren Oswald, RD, CDE Darcy Owen, MS, RD, CDE