Dietary survey of Finnish adolescent diabetics and non-diabetic controls

Sweets, snacking habits, and skipping meals in children and adolescents on intensive insulin treatment

AIM

To examine the association between skipping meals and snacking events and dietary and clinical characteristics in children and adolescents using modern insulin treatment.

METHODS

Dietary intake was recorded for 4 d in food diaries in 655 young diabetic patients. Number of meals and snacking events was recorded in a separated questionnaire, while clinical data were obtained from case record forms. Skipping meals refer to consuming a main meal (e.g., breakfast) five times a week or less.

RESULTS

Modern insulin treatment may favor a more flexible lifestyle. This study shows that there are fewer young diabetic patients who skip meals than non-diabetic controls (p < 0.001) even when using modern intensified insulin treatment. However, skipping meals among young diabetic patients was associated with negative characteristics such as having suboptimal hemoglobin A1c (HbA1c) (OR 4.7, p = 0.02), higher low-density lipoprotein (LDL) cholesterol levels (OR 4.0, p < 0.001), watching more TV (OR 3.6, p < 0.001), being overweight (OR 2.8, p = 0.03), as well as having a higher intake of added sugar (OR 2.1, p = 0.01) and lower intake of fiber (OR 0.2, p = 0.04) compared with those not skipping meals. Having more than two snacking events during the day was associated with higher HbA1c, higher intake of added sugar and sweets, and spending more hours in front of the TV or personal computer.

CONCLUSIONS

In general, fewer children and adolescents with type 1 diabetes skip meals compared with healthy peers. Those who skip meals and have more snacking events have poorer glycemic control and less healthy dietary and leisure habits.

Review article: fructose malabsorption and the bigger picture

Fructose is found widely in the diet as a free hexose, as the disaccharide, sucrose and in a polymerized form (fructans). Free fructose has limited absorption in the small intestine, with up to one half of the population unable to completely absorb a load of 25 g. Average daily intake of fructose varies from 11 to 54 g around the world. Fructans are not hydrolysed or absorbed in the small intestine. The physiological consequences of their malabsorption include increasing osmotic load, providing substrate for rapid bacterial fermentation, changing gastrointestinal motility, promoting mucosal biofilm and altering the profile of bacteria. These effects are additive with other short-chain poorly absorbed carbohydrates such as sorbitol. The clinical significance of these events depends upon the response of the bowel to such changes; they have a higher chance of inducing symptoms in patients with functional gut disorders than asymptomatic subjects. Restricting dietary intake of free fructose and/or fructans may have durable symptomatic benefits in a high proportion of patients with functional gut disorders, but high quality evidence is lacking. It is proposed that confusion over the clinical relevance of fructose malabsorption may be reduced by regarding it not as an abnormality but as a physiological process offering an opportunity to improve functional gastrointestinal symptoms by dietary change.

Children and adolescents with type 1 diabetes eat a more atherosclerosis-prone diet than healthy control subjects

AIMS/HYPOTHESIS

We evaluated how well the diet of Norwegian children and adolescents with type 1 diabetes fulfils the Nordic and European dietary recommendations, focusing on parameters affecting prevention of atherosclerosis. We also compared the diet of this patient group with that of healthy same-age control subjects.

MATERIALS AND METHODS

A total of 177 children and adolescents with type 1 diabetes (9-10-year-olds, 12-13-year-olds) and 1,809 healthy same-age control subjects recorded their food intake for 4 days in precoded food diaries.

RESULTS

In children and adolescents with type 1 diabetes the percentage of energy (E%) from fat (33-35 E%) and saturated fat (14-15 E%) was higher than recommended for that group. Furthermore their intake of fibre was lower (16-19 g/day) than current recommendations. There were no differences in energy intake between diabetic subjects and healthy control subjects. Percentage of energy from fat (mean difference: 3.4 E%, p < 0.001) and saturated fat (mean difference: 1.0 E%, p < 0.001) was significantly higher among diabetic subjects than control subjects. Intake of fruits and vegetables was low (210 g/day) compared with recommendations, both in the diabetic and control subjects.

CONCLUSIONS/INTERPRETATION

Diabetic children and adolescents had a high intake of energy from saturated fat and low intake of fibre, fruits and vegetables, which could increase the risk of development of atherosclerosis. This study supports the idea that nutritional guidance in the treatment of children and adolescents with type 1 diabetes should be more focused, especially with regard to intake of fibre, fruits and vegetables and to quality and quantity of fat intake.

Food habits, energy and nutrient intake in adolescents with Type 1 diabetes mellitus

AIMS

The aims were to describe the food habits of adolescents with Type 1 diabetes (Type 1 DM) and to compare them with healthy control subjects; to describe the distribution of energy-providing nutrients in patients and compare it with current recommendations and previous reports; and finally, to investigate associations between dietary intake and glycaemic control.

METHODS

One hundred and seventy-four adolescents with Type 1 DM and 160 age- and sex-matched healthy control subjects completed a validated food frequency questionnaire, and 38 randomly chosen patients completed a prospective 4-day food record.

RESULTS

Patients ate more regularly, and more often ate fruit and fruit juice, potatoes and root vegetables, meat, fish, egg, offal and sugar-free sweets than control subjects. Control subjects more often ate ordinary sweets and snacks. Patients chose coarse rye bread and dairy products with less fat to a greater extent than control subjects. Patients were heavier than control subjects. The intake of saturated fat was higher in patients compared with recommendations and, for boys with diabetes, the intake of protein was higher than recommended. Patients with poorer glycaemic control ate vegetables, fruit and fish less often than patients with better control.

CONCLUSIONS

The food habits of adolescents with Type 1 DM were healthier than those of control subjects. The intake of energy-providing nutrients was in line with current recommendations and showed improvements compared with previous reports, with the exception of fibre intake. The association between dietary intake and glycaemic control needs further investigation in prospective studies.

Physical activity and energy intake in adolescent girls with Type 1 diabetes

AIMS

Girls with Type 1 diabetes often gain excessive weight during puberty. The aims of this study were to compare objectively assessed physical activity and energy intake in girls with Type 1 diabetes with those in healthy age-matched controls.

METHODS

This prospective cohort study comprised 26 girls with Type 1 diabetes and 49 control girls. The mean age of the diabetic girls was 15.7 +/- 2.1 years and that of the control girls 15.8 +/- 2.1 years. In the diabetic group, mean haemoglobin A1c was 7.6 +/- 1.4% and daily insulin dosage was 1.1 +/- 0.3 U/kg. Physical activity was measured during 7 consecutive days with a uniaxial accelerometer, and energy intake was assessed concurrently with a 7-day food diary.

RESULTS

There was a tendency towards lower total amount of physical activity in the diabetes group but the difference between the study groups did not reach statistical significance (Diabetes: 464 +/- 123 counts/min/day;

CONTROLS

523 +/- 138 counts/min/day; P = 0.06). No difference was found between the groups regarding total energy intake (Diabetes: 8.5 +/- 1.8 MJ/day;

CONTROLS

8.4 +/- 2.6 MJ/day). The carbohydrate intake was lower and the protein and fibre intakes were higher in girls with diabetes. No association was observed between physical activity, energy intake and HbA1c.

CONCLUSIONS

In this prospective cohort study, we found a tendency towards lower physical activity but no differences in energy intake between girls with Type 1 diabetes and age-matched controls. Larger studies are needed to further explore the importance of the total amount of physical activity for excessive weight gain in adolescent girls with Type 1 diabetes.

Two year prospective dietary survey of newly diagnosed children with diabetes aged less than 6 years

The food consumption of 38 children newly diagnosed with diabetes aged < 6 years at diagnosis was assessed by 5 day food records. During the 2 year follow up, the proportion of the total energy intake made up of protein decreased from 20% to 18%, that of carbohydrates from 54% to 52%, and that of fat increased from 26% to 30%. The energy intake from sucrose (3%) did not change. In addition, There was a small decrease in the intake of fibre and several vitamins and minerals. One year after diagnosis, the diet of diabetic children was compared with that of 66 age, sex, and social status matched control children. More energy was derived from protein (19% v 15%) and carbohydrates (53% v 50%), and less from fat (28% v 35%), especially from saturated fatty acids (11% v 15%), and sucrose (3% v 16%) in the diet of children with diabetes compared with that of control children. The higher intakes of several vitamins and minerals reflected the higher nutrient density of the diet of children with diabetes. Therefore, the diet of young children with diabetes met the dietary recommendations for subjects with diabetes. Only the protein content of the diet was higher than necessary.

School based screening for hypothyroidism in Down's syndrome by dried blood spot TSH measurement

OBJECTIVE

To determine the feasibility of annual hypothyroid screening of children with Down's syndrome by measuring thyroid stimulating hormone (TSH) on dried blood spots at school, and to describe the outcome in positive children.

DESIGN

Establishment of a register of school children with Down's syndrome, and procedures for obtaining permission from parents, annual capillary blood samples, TSH measurement, and clinical assessment of children with TSH values > 10 mU/litre.

SUBJECTS

All school age children with Down's syndrome within Lanarkshire and Glasgow Health Boards during 1996-7 and 1997-8.

RESULTS

200 of 214 school children with Down's syndrome were screened. Four of the unscreened children were receiving thyroxine treatment, and only 5 remained unscreened by default. 15 of the 200 children had capillary TSH > 10 mU/litre, and all but 1 had evidence of Hashimoto's thyroiditis. Seven of the 15 children started thyroxine treatment immediately, 6 with a pronounced rise in venous TSH and subnormal free thyroxine (fT4), and one with mildly raised TSH and normal fT4 but symptoms suggesting hypothyroidism. Eight children with mildly raised venous TSH and normal fT4 were left untreated; 1 year after testing positive, fT4 remained > 9 pmol/litre in all cases, but 4 children were started on thyroxine because of a rise in TSH. TSH fell in 3 of the 4 remaining children and there was a marginal rise in 1; all remain untreated. The prevalence of thyroid disease in this population is >/= 8.9%.

CONCLUSION

Dried blood spot TSH measurement is effective for detecting hypothyroidism in Down's syndrome and capillary sampling is easily performed at school. The existing programme could be extended to the whole of Scotland within a few years.

Dietary intake of Austrian diabetic children 10 to 14 years of age

BACKGROUND

The dietary intake of 63 children with insulin-dependent diabetes mellitus (IDDM; age 10 to 14 years) was weighed by dietitians for 2 days during a summer camp for youth with diabetes. Data were analyzed for the content of macronutrients with the help of a computer database program.

METHODS

The dietary intake of children with diabetes was compared with that of healthy Austrian school children and with the current nutritional recommendations for children with IDDM.

RESULTS

The mean intake of carbohydrate did not meet the recommended level, whereas sucrose, fiber, and protein intake approximated the recommendations. The total consumption of fat and cholesterol, however, exceeded the recommended values. The nutritional intake of Austrian children with IDDM was similar to that of healthy children of the same age and thus reflected regional dietary habits.

CONCLUSION

Dietary educational measures on a national basis are needed to change harmful local eating patterns.

Jejuna of patients with insulin-dependent diabetes mellitus (IDDM) show signs of immune activation

The roles of enteric viruses and food antigens as possible triggers in human insulin-dependent diabetes mellitus and the evidence that mucosal-associated homing receptors are important in both human and experimental diabetes prompted us to undertake an immunohistochemical study of intestinal specimens from patients with IDDM. We studied jejunal morphology and immunohistochemistry in 26 patients with IDDM, 13 of whom had the HLA-DQB1*0201 gene and therefore a higher risk of coeliac disease. The findings were compared with those in specimens from age-matched controls. Villous structure and the density of the intraepithelial lymphocytes were normal in every biopsy specimen. The extent of positivity with anti-DR and -DP antibodies in the villous epithelium was significantly greater in the specimens from patients than in those from controls (P = 0.0002 in both comparisons). The crypts were also more positive: for DR P = 0.0001, and for DP P = 0.002. The densities of T cells, CD4+, CD8+, and T cell receptor alpha/beta+ and gamma/delta+ cells in the epithelium and lamina propria were similar in patients and controls, but the patients had significantly more alpha 4/beta 7 integrin+ cells in the lamina propria (P = 0.006). No difference was seen between HLA-DQB1*0201-positive and -negative patients. These findings reflect a stage of inflammation in the structurally normal intestines of patients with IDDM and suggest secretion of inflammatory Th1-type cytokines in the intestine.

Serum lipids and lipoproteins in patients treated with antiepileptic drugs

The concentration levels of serum lipids and lipoproteins were measured in three groups of children and adolescents treated with antiepileptic drugs: carbamazepine (14 patients), phenobarbital (20 patients), and valproic acid (20 patients). Patients treated with these drugs revealed significant changes in lipids and lipoproteins, but when the authors reevaluated the three groups of children 1 year after the end of treatment, a complete return to normal of all parameters was observed. These data demonstrate that the changes induced by these drugs are transient and reversible.

Diet, obesity, and metabolic control in girls with insulin dependent diabetes mellitus

OBJECTIVE

To investigate whether girls with insulin dependent diabetes mellitus (IDDM) were more overweight than nondiabetic girls, and how diet, insulin treatment, metabolic control, age, and pubertal status were related to body weight and fat content.

DESIGN

Case-control study.

SUBJECTS AND METHODS

48 IDDM girls aged 10-19 years and controls matched for age and social class participated in the study. Overweight was assessed by body mass index (BMI), relative weight, and body fat from skinfold thicknesses. Food consumption data were collected by a 48 hour recall method.

RESULTS

The girls with IDDM were more overweight than control girls according to all measures of obesity (for example, mean BMI 20.3 v 18.9 kg/m2). The daily insulin dose/body weight correlated positively with BMI and per cent body fat.

CONCLUSIONS

Girls with IDDM are more overweight than their peers, which indicates that a more effective prevention of obesity is needed in the treatment of diabetes.

Influence of puberty on lipids and lipoprotein profile in children with type 1 diabetes mellitus

In order to assess whether or not the lipoprotein profile worsens throughout puberty in children with type 1 diabetes mellitus and if this change is related to dietary compliance, we studied 46 (20 female, 26 male) children. At the beginning of the study, the mean age (+/- SD) was 10.9 +/- 1.1 years; all the children studied had reached a pubertal stage of P1, G1. The mean duration of diabetes (+/- SD) was 4.9 +/- 1.8 years. The diet and the lipoprotein profile of diabetic children were analysed at the beginning of the study and after 6 years. The quality of metabolic control of subjects studied had not changed significantly at the end of the study (haemoglobin HbA1c 7.6% +/- 2.1% vs 7.9% +/- 2.0%; NS). After puberty, the diabetic patients received more energy from carbohydrate and less from lipids. Total serum cholesterol and triglycerides and levels of low-density lipoproteins were significantly higher and of high-density lipoproteins lower in the diabetic patients after puberty than before (4.47 +/- 0.7 mmol/l vs 5.99 +/- 0.6, P < 0.01; 0.90 +/- 0.02 mmol/l vs 1.45 +/- 0.03, P < 0.01; 2.2 +/- 0.3 mmol/l vs 2.8 +/- 0.5, P < 0.01; 1.5 +/- 0.2 vs 1.1 +/- 0.2, P < 0.01, respectively). These results suggest a detrimental effect of puberty on lipoproteins; probably, dietary compliance plays a role in this worsening. Dietary education should be intensified during adolescence in order to present these changes.

Apolipoprotein E phenotypes and plasma lipids in diabetic children and adolescents

Apolipoprotein E (apoE) polymorphism is a genetic determinant of serum lipoprotein levels and coronary heart disease risk. ApoE appears in three major isoforms E2, E3 and E4, coded by corresponding alleles epsilon 2, epsilon 3 and epsilon 4. These give six different phenotypes. Patients with insulin dependent diabetes (IDDM) have been reported to have increased incidence of E2/2 homozygosity. We studied the frequencies of apoE phenotypes and their association with plasma lipids in 201 diabetic children, aged 2-17 years, and in 216 healthy controls with the same age range. Phenotyping was performed directly from plasma by iso-electric focusing and immunoblotting. Plasma total and high density lipoprotein (HDL) cholesterol (C) and triglycerides were determined by routine laboratory methods. Apolipoprotein A1 (apoA1) and B (apoB) were measured by turbidometry. There were no differences in apoE phenotype or allele distributions between the diabetic and control subjects. The frequencies of epsilon 2, epsilon 3, and epsilon 4 in the diabetic and control children were 0.08 versus 0.07, 0.73 versus 0.72 and 0.19 versus 0.21. The difference in apoE2/2 frequencies (2.0 in diabetic and 0.5% in normal children) was not statistically significant. In the diabetic children, there was a distinct relation between apoE phenotype and plasma lipids; presence of apoE2 was associated with the lowest and that of apoE4 with the highest concentrations of total and low density lipoprotein (LDL) C, and apoB. Ratios of HDL-C/LDL-C and apoA1/apoB showed on opposite trend. The influence of apoE polymorphism on plasma lipids was less clear in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Caries and saliva in 12-18-year-old diabetics and controls

Eighty-five 12-18-yr-old adolescents suffering from insulin-dependent diabetes mellitus (IDDM) and their healthy age- and sex-matched controls were investigated with respect to dental caries, salivary flow rate, pH and buffering capacity of saliva, counts for lactobacilli and mutans streptococci, and salivary glucose content. The diabetics had their disease well controlled according to the HbA1 levels. The results showed no statistically significant difference between diabetics and controls in DMF and DMFS indexes and the number of initial caries lesions. Mean number of initial caries lesions was 3.2 in diabetics, 2.3 in controls. Mean stimulated salivary flow rate was 1.2 ml/min in the patients, 1.4 ml/min in the controls. The pH and buffering capacity values were 7.3 and 4.8 in the patients, 7.4 and 5.1 in the controls, respectively. High counts of mutans streptococci (> 10(6) CFU/ml) and lactobacilli (> 10(5) CFU/ml) were observed more often, but not significantly so, among the patients than in the controls. The mean concentration of glucose in saliva was 10.3 micrograms/ml in the patients, 9.7 1 microgram/ml in the controls. Thus, if the patients' IDDM is well controlled, their salivary and caries data does not differ from that of healthy controls.

Metabolic control and diet in Finnish diabetic adolescents

The effects of dietary, clinical and demographic factors on metabolic control in 105 diabetic adolescents were studied. All patients had diabetes for longer than two years and a daily insulin dose greater than 0.5 IU/kg body weight. Low body mass index, high social class, high number of daily eating occasions, high day-to-day variation in energy intake, high number of urine tests and a long interval between insulin injection and eating were associated with good metabolic control. Many of these determinants reflect also the general compliance with the diabetic regimen. The results stress the importance of good coordination between insulin injections and eating habits.

A follow-up study of the diet of Finnish diabetic adolescents

Changes with age and time in energy-adjusted food consumption and nutrient intake of 74 diabetic subjects initially aged 12-17 years were studied. Food consumption was measured by the 48-h recall method. During the three-year follow-up (from 1985 to 1988), the proportion of carbohydrate of total energy intake decreased from 49% to 47%, that of fat increased from 33% to 36% and that of protein decreased slightly. The densities of fibre and several vitamins decreased in the diet of the diabetic adolescents. These unfavourable changes in the diet of diabetic adolescents took place with increasing age and duration of diabetes, while virtually no changes with time were detected.

Composition of the diet of young Finns in 1986

The aim was to describe the energy intake and composition of the diet of 1200 9-, 12-, 15-, 18-, 21- and 24-year-old Finns in 1986 and changes in their diet from 1980 to 1986. Data on food consumption were collected using the 48 h recall method. In 1980 protein accounted for 14%, fat for 38% and carbohydrates for 48% of total energy intake, and in 1986 for 15%, 38% and 47%, respectively. The mean P/S ratio increased from 0.24 to 0.31 while the regional differences in the intakes of fatty acids remained unchanged, the P/S ratio being higher in urban than in rural areas and higher in western than in eastern Finland. In 1986 the diet of 15-, 18- and 24-year-old males contained more fat, saturated fatty acids and monounsaturated fatty acids but less sucrose than that of females. The difference in the diet between young men and women, if continued, might increase the male/female ratio at risk for coronary heart disease, which is already pronounced in Finland.

The influence of dietary education in diabetic children

The aim of our study was to evaluate the efficacy of dietary education in inducing modification of the diet and to measure biochemical parameters in 36 children and adolescents with IDDM. At the beginning of the study, each patient was evaluated as follows: food intake (by the method of the 24-h recall for 3 days), auxological parameters, biochemical parameters. Thereafter a program of nutritional guidelines was provided. Subsequent meetings took place at 1-month-intervals. The study ended 3 months later, when all the parameters were completely revalued. We observed improved nutrition in our patients both in terms of total caloric intake and calorie distribution. In particular there was an increase in carbohydrates and a reduction in lipids, reaching the percentage levels recently recommended. With a reduction in lipid intake a significant decrease in LDL cholesterol and a significant increase in HDL cholesterol were noticed in our patients. These modifications are very important for the prevention of arteriosclerosis and thus macrovascular disease. We maintain that dietary education plays an important role in helping children and adolescents with IDDM to follow a suitable diet.