Impact of Healthy Eating, Nutrition Knowledge & Practices in Youth with Type 1 Diabetes

Transcription

1 Impact of Healthy Eating, Nutrition Knowledge & Practices in Youth with Type 1 Diabetes Lina Huerta-Saenz, MD Division of Pediatric Endocrinology Children s Mercy Hospital Wichita Specialty Clinic The Children s Mercy Hospital, 2016 The Children's Mercy Hospital, 2015

2 Healthy Eating

3 Financial Disclosures The Helmsley Charitable Trust Fund (Abstract Award Winner at the ICE/ 96 th Endocrine Society Meeting, June 2014) 3

4 Objectives 1. Understand the importance of medical nutrition therapy (MNT) in the glycemic control of youth with type 1 diabetes 2. Remember that MNT is a successful treatment option for youth with type 1 diabetes (T1D) 3. Consider the revised NutriCarbQuiz (NCQ) as a validated clinical tool to assess carbohydrate counting, healthy eating, and T1D knowledge in youth with T1D 4

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6 Phone call: Clinical Case 6 yo girl is presenting severe post-prandial hyperglycemia (BG 420 mg/dl) after eating 16 pieces of McDonald s chicken nuggets (CHO= 1:20) despite receiving meal insulin and correction (ISF=50) 6

7 Per The Calorie King book: 1 piece (0.6 oz) of McNuggets w/o sauce= 3g Carbs, 3g Total Fat, 2.2g Protein 16x3= 48 g of carbs (CHO ratio 1:20) 7

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9 What caused the severe postprandial hyperglycemia? Inadequate CHO counting calculation? Was insulin given after the meal instead of before the meal? Were the chicken nuggets too fatty? 9

10 Background Type 1 diabetes (T1D) incidence and prevalence have increased dramatically during the last 2 decades but also the incidence of overweight & diabetes in youth with T1D

11 From: Prevalence of Type 1 and Type 2 Diabetes Among Children and Adolescents From 2001 to JAMA. 2014;311(17): doi: /jama

12 Obesity in Youth with T1D T1D Exchange Clinic Network and Diabetes Prospective Follow-Up Registry: T1D Exchange (N= 11,435) Diabetes Prospective Follow Up (N= 21,501) BMIz vs. HbA1C vs. Severe hypoglycemia In: Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States. J Pediatr Sep,; 167(3):

13 BMI values > national references BMIz > in the T1D Exchange vs. Diabetes Prospective Follow-Up Greater BMIz correlated to greater A1C and severe hypoglycemia DuBose SN,et al. Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States. J Pediatr Sep,; 167(3):

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15 Achieving Optimal Glycemic Control The Children s Mercy Hospital,

16 Per the DCCT and the EDIC study, tight glycemic control is critical for: Reducing both microvascular and macrovascular complications 16

17 In: Effect of Intensive diabetes treatment on the development and progression of longterm complications in adolescents with insulin-dependent diabetes mellitus: DCCT study. J Pediatr Vol 125 (2): ,

18 Intensive insulin treatment and what else is needed? 18

19 Medical Nutrition Therapy (MNT) Definition: Proper nutritional management of children with diabetes MNT Diet Involves meal planning In: Evidence-based Nutrition Principles and recommendations for the Treatment and prevention of Diabetes related complications. Diabetes Care, Vol. 26 (S1), January

20 Medical Nutrition Therapy is crucial for short and long term management of youth with T1D 20

21 MNT - Components 1. Nutrition Education 2. Adherence to Healthy Diet 3. Carbohydrate Counting 21

22 MNT Only Carbohydrate Counting 22

23 ARE THESE HEALTHY MEALS? Yes Yes or No? 23

24 In: Diabetes Care, Volume 31, supp. 1, January

25 Carbohydrate Intake Variety of carbohydrates Monitoring carbohydrates Use of glycemic index and load Sucrose-containing foods Fiber intake/ sugar alcohols & non-nutritive sweeteners In: Dietary Carbohydrate intake and type in the prevention and management of Diabetes: ADA statement. Diabetes Care 27: ,

26 Amount & Type of Carbohydrate RDA for carbohydrates= 130 g/day (minimum requirement) Amount of Carbs= Primary determinant of postprandial response Type of starch, style of preparation, etc. 26

27 Fiber (Min. 14g/1000 Kcal) Legumes Fiber-rich cereals ( 5g fiber/serving) Fruits Vegetables Whole-grain products 27

28 Why do youth with T1D need to eat healthy? 28

29 Medical Nutrition Therapy (MNT) Can MNT prevent diabetes progression? Can MNT slow down insulitis? Can MNT prevent diabetes complications? 29

30 Goals of MNT for Diabetes Treatment 1) To achieve and maintain: BG levels within the normal range A good lipid profile that risk for CV disease 30

31 Additional Goals 2. To prevent, or at least slow, the rate of development of the chronic complications of diabetes 3. To address individual nutrition needs 4. To maintain the pleasure of eating 31

32 Goals of MNT (Specific Situations) 1) For youth with T1D, youth with T2DM, pregnant and lactating women, and older adults with diabetes 2) For individuals treated with insulin or insulin secretagogues 32

33 Additional Aims of MNT Achieve & maintain appropriate BMI & waist circ. Balance between: 1. Food intake 2. Metabolic requirements 3. Energy expenditure 4. Insulin action profile 33

34 What Have We Learned from Prior Studies in MNT and T1D Youth? There are no nutrition recommendations for T1D prevention Avoiding overweight and obesity can decrease the risk of T2D and/or insulin resistance 34

35 Nutrition Recommendations for Management of Diabetes Carbohydrate intake Fiber Fat and cholesterol Resistance-starch/amylose foods 35

36 Optimal Macronutrient Distribution Carbohydrates= 50-55% of energy Fat = < 35% of energy (saturated fat should be < 10%) Protein= 15-20% of energy In: Nutritional Management in children and adolescents with diabetes. Pediatric Diabetes 2014:15 (Suppl. 20):

37 Carbohydrate in Diabetes Management Includes fruits, vegetables, whole grains, legumes, low-fat milk Monitoring CHO counting, exchanges Avoid excess energy intake Adequate fiber intake 37

38 Dietary Fat and Cholesterol Saturated fat to < 7% of total calories Minimize intake of trans fat Dietary cholesterol < 200 mg/day 2 or more servings of fish per week (n-3 PUFA) 38

39 Protein in Diabetes Management High-protein diets are not recommended Specific recommendations for patients with T1D and impaired renal function Protein should not be used to treat acute or prevent night-time hypoglycemia 39

40 Macronutrients Best mix depends on growth rate and individual circumstances Follow the DRIs (dietary reference intakes) 40

41 Micronutrients There are not enough clinical studies in T1D patients showing enough evidence for specific recommendations Vitamin C, D, E? / Antioxidants?, Zinc? Sodium intake (<2000 mg if heart failure) 41

42 Adherence to insulin regimen (behavior: MI)** Well controlled T1D Adequate education about MNT Healthy Eating habits** Adequate family/social support 42

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44 Can we change the dietary habits of our T1D youth? How can we know if these youth are eating well or if they have enough knowledge to make good decisions about their daily eating habits? 44

45 THE HEALTHY EATING STUDY IN YOUTH WITH T1D Revised NutriCarbQuiz 45

46 Healthy Eating Study in Youth with Study phases: Type 1 Diabetes 1) Assessment of nutrition, HE, T1D knowledge and glycemic control & variability 2) Dietary Quality Assessment 46

47 Healthy Eating Study 1 st Phase Study Enrollment period: 08/ /2014 Study Sites (4): CMH Broadway, South, North and East Clinic IRB approved Economic stipend provided 47

48 Primary Study Goals 1. To determine nutrition, HE and T1D knowledge measured by the revised NCQ in youth with T1D 2. To validate the revised NCQ 3. To determine whether the NCQ scores correlate with dietary practices among youth with T1D measured by the YAQ 48

49 Inclusion Criteria 1. Age range (1 to 21-yrs old) 2. Prior documented diagnosis of T1D for at least 6 months prior to enrollment 3. Subjects 1-17 years old must have one parent/primary caregiver attending the Diabetes Clinic visit with the subject at the CMHC 4. Children with T1DM receiving treatment with insulin with at least 0.5 unit/kg/day by multiple dose injections (MDI) or continuous subcutaneous insulin infusion (CSII) 49

50 Exclusion Criteria 1. Children with MODY diabetes, type 2 diabetes, CFRD, or diabetes secondary to other conditions 2. Children with T1D receiving any medical treatment that can impact their diabetes control: Chronic steroids therapy, immunosuppressive therapy 3. Any documented history of thalassemia affecting the hemoglobin A1C level 4. Celiac disease 50

51 Secondary Study Goals 1. To determine whether NCQ scores correlate with nutritional status 2. To determine dietary quality of youth with T1D by the YAQ 51

52 Clinical Data: Data Collection HbA1C, BMI, blood pressure, prior existent lipid profile, 14-day glucometer download Demographic Data: T1D diagnosis date, age, SES*, race/ethnicity 52

53 Study Instruments 1. Revised NCQ: NutricarbQuiz 15 questions ( ~ 10 minutes) 2. NKS: Nutrition Knowledge Survey* 23 questions ( ~ 15 minutes) 3. Youth/Adolescent Frequency Questionnaire(YAQ) 152 questions ( ~ 30 minutes) 53

54 Revised NCQ (Scoring) Total Score= 32 points CHO score= 19 points HE score= 11 points T1D score= 2 points 54

55 English revised NCQ 55

56 Youth/Adolescent Questionnaire (YAQ) Harvard School of Public Health & Nutrition Food frequency questionnaire: 9-18 yo Versions available: English / Spanish 152 questions ( ~ min completion time) 56

57 Revised NutriCarbQuiz (NCQ) 15 Questions ( ~ 10 minutes) Domains: 1. Healthy eating (HE) 2. Carbohydrate counting (CHO) 3. Type 1 diabetes knowledge (T1D) Flesch-Kincaid Index (literacy level): 6th grade 57

58 YAQ: Nutritional Analysis Energy intake (Kcal), protein intake (grams), carbohydrates, fat, percentage of fat (macronutrients); Saturated fat (grams), MUFA (g), PUFA(g), cholesterol (mg), dietary fiber (g), vitamins, oligo elements, Na, potassium, calcium, iron, sucrose 58

59 Youth/Adolescent Questionnaire (YAQ) 59

60 Keeper of the Plains Wichita, KS 60

61 First Phase of the HE Study Glycemic variability and nutrition knowledge measured by the revised NutriCarbQuiz (NCQ) 61

62 Results Participants= 137 youth Parents Withdrawals=1 62

63 Demographic & Clinical Data Characteristic (Parents=124/Youth= 98) Age: Sex: Race: o White o Black o Other Male Female Ethnicity o Non-Hispanic o Hispanic Type 1 Diabetes duration (years) Type of treatment: CSII MDI Mean ± SD or N (%) 12.7 ± 4.3 years 54% 46% 87% 10% 3% 90% 10% 5.3 ± 3.3 years 91% (124) 9% (13) SES (Hollingshead score) 38 ±

64 Characteristic Mean ± SD or N (%) Hemoglobin A1C 8.96% ± 1.8 Mean Blood Glucose (MBG) (mg/dl) ± 71.7 Standard deviation BG (SDBG) ± 34.7 Number of Hypoglycemic events (< 65 mg/dl) 3.2 ± 4.1 Number of Hyperglycemic events ( > 180 mg/dl) 31 ±

65 NCQ External Validation Table 1. Descriptive Statistics NKS RovnerChild NKSPTOTALCHILD NCQPTOTALCHILD NKS RovnerParent NKSPTOTALPARENT NCQPTOTALPARENT N Minimum Maximum Mean Std. Deviation

66 Internal Consistency Cronbach s alpha of NKS and NCQ scores for children (parent) equals (0.672) denoting that the reliability of the NCQ relative to the NKS is good for children and (parents) respectively. 66

67 Nutrition, HE and CHO Knowledge Measured by the Revised NCQ Parent Youth NCQ Total NCQ-CHO NCQ-HE 67

68 Glycemic Control & Knowledge by Revised NCQ Youths Score (points) (Mean ±SD) Correlation with NCQ Total Score HbA1C MBG SDBG Hypoglycemic episodes Hyperglycemic episodes NCQ total 21.8 ± * * ** NCQCHO 13 ± ** ** ** NCQHE 7.9 ± ** ** NCQT1D 0.86 ± * * Parents NCQ total 24 ± * * NCQCHO 13.9 ± ** * * NCQHE 7.9 ± ** NCQT1D 0.98 ± ** (*) p < 0.01 (**) p < 0.05 Poster presented at the ICE/ 96 th. Endocrine Society meeting, June Chicago, IL 68

69 Multivariate Analysis Model 69

70 Second Phase of the Study To measure the dietary quality of enrolled youth with T1D using the Youth/Adolescent Questionnaire (K95 version) 70

71 Demographic Data Characteristic Median(IQR) Age (N=60) 13 yo [9.5, 16] Gender - Male/ Female 52% / 48% Race: White 93% Ethnicity: Non-Hispanic 87.5% Diabetes duration (years) 5.4 [2.4, 7.1] Type of treatment - MDI/ CSII 6.7% / 93.3% Mean blood glucose (MBG) [mg/dl] [187, 250] Standard Deviation Blood Glucose (SDBG) 99.5 [85.5, 116.5] Hemoglobin A1C (HbA1C) 8.6% [8, 9.9] 71

72 Dietary Quality Measured by the YAQ Dietary Intake (per day) Median(IQR) USDA DRI*/ Compliance Total calorie intake (TCI) [Kcal/day] 1701 [1270, 2204] Depends of age & GV Carbohydrates (% of TCI) 49% [45, 52.5] 45-65% / Good Sucrose (% of TCI) 7% [6, 9.5] Up to 10%/ Good Protein (% of TCI) 18% [16, 20] 10-30%/ Good Total Fat (% of TCI) 35 % [31, 38] < 35%/ High Saturated Fat (% of TCI) 12% [11, 14] < 10%/ High PUFA (% of TCI) 7% [6-8] < 10% / Good MUFA (% of TCI) 12% [11, 13] >10%/ Good Dietary Fiber (g) 14 g [10-20] g/ Low Total Cholesterol (mg) g [177, 320] < 200 mg/ High Vitamin D (IU) 356 IU [137, 607] IU/ Low Vitamin C (mg) 87 mg [43, 143] mg/ Good Calcium (mg) [ ] 1,300 mg/ Low Niacin (mg) 26 [17, 38] 9-12 mg/ High Poster presented at the Midwest Society of Pediatric Research Symposium (MWSPR) Meeting, 09/22/2016. Chicago, IL. 72

73 Mayer-Davis, EJ et al. Dietary Intake among Youth with Diabetes: the SEARCH for Diabetes in Youth Study. J Am Diet Assoc. 2006; 106:

74 Nutrition Status of Enrolled Youth per BMI Overweight 23% Obesity 12% Underweight 3% Healthy BMI 62% 74

75 DuBose et. Al. J Pediatr 2015; 167:

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77 Conclusions The revised NCQ is a brief, valid measure of nutrition and CHO counting knowledge for youth with T1D and correlates well with HbA1C and MBG YAQ showed suboptimal dietary quality intake in these T1D youth despite of adequate HE knowledge Youth with T1D require not only CHO, HE & nutrition education for optimal glycemic control 77

78 Research Staff Research Team: Nicole Knecht, RD, CDE Stella Vergara-Bagby, RD, CDE Lois Hester, RN, RC (*) Jennifer Bedard, RC Aliza Elrod, research data entry Darlene Brenson-Hughes, RC Jamie Wierson, RN, RC New research members: Julie De La Garza, RN, RC Liz Ramey, RD, RC Natalie Farha, KU Summer Research Scholar 78

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81 Research Mentors: Mark Clements, MD, PhD Susana Patton, PhD, CDE Biostatisticians/ Data analysis: Stephen De Lurgio, PhD David Williams, MPH 81

82 Acknowledgements Pediatric Endocrinology Fellowship Research Funding at Children s Mercy Hospital Helmsley Charitable Trust Fund for supporting early career investigators performing research in Type 1 Diabetes 82