ISPAD Clinical Practice Consensus Guidelines 2014. Nutritional management in children and adolescents with diabetes

Mitigating iftar-related glycemic excursions in adolescents and young adults with type 1 diabetes on MiniMed™ 780G advanced hybrid closed loop system: a randomized clinical trial for adjunctive oral vildagliptin therapy during Ramadan fasting

BACKGROUND

Ramadan Iftar meal typically causes glucose excursions. Dipeptidyl peptidase-4 inhibitors increase glucagon-like peptide-1 and thus, decrease blood glucose levels with low risk of hypoglycemia.

AIM

To investigate the efficacy and safety of vildagliptin as an add-on therapy on glucose excursions of Iftar Ramadan meals among adolescents and young adults with type 1 diabetes mellitus (T1DM) using advanced hybrid closed-loop (AHCL) treatment.

METHODS

Fifty T1DM patients on MiniMed™ 780G AHCL were randomly assigned either to receive vildagliptin (50 mg tablet) with iftar meal during Ramadan month or not. All participants received pre-meal insulin bolus based on insulin-to-carbohydrate ratio (ICR) for each meal constitution.

RESULTS

Vildagliptin offered blunting of post-meal glucose surges (mean difference - 30.3 mg/dL [- 1.7 mmol/L] versus - 2.9 mg/dL [- 0.2 mmol/L] in control group; p < 0.001) together with concomitant exceptional euglycemia with time in range (TIR) significantly increased at end of Ramadan in intervention group from 77.8 ± 9.6% to 84.7 ± 8.3% (p = 0.016) and time above range (180-250 mg/dL) decreased from 13.6 ± 5.1% to 9.7 ± 3.6% (p = 0.003) without increasing hypoglycemia. A significant reduction was observed in automated daily correction boluses and total bolus dose by 23.9% and 16.3% (p = 0.015 and p < 0.023, respectively) with less aggressive ICR settings within intervention group at end of Ramadan. Coefficient of variation was improved from 37.0 ± 9.4% to 31.8 ± 7.1%; p = 0.035). No severe hypoglycemia or diabetic ketoacidosis were reported.

CONCLUSION

Adjunctive vildagliptin treatment mitigated postprandial hyperglycemia compared with pre-meal bolus alone. Vildagliptin significantly increased TIR while reducing glycemic variability without compromising safety. Trial registration This trial was registered under ClinicalTrials.gov Identifier no. NCT06021119.

Post-Hypoglycemic hyperglycemia are highly relevant markers for stratification of glycemic variability and partial remission status of pediatric patients with new-onset type 1 diabetes

AIMS

To evaluate whether parameters of post-hypoglycemic hyperglycemia (PHH) correlated with glucose homeostasis during the first year after type 1 diabetes onset and helped to distinguish pediatric patients undergoing partial remission or not.

METHODS

In the GLUREDIA (GLUcagon Response to hypoglycemia in children and adolescents with new-onset type 1 DIAbetes) study, longitudinal values of clinical parameters, continuous glucose monitoring metrics and residual β-cell secretion from children with new-onset type 1 diabetes were analyzed during the first year after disease onset. PHH parameters were calculated using an in-house algorithm. Correlations between PHH parameters (i.e., PHH frequency, PHH duration, PHH area under the curve [PHHAUC]) and glycemic homeostasis markers were studied using adjusted mixed-effects models.

RESULTS

PHH parameters were strong markers to differentiate remitters from non-remitters with PHH/Hyperglycemia duration ratio being the most sensitive (ratio<0.02; sensitivity = 86% and specificity = 68%). PHHAUC moderately correlated with parameters of glucose homeostasis including TIR (R2 = 0.35, p-value < 0.05), coefficient of variation (R2 = 0.22, p-value < 0.05) and Insulin-Dose Adjusted A1c (IDAA1C) (R2 = 0.32, p-value < 0.05) and with residual β-cell secretion (R2 = 0.17, p-value < 0.05). Classification of patients into four previously described glucotypes independently validated PHH parameters as reliable markers of glucose homeostasis and improved the segregation of patients with intermediate values of IDAA1C and estimated C-peptide (CPEPEST). Finally, a combination of PHH parameters identified groups of patients with specific patterns of hypoglycemia.

CONCLUSION

PHH parameters are new minimal-invasive markers to discriminate remitters from non-remitters and evaluate glycemic homeostasis during the first year of type 1 diabetes. PHH parameters may also allow patient-targeted therapeutic management of hypoglycemic episodes.

Deep Analysis of Clinical Parameters and Temporal Evolution of Glycemic Parameters Based on CGM Data for the Characterization of Severe Hypoglycemia in a Cohort of Children and Adolescents with Type 1 Diabetes

This study aims to evaluate the determinants and clinical markers of patients at risk for severe hypoglycemia (SH) in children and adolescents with type 1 diabetes. In the EPI-GLUREDIA study, clinical parameters and continuous glucose monitoring metrics from children and adolescents with type 1 diabetes were retrospectively analyzed between July 2017 and June 2022. Their clinical parameters were collected during traditional and quarterly medical consultations according to whether they experienced severe hypoglycemia or not. Then, continuous glucose monitoring metrics were analyzed on days surrounding SH during specific periods. According to the glycemic parameters, glycemic hemoglobin and glycemic mean were significantly lower in the three months preceding a SH compared with during three normal months (p < 0.05). Moreover, the time spent in hypoglycemia(time below the range, TBR_<3.3) and its strong correlation (R = 0.9, p < 0.001) with the frequency of SH represent a sensitive and specific clinical parameter to predict SH (cut-off: 9%, sensitivity: 71%, specificity: 63%). The second finding of the GLUREDIA study is that SH is not an isolated event in the glycemic follow-up of our T1DM patients. Indeed, most of the glycemic parameters (i.e., glycemic mean, glycemic variability, frequency of hypoglycemia, and glycemic targets) vary considerably in the month preceding an SH (all p < 0.05), whereas most of these studied glycemic parameters remain stable in the absence of a severe acute complication (all p > 0.05). Furthermore, the use of ROC curves allowed us to determine for each glycemic parameter a sensitive or specific threshold capable of more accurately predicting SH. For example, a 10% increase in the frequency of hypoglycemia predicts a risk of near SH with good combination of sensitivity and specificity (sensitivity: 80%, specificity: 60%). The GLUREDIA study aimed to target clinical and glycemic parameters to predict patients at risk for SH. First, we identified TBR_<3.3 < 9% as a sensitive and specific tool to reduce the frequency of SH. In addition, SH was not an isolated event but rather it was accompanied by glycemic disturbances in the 30 days before SH.

From Metabolic Syndrome to Type 2 Diabetes in Youth

In the frame of metabolic syndrome, type 2 diabetes emerges along a continuum of the risk from the clustering of all its components, namely visceral obesity, high blood pressure and lipids, and impaired glucose homeostasis. Insulin resistance is the hallmark common to all the components and, in theory, is a reversible condition. Nevertheless, the load that this condition can exert on the β-cell function at the pubertal transition is such as to determine its rapid and irreversible deterioration leading to plain diabetes. The aim of this review is to highlight, in the context of metabolic syndrome, age-specific risk factors that lead to type 2 diabetes onset in youth; resume age specific screening and diagnostic criteria; and anticipate potential for treatment. Visceral obesity and altered lipid metabolism are robust grounds for the development of the disease. Genetic differences in susceptibility to hampered β-cell function in the setting of obesity and insulin resistance largely explain why some adolescents with obesity do develop diabetes at a young age and some others do not. Lifestyle intervention with a healthy diet and physical activity remains the pillar of the type 2 diabetes treatment in youth. As to the pharmacological management, metformin and insulin have failed to rescue β-cell function and to ensure long-lasting glycemic control in youth. A new era might start with the approval for use in pediatric age of drugs largely prescribed in adults, such as dipeptidyl peptidase-4 and sodium-dependent glucose transport inhibitors, and of new weight-lowering drugs in the pipeline such as single and multiple agonists of the glucagon-like peptide 1 receptor. The latter drugs can have tremendous impact on the natural history of the disease. By treating diabetes, they will reduce the burden of all the metabolic abnormalities belonging to the syndrome while causing a tremendous weight loss hitherto never seen before.

Disordered eating and behaviors among young Egyptians with type 1 diabetes: risk factors and comorbidities

OBJECTIVES

The study aimed to assess occurrence of eating disorders and its nature, associated risk factors, and comorbidities in a cohort of adolescents with type 1 diabetes (T1D).

METHODS

In this cross-sectional study, 138 patients were recruited to complete three questionnaires for assessment of eating disorder (ED); Eating Attitude Test (EAT-26) and Eat Behavior questionnaire (ORTO-15) and Eating Disorder Examination Questionnaire version 6 (EDE-Q6) to assess diabetes-related medical outcomes.

RESULTS

Patients were categorized as having an ED according to predetermined cutoff value for each questionnaire. Of the 138 patients, 24 (17.4%) had risk for EDs by EAT-26 score, 53 (38.4%) have got orthorexia nervosa by ORTO-15 and 45 (32.6%) were having a disordered eating behavior by EDE-Q6. Patients with risk of EDs had lower mean ORTO-15 score (p=0.01), and higher mean Global EDE-Q6 (p<0.001). A positive correlation was found between EAT-26 scores and both age (p<0.0001) and body mass index (p<0.0001). ORTO-15 score was correlated with duration of diabetes (p=0.0418). Diabetic ketoacidosis, peripheral neuropathy, and microalbuminuria occurred frequently in patients with ED high score. Hypoglycemic episodes were reported more in those with high EAT-26 or Global EDE-Q6 scores.

CONCLUSIONS

Subclinical EDs and abnormal eating behaviors are common in Egyptian adolescents with T1D.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

Physical Activity and Nutrition Interventions for Type 1 Diabetes: A Meta-analysis

BACKGROUND AND OBJECTIVES

Current evidence is lacking on physical activity and nutrition-based interventions focusing on the management of type 1 diabetes mellitus (T1DM) and health-related quality of life among children. To assess the effects of physical activity interventions and nutrition-based interventions for children with T1DM.

METHODS

Data sources include the Cochrane Central Register of Controlled Trials, Medline, clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, CINAHL through January 2022. Study selection includes randomized controlled trials of children aged 18 years and below with T1DM comparing either a physical activity intervention, a nutrition-based intervention, or hybrid physical activity and nutrition-based intervention with placebo or no-treatment control. Data were pooled using a random-effects model. Primary outcomes were hemoglobin A1c (HbA1c), and health-related quality of life.

RESULTS

Eighteen trials were included. Physical activity compared with the no-treatment group showed a lack of effect on HbA1c (mean difference = -0.58, 95% confidence interval -1.20 to 0.05; P value = .07). Nutrition-based intervention compared with no-treatment control for HbA1c level revealed a lack of effect (mean difference = -0.61, 95% confidence interval -1.48 to 0.26; P value = .17). Limitations include paucity of studies and low quality of evidence caused by the risk of bias.

CONCLUSIONS

Despite the lack of significant evidence, the generally favorable results highlight the potential of such interventions in enhancing glycemic control and health-related quality of life. Additionally, promising results from a single physical activity-nutrition-based hybrid intervention in terms of glycemic control indicate the plausible effectiveness of a mixed intervention.

The relationship between meal carbohydrate quantity and the insulin to carbohydrate ratio required to maintain glycaemia is non-linear in young people with type 1 diabetes: A randomized crossover trial

OBJECTIVE

To determine if the relationship between meal carbohydrate quantity and the insulin to carbohydrate ratio (ICR) required to maintain glycaemia is linear in people with type 1 diabetes.

METHODS

We used an open labelled randomized four-arm cross-over study design. Participants (N = 31) aged 12-27 years, HbA1c ≤ 64 mmol/mol (8.0%) received insulin doses based on the individual's ICR and the study breakfast carbohydrate quantity and then consumed four breakfasts containing 20, 50, 100 and 150 g of carbohydrate over four consecutive days in randomized order. The breakfast fat and protein percentages were standardized. Postprandial glycaemia was assessed by 5 h continuous glucose monitoring. The primary outcome was percent time in range (TIR) and secondary outcomes included hypoglycaemia, glucose excursion and incremental area under the curve. Statistical analysis included linear mixed modelling and Wilcoxon signed rank tests.

RESULTS

The 20 g carbohydrate breakfast had the largest proportion of TIR (0.74 ± 0.29 p < 0.04). Hypoglycaemia was more frequent in the 50 g (n = 13, 42%) and 100 g (n = 15, 50%) breakfasts compared to the 20 g (n = 6, 20%) and 150 g (n = 7, 26%) breakfasts (p < 0.029). The 150 g breakfast glucose excursion pattern was different from the smaller breakfasts with the lowest glucose excursion 0-2 h and the highest excursion from 3.5 to 5 h.

CONCLUSIONS

A non-linear relationship between insulin requirement and breakfast carbohydrate content was observed, suggesting that strengthened ICRs are needed for meals with ≤20 and ≥150 g of carbohydrate. Meals with ≥150 g of carbohydrate may benefit from dual wave bolusing.

Rethinking Carbohydrate Intake and Time in Range in Children and Adolescents with Type 1 Diabetes

The aim of this study was to evaluate the association between macronutrient intake and time in range (TIR) of 70–180 mg/dL in children and adolescents with type 1 diabetes (T1D). A multi-center study recruited patients with T1D using continuous glucose monitoring (CGM) between January 2019 and January 2020 from centers across Italy. Diet intake was recorded using three-day weighed food diaries. Nutrients were evaluated as percentages of total intake. TIR was considered at target if the percentage of readings was higher than 70%. Clinical and nutritional factors associated with TIR at target were analyzed using multiple correspondence analysis and multiple logistic regression. Data from 197 participants (53% male, median age 11.6 years, median HbA1c 55.2 mmol/mol, median TIR 60%) were analyzed. Macronutrient intake was 45.9% carbohydrates, 16.9% protein, 37.3% fat, and 13.1 g/day fiber (median values). TIR > 70% was observed in 28% of participants; their diet contained more protein (17.6%, p = 0.015) and fiber (14.4 g/day, p = 0.031) than those not at target. The probability of having a TIR > 70% was significantly higher with 40–44% consumption of carbohydrates compared with 45–50% consumption of carbohydrates and with the use of a carbohydrate counting system. Based on these results, a five percent reduction in the percentage of carbohydrate intake can help children and adolescents with T1D achieve the goal of a TIR > 70%. Both a lower and higher percentage of carbohydrate intake appears to reduce the probability of reaching the target TIR > 70%. These results require validation in other populations before being used in clinical practice.

Combined Algorithm-Based Adaptations of Insulin Dose and Carbohydrate Intake During Exercise in Children With Type 1 Diabetes: Results From the CAR2DIAB Study

Objectives

To evaluate the evolution of subcutaneous glucose during two sessions of monitored aerobic exercise in children or adolescents with type 1 diabetes after adaptation of insulin doses and carbohydrate intake according to a combined algorithm.

Methods

Twelve patients with type 1 diabetes (15.1 ± 2 years; diabetes duration: 9.5 ± 3.1 years) performed two series of exercise sessions after cardiac evaluation. The first series (TE#1) consisted in a monitored exercise of moderate to vigorous intensity coupled with a bout of maximum effort. The second series of exercises (TE#2) was carried out in real life during exercises categorized and monitored by connected watches. TE#2 sessions were performed after adaptation of insulin doses and fast-acting carbohydrates according to decision algorithms.

Results

Patients did not experience episodes of severe hypoglycemia, symptomatic hyperglycemia, or hyperglycemia associated with ketosis. Analysis of CGM data (15 h) during TE#2 sessions revealed an overall improvement in glycemic average [± standard deviation] (104 ± 14 mg/dl vs. 122 ± 17 mg/dl during TE#1; p < 0.001), associated with a decrease in proportion of hyperglycemia in periods ranging from 4 h to 15 h after performing the exercises. The proportion of hypoglycemia was not changed, except during the TE#2 +4-8 h period, where a significant increase in hypoglycemia <60 mg/dl was observed (25% vs. 6.2%; p = 0.04), yet without concurrent complications.

Conclusion

In our pediatric series, the application of algorithmic adaptations of insulin doses and carbohydrate intake has globally improved glycemic control during 15 h after real-time exercises performed by children and adolescents with type 1 diabetes.

Reliability and Validity of a Carbohydrate-Counting Knowledge Questionnaire for Young Australians With Type 1 Diabetes

OBJECTIVE

To test the reliability and validity of a carbohydrate-counting knowledge questionnaire in young Australians with type 1 diabetes mellitus (T1DM).

METHODS

Children or young adults (<20 years) with T1DM, or their parents, completed the 72-item Australian PedCarbQuiz (AusPCQ), adapted from the American PedCarbQuiz, and an expert assessment of carbohydrate-counting knowledge. Responses were scored and summed (0-72, higher scores = greater knowledge). Internal reliability was assessed using Cronbach α, and relative validity using Spearman correlations (with HbA1c) and Bland-Altman analysis (with the expert assessment).

RESULTS

Australian PedCarbQuiz reliability (n = 44, mean score = 59.7 ± 5.6) was acceptable (α = 0.83). There was a lack of agreement (mean bias = 10.7, P = 0.008) and significant proportional bias between AusPCQ scores and expert assessments (β = -0.73 [95% confidence interval, -1.82 to -0.79]; P < 0.001).

CONCLUSIONS AND IMPLICATIONS

The AusPCQ was shown to be reliable but not valid in a small sample. Testing in a larger sample is warranted.

Disordered Eating Behaviors Among Italian Adolescents with Type 1 Diabetes: Exploring Relationships with Parents' Eating Disorder Symptoms, Externalizing and Internalizing Behaviors, and Body Image Problems

The purpose of this study is to examine associations of disordered eating behaviors (DEBs) with body image problems, parents' eating disorder symptoms, and emotional and behavioral problems among adolescents with type 1 diabetes (T1D). 200 adolescents (M age = 15.24 ± 1.45 years) with T1D completed a self-report measure of DEBs and body ideal internalization, and their parents completed self-report measures of parents' eating problems and child's psychological symptoms. Seventy-three (36.5%) adolescents were DEPS-r-positive (scores ≥ 20), with higher rates among girls (χ² = 9.034, p = .003). Adolescents with T1D and DEBs reported lower SES, worse metabolic control, higher zBMI (p < .001), more eating disorder symptoms, more body image problems, and more emotional and behavioral problems than adolescents with T1D but no DEBs (all p < .05). Parents of adolescents with DEBs showed higher levels of bulimia (p = .028) than parents of adolescents without DEBs. In both genders, pressure to conform to societal norms about body image (p < .01) and externalization symptoms (p < .05) emerged as significant predictors of DEBs. Findings suggest that adolescents with T1D and DEBs showed an alarming psychological condition, with higher level of body image and more emotional and behavioral problems.

Dietary management practices for type 1 diabetes mellitus by dietitians in KwaZulu-Natal

Background

In South Africa, 5% – 15% of diabetics have type 1 diabetes mellitus (T1DM). Dietitians are an important part of the diabetes management team; however, there is a lack of published data on the dietary management practices for T1DM by dietitians.

Aim

The aim of this study was to determine the dietary management practices for T1DM by dietitians in KwaZulu-Natal (KZN).

Setting

This study was conducted in KZN.

Methods

A cross-sectional, descriptive study was conducted using a self-administered electronic questionnaire.

Results

Of the 69 dietitians who participated, 58% (n = 40) used the American Diabetes Association (ADA) guidelines to manage T1DM; just under 35% (n = 24) spent over an hour with new cases; and 87% (n = 60) used face-to-face consultations for follow-up. Dietitians used the glycaemic index, portion control using the healthy eating plate, carbohydrate counting using nutritional labels and household measures and carbohydrate awareness to manage T1DM (p < 0.05). Dietitians also used the healthy eating plate (71%; n = 49) (p < 0.05) and household measures (73.9%; n = 51) (p < 0.05) to manage T1DM. Time constraints, the literacy level of the patient, available resources and language barriers all played a role in determining the dietary management practices used (p < 0.05).

Conclusion

Most dietitians in KZN used the ADA dietary guidelines to manage T1DM, which highlights the need for South African dietary guidelines for the management of T1DM. Dietitians used a variety of different dietary methods to manage T1DM in practice. This suggests that dietitians are flexible in how they manage T1DM with no one particular method being used. A variety of factors also influenced which dietary management practices were chosen.

Caregivers' Nutrition Knowledge and Dietary Intake of Type 1 Diabetic Children Aged 3-14 Years in Uganda

PURPOSE

This study aimed to assess the association between caregiver's level of type 1 diabetes (T1D) nutrition knowledge with children's dietary diversity score (DDS), mean intake of macronutrients, nutrient adequacy ratios (NARs) and mean adequacy ratio (MAR).

RESEARCH DESIGN AND METHODS

A cross-sectional analytical study design was used. The study was conducted at 6 diabetes clinics in Uganda among 59 caregivers and 61 children. T1D nutrition knowledge survey (NKS) was used to assess the caregiver's nutrition knowledge, and the 24-hour dietary recall and dietary diversity score (DDS) questionnaires were used to collect data on the child's dietary intake.

RESULTS

Majority (93.2%) of the caregivers had low T1D nutrition knowledge. Carbohydrate counting was the least performed nutrition knowledge domain. The children's mean DDS, calorie intake and MAR were 5.7 ± 1.6, 666.7 ± 639.8 kcal and 0.7 ± 0.3, respectively. The mean NARs of carbohydrate, protein, and fat were 0.9 ± 0.3, 0.9 ± 0.4, 0.5 ± 0.5, respectively. There was a significant association between DDS with NARs of carbohydrate, protein, fat, vitamins A, B2, B3, B5, B12, folic acid, zinc and MAR. No formal education was significantly associated with a lower mean NKS score among caregivers (p = 0.039). Caregivers' T1D nutrition knowledge, age and family size explained 14% of variation in the child's dietary diversity (p = 0.041).

CONCLUSION

Despite poor nutrition knowledge among caregivers especially on carbohydrate counting, dietary diversity among children with T1D remained favorable. Excess carbohydrate intake was observed with inadequate intake of proteins, fats and micronutrients (vitamin A, B vitamins and calcium). Caregivers with low education were more likely to register poor nutrition knowledge; therefore, there is need to develop and tailor nutrition education programmes to enhance comprehensive learning among caregivers for improved outcomes.

Low-carb Diet in Hospitalized Late Pubertal Type 1 Diabetic Girls: A Short-Term CGM Study

OBJECTIVE

We conducted the present study to observe potential short-term benefits or risks of low-carb diet (LCD).

METHODS

This is a prospective randomized cross-over study. Type 1 diabetic girls were hospitalized in ternary groups for 7 days and each group randomly started with LCD or regular diet. Continuous glucose monitoring (CGM) was performed between 0 and 168 h.

RESULTS

Twenty-eight subjects completed the study. Total energy, protein, and fat consumption were high (P < 0.001); carbohydrate consumption and rapidly acting insulin dose were low (P < 0.001 and P = 0.002, respectively) during LCD. Morning postprandial, noon postprandial, and evening preprandial capillary blood sugar levels were lower during LCD (P = 0.013, 0.018, and 0.048, respectively).

CONCLUSION

LCD may have the advantage of better glycemic control despite lower insulin dose which is a favorable outcome with regard to weight control and atherosclerosis prevention. No adverse events were observed.

Effect of adherence to carbohydrate counting on metabolic control in children and adolescents with type 1 diabetes mellitus

PURPOSE

Carbohydrate counting provides better glycemic control and flexibility than other food planning methods. Consistent adherence to such a complex method is difficult, especially for youth. However, studies that determine adherence to this method and whether it alters metabolic control are limited. The aim of the current study was to determine adherence to this method and investigate its effect on metabolic control, anthropometric measurements, insulin dose, and energy intake.

METHODS

In this prospective cross-sectional study, 53 children and adolescents with type 1 diabetes mellitus aged 2 to18 years and receiving intensive insulin therapy were trained and followed for 6 months. Demographics, anthropometrics, insulin requirements, hemoglobin A1c (HbA1c), fasting lipids, and food records at baseline and study conclusion were evaluated. At the end of the study patients were divided into adherer and nonadherer groups according to carbohydrate estimate deviations from standardized daily sample menus and calculations for accurate insulin doses. More than 10-g variation in daily consumed carbohydrate amount or failure to decide bolus insulin dose was defined as a nonadherer.

RESULTS

The mean HbA1c, low-density lipoprotein cholesterol, and body mass index standard deviation score changed after the carbohydrate counting training while the mean HbA1c between groups was significant (P<0.05). Total daily insulin doses increased, and the mean high-density lipoprotein cholesterol levels decreased in both groups. There were significant correlations between HbA1c and carbohydrate deviation scores as well as HbA1c and caregiver's education level.

CONCLUSION

Since adherence to carbohydrate counting may affect metabolic control, health professionals should evaluate and monitor carbohydrate counting skills of caregivers and patients in order to improve efficiency.

Challenges Experienced by Parents of Emerging Young Adults With Type 1 Diabetes Mellitus During the Transition to College

PURPOSE

The purpose of this study is to gain a deeper understanding of the challenges experienced by parents of emerging young adults (EYAs) with type 1 diabetes mellitus (T1DM) who completed their freshman or sophomore year of college.

METHODS

Using a descriptive, qualitative design, 16 parents participated in semistructured interviews that explored factors impacting the college transition for parents of college freshmen and sophomores with T1DM. Participants were recruited from local endocrinology clinics as well as the College Diabetes Network (CDN) Parent Facebook page, the CDN Facebook page, the CDN Twitter feed, and the Delaware Chapter of the JDRF (formerly Juvenile Diabetes Research Foundation). Researchers used a thematic analysis to analyze the data and develop categories. Interviews were conducted and recorded via video conferencing from July 2019 to September 2019.

RESULTS

Results represent data from 16 interviews comprising 15 (94%) mothers and 1 father. Thematic analysis resulted in the emergence of 3 themes: managing parental concerns, changes in the parental role, and identifying sources of parental support. Parents identified several challenges including the EYAs' ability to manage T1DM at college, communication with the EYA, and the availability of support for parents.

CONCLUSION

Parents experience several challenges during their EYA's transition to college with T1DM. Supporting the needs of parents and EYAs during this time may serve to reduce diabetes-related complications for EYAs and increase overall quality of life for both members of the dyad.

Body fat composition and miR-378 expression profiling in patients with type 1 diabetes

PURPOSE

Type 1 diabetes (T1D) is an autoimmune disease that involves genetic, epigenetic, and environmental factors. Change in body composition is a potential mechanism for explaining the increased incidence of T1D. Micro RNA-378 (miRNA-378) is a positive regulator of adipogenesis that has yet to be studied in such patients. This study aims to evaluate the miRNA-378 expression profile in peripheral mononuclear cells of T1D patients and controls and to determine its possible association with levels of body fat, interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-α).

METHODS

Twenty-four T1D subjects and 20 controls under 18 years of age without autoimmune diseases were studied. miRNA-378 expression profile was determined by TaqMan probes. Body composition was determined by multifrequency bioimpedance. IL-6 and TNF-α serum levels were determined by LUMINEX. AntiGAD65, anti-IA2, and anti-ZnT8 antibodies were quantified in serum by enzyme immunoassays. Statistical significance was considered P&lt;0.05.

RESULTS

Similar body mass index and body fat (kg) were observed between the T1D and control subjects (P=0.55 and P=0.69, respectively). The miRNA-378 expression profile was significantly higher in T1D patients compared with the controls (P&lt;0.05). Lower miRNA-378 expression in prepubertal controls was observed compared to pubertal controls, prepubertal T1D, and pubertal T1D (P&lt;0.05). AntiGAD65, AntilA2, and AntiZnT8 were positively correlated with miRNA-378 (P=0.002, P=0.053, and P=0.007). No statistically significant correlation was observed between miRNA-378 expression and IL-6, TNF-α, or body fat.

CONCLUSION

Elevated miRNA-378 expression in T1D patients compared with controls is linked to pubertal stage but is not associated with proinflammatory status or body composition.

The Effects of Synbiotic Supplementation on Glycemic Status, Lipid Profile, and Biomarkers of Oxidative Stress in Type 1 Diabetic Patients. A Placebo-Controlled, Double-Blind, Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

The aim of the present study was to evaluate the effects of synbiotic on glycemic status, lipid profile, and biomarkers of oxidative stress in type 1 diabetes mellitus (T1DM) patients.

MATERIALS AND METHODS

In this double-blind clinical trial, 50 T1DM patients were randomly allocated to intervention (n = 25) and control (n = 25) groups and received either synbiotic powder (Lactobacillus sporogenes GBI-30 (probiotic), maltodextrin and fructooligosaccharide (prebiotic)) or placebo 2 g per day for 8 weeks. Fasting blood samples were collected before and after the intervention to measure fasting blood glucose (FBG), insulin concentration, hemoglobin A1c (HbA1c), lipid profile, and biomarkers of oxidative stress such as total antioxidant capacity (TAC) and hs-C-reactive protein (hs-CRP).

RESULTS

Supplementation with synbiotic resulted in a significant decrease in the mean serum levels of HbA1c and hs-CRP (p = 0.01 and p = 0.004, respectively), and marginally significant decrease in FBG (p = 0.05) in the intervention group post- intervention. Also, the mean changes of FBG and hs-CRP were significantly lower in the intervention group compared with the control group (p = 0.03 and p = 0.005, respectively). There were no significant changes found in lipid profile in intervention group post-intervention (p≥ 0.05). The mean serum levels of insulin and TAC were significantly increased in the intervention group post-intervention (p = 0.001). There was a significant increase in the mean changes of TAC (p = 0.005) in the intervention group compared with the control group.

CONCLUSION

The 8-week synbiotic supplementation in T1DM patients may be effective in improvement of FBG, HbA1c, insulin, hs-CRP, and TAC.

A Clinical Review on Nutritional Requirements and Assessment for Type 2 Diabetes Mellitus with Chronic Renal Disease

BACKGROUND

A significant correlation exists between type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), where up to 40% of diabetic patients suffer from CKD as a direct result of diabetic complications. The management of diabetes in CKD patients can be challenging due to their need for disease-specific diets, as well as increased risks of complications due to malnutrition, which is why their dietary needs and nutritional requirements require attention to detail, and have to be assessed and tailored according to the patient's needs.

OBJECTIVES

This systematic review aimed to assess nutritional requirements for type 2 diabetes mellitus patients with chronic renal failure.

METHODS

In this review, 85 articles were screened, and 22 articles were then analyzed and selected as per the study criteria. PRISMA guidelines were used to select and screen the articles. Data search included a PubMed search using MeSH terms, and a literature review through the Cochrane library and the British Medical Journal.

RESULTS

The study highlighted the important nutrients and minerals needed to be maintained within a specified range in accordance with the patient's needs and conditions. In addition, dietary restrictions must be set to prevent disease progression and deterioration. Dietary intake in hemodialysis patients must be carefully calculated based on their needs, with tight monitoring of their blood glucose. Protein intake in hemodialysis patients should be determined based on risk-to-benefit ratios.

CONCLUSION

Dietary requirements should be individualized based on the patient's disease severity and progression. Assessment of the patient's previous and current diet, as well as matching it with their dietary requirements and preferences is crucial.

Zinc supplementation improves glucose homeostasis in patients with β-thalassemia major complicated with diabetes mellitus: A randomized controlled trial

OBJECTIVES

The development of abnormal glucose tolerance in β-thalassemia major (β-TM) is associated with alterations in the oxidant-antioxidant status. Zinc is an antioxidant and an essential element for insulin synthesis, storage, and secretion. This randomized controlled trial assessed the effect of oral zinc supplementation on glucose homeostasis in pediatric β-TM patients complicated with diabetes mellitus (DM).

METHODS

Eighty patients were randomly assigned into two groups: an intervention group that received oral zinc in a dose of 40 mg/d for 12 wk and a placebo group. Hemolysis markers, serum ferritin, fasting blood glucose (FBG), fructosamine, fasting C-peptide, urinary albumin excretion (UAE), and serum zinc levels were assessed. Homeostasis model assessment insulin resistance index (HOMA-IR) was calculated.

RESULTS

Baseline clinical and laboratory parameters were consistent among both groups. Baseline zinc levels were decreased in both groups compared with control values. After 12 wk, supplementation with zinc for the intervention group resulted in a significant decrease in lactate dehydrogenase, serum ferritin, FBG, fructosamine, HOMA-IR, and UAE, whereas fasting C-peptide was higher compared with baseline levels and with the placebo group (P < 0.05). Baseline serum zinc was negatively correlated to FBG (r = -0.534, P < 0.001) and fructosamine (r = -0.555, P < 0.001) but positively correlated to fasting C-peptide (r = 0.777, P = 0.002).

CONCLUSIONS

Zinc supplementation as an adjuvant therapy in β-TM patients with DM reduced iron burden, decreased hyperglycemia, increased insulin secretion, and improved glycemic control without any adverse effects.

Australian children with type 1 diabetes consume high sodium and high saturated fat diets: Comparison with national and international guidelines

AIM

We aimed to evaluate the diets of children with type 1 diabetes (T1D) against recommended Australian dietary intakes and international T1D guidelines and compare them to children without T1D.

METHODS

A cross-sectional analysis in 143 children (103 children aged 8-18 years with T1D and 40 age- and gender-matched controls) and longitudinal analysis at 0, 3, 6 and 12 months in 90 T1D children were conducted. Diet was assessed using an Australian validated food frequency questionnaire. Diet quality was assessed against recommended servings and nutrient intakes from Australian Dietary Guidelines and International Society for Pediatric and Adolescent Diabetes (ISPAD) Nutritional Guidelines.

RESULTS

Diet was evaluated in 478 questionnaires. Diet composition did not differ between T1D and controls, and both groups did not meet the majority of the Australian Dietary Guidelines, except for fruit intake. The majority of T1D children and controls (80-83%) were overconsuming sodium (2837 ± 848 mg/day), discretionary foods (5.9 ± 2.5 serves/day) and saturated fat and trans fatty acids (13.1 ± 2.7% of total daily energy intake) in comparison with Australian and ISPAD guidelines. A total of 84% of T1D children and controls achieved the recommended intake of fibre (34.4 ± 11.0 g/day). Longitudinal analysis in children with T1D showed that total daily energy, macronutrient, micronutrient and food group servings intake did not change over the 12 months. Overconsumption of sodium, discretionary foods and saturated fat persisted over the 12-month study period.

CONCLUSIONS

The majority of Australian children, with and without T1D, is not meeting recommended dietary guidelines. Significant overconsumption of sodium, saturated fat and discretionary foods attracts the most concern.

Predictor factors of glycemic control in children and adolescents with type 1 diabetes mellitus treated at a referral service in Rio de Janeiro, Brazil

AIM

To evaluate the predictive factors of glycemic control in children and adolescents with type 1 diabetes mellitus (T1DM).

METHODS

Cross-sectional study at a referral service in Rio de Janeiro, Brazil. Sociodemographic, anthropometric, clinical, and dietary factors were evaluated. Food consumption was evaluated by 24 h dietary recall and the NOVA system was adopted for classifying the foods according to the extent and purpose of industrial processing. The predictive factors were evaluated by multivariate linear regression, adopting p < 0.05.

RESULTS

One hundred and twenty children and adolescents participated, with a mean age of 11.74 years (±2.88) and HbA1c of 8.13% (±1.26). The mean diabetes duration was 6.68 years (±3.33) and the insulin used was 1.05 units per kilogram of ideal weight (IU/kg of ideal weight; ±0.46) About 80% (n = 96) used carbohydrate counting and it was verified that 24.27% (±17.89) of the participants' total calories came from ultraprocessed foods. For each year of diagnosis with T1DM and for each IU/kg of weight used, HbA1c increased by 0.087% (β = 0.087, p = 0.007) and 0.651%, respectively (β = 0.651; p = <0.001). Use of carbohydrate counting was associated with a 1.058% reduction in HbA1c (β = -1.058; p = 0.001).

CONCLUSION

Disease duration and insulin dose were directly reflected in HbA1c concentrations, while carbohydrate counting showed an inverse association.

Barriers and Facilitators Influencing Parental Transition of College-Bound Youth with Type 1 Diabetes Mellitus: An Integrative Review

PURPOSE OF REVIEW

The purpose of this review was to synthesize current research about potential barriers impacting parents as they transition their college-bound youth with type 1 diabetes mellitus (T1DM) to college.

RECENT FINDINGS

Seven studies, 5 qualitative and 2 quantitative, met the qualifications for inclusion in this study by focusing on parents and were included in this review. Three potential barriers impacting the parental experience during the transition of their youth with T1DM to college were identified: developing and promoting autonomy, evolving relationships and roles in the parent/youth dyad, and distress. Parents consistently indicated concern about their youth's ability to self-manage their T1DM and lack of support for their own transition. This review indicates that several barriers may influence parents of adolescents with T1DM as they transition to becoming the parent of a college-bound youth with T1DM. The parental transition of launching their youth to college is more complex and unique for parents of youth with T1DM parents of youth without chronic conditions. Additional research focusing on the identification of desired supports for parents and the development of specific interventions to assist parents as they transition with their college-bound youth with T1DM is recommended.

Self-Perceived Health Status and Sense of Coherence in Children With Type 1 Diabetes in the West Bank, Palestine

Introduction: Self-perceived health status and sense of coherence (SOC) are essential constructs for capturing health outcomes in children with type 1 diabetes (T1D). This study measured self-perceived health status and SOC in children with T1D and compared them with a healthy reference group in West Bank, Palestine. Methodology: One hundred children with T1D aged 8 to 18 years and 300 healthy children completed PedsQL 4.0 Generic Core Scales and SOC-13 in a cross-sectional descriptive study. Results: All children reported acceptable self-perceived health status and low degree of SOC. In the diabetes group, high degree of SOC was associated with better self-perceived health status and more optimal metabolic control. Males in the diabetes group reported higher self-perceived health status than females. Discussion: The unstable political situation in Palestine may threaten SOC in children in general. Health professionals can monitor self-perceived health status and SOC to evaluate interventions aiming to improve glycemic control.

Variation of carbohydrate intake in diabetic children on carbohydrate counting

AIMS

Carbohydrate counting (CC) is a technique for managing diabetes particularly based on the counting of carbohydrates. It allows diabetic patients to vary their amount of carbohydrates from one meal to another by adjusting their insulin dose. The primary objective was to determine the variation of carbohydrate intake (CI) in children on CC.

METHOD

This was a prospective study conducted between 2014 and 2016. We collected the amount of carbohydrates eaten at each meal by 77 diabetic over a period of 28 days (i.e. 8068 data). We analyzed the number and percentage of significant CI variation rates from one day to another, both for the whole day and for each meal. The CI variation rate was deemed significant if it was greater than or equal to 30%.

RESULTS

The percentage of significant CI variation rates was 30% at the daily level, 34% for breakfast, 44% for lunch and dinner, and 53% for snack. The percentage of significant variation rates varied according to age, treatment and occurrence of events.

CONCLUSION

Children varied their CI significantly from one meal to another more than one in three times. CC offers flexibility and a better quality of life for children using this method.

The ups and downs of low-carbohydrate diets in the management of Type 1 diabetes: a review of clinical outcomes

Dietary management has been a mainstay of care in Type 1 diabetes since before the discovery of insulin when severe carbohydrate restriction was advocated. The use of insulin facilitated re-introduction of carbohydrate into the diet. Current management guidelines focus on a healthy and varied diet with consideration of glycaemic load, protein and fat. As a result of frustration with glycaemic outcomes, low-carbohydrate diets have seen a resurgence in popularity. To date, low-carbohydrate diets have not been well studied in the management of Type 1 diabetes. Studies looking at glycaemic outcomes from low-carbohydrate diets have largely been cross-sectional, without validated dietary data and with a lack of control groups. The participants have been highly motivated self-selected individuals who follow intensive insulin management practices, including frequent blood glucose monitoring and additional insulin corrections with tight glycaemic targets. These confounders limit the ability to determine the extent of the impact of dietary carbohydrate restriction on glycaemic outcomes. Carbohydrate-containing foods including grains, fruit and milk are important sources of nutrients. Hence, low-carbohydrate diets require attention to vitamin and energy intake to avoid micronutrient deficiencies and growth issues. Adherence to restricted diets is challenging and can have an impact on social normalcy. In individuals with Type 1 diabetes, adverse health risks such as diabetic ketoacidosis, hypoglycaemia, dyslipidaemia and glycogen depletion remain clinical concerns. In the present paper, we review studies published to date and provide clinical recommendations for ongoing monitoring and support for individuals who choose to adopt a low-carbohydrate diet. Strategies to optimize postprandial glycaemia without carbohydrate restriction are presented.

Vitamin B complex supplementation as a homocysteine-lowering therapy for early stage diabetic nephropathy in pediatric patients with type 1 diabetes: A randomized controlled trial

BACKGROUND

Homocysteine levels are elevated in patients with type 1 diabetes mellitus (T1DM) and could induce renal injury. B vitamins have an important role in preventing microvascular complications of diabetes.

AIM

We performed a randomized-controlled trial of oral supplementation with vitamin B complex as an adjuvant therapy for nephropathy in pediatric T1DM patients and assessed its relation to homocysteine and cystatin C as a marker of nephropathy.

METHODS

This trial included 80 T1DM patients with microalbuminuria, despite oral angiotensin-converting enzyme inhibitors, aged 12-18 years with at least 5 years disease duration and HbA1c ≤8.5%. Patients were randomly assigned into two groups; intervention group which received oral vitamin B complex (B1, B6 and B12) once daily and placebo group. Both groups were followed-up for 12 weeks with assessment of plasma homocysteine, HbA1c, urinary albumin excretion (UAE) and cystatin C.

RESULTS

Both groups were well-matched in baseline clinical and laboratory parameters. Baseline homocysteine levels were elevated in both groups compared with reference control values. After 12 weeks, supplementation with vitamin B complex for the intervention group resulted in a significant decrease of homocysteine, fasting blood glucose, HbA1c, triglycerides, total cholesterol, UAE and cystatin C compared with baseline levels (p < 0.001) and with placebo group (p < 0.001). No adverse reactions were reported. Baseline cystatin C was negatively correlated to vitamin B12 (r = -0.77, p = 0.001).

CONCLUSIONS

Vitamin B complex improved glycemic control and renal function through decreasing homocysteine and could be a safe and effective strategy for treatment of early stage nephropathy in pediatric T1DM. This trial was registered at ClinicalTrials.gov (NCT03594240).

Resemblance of Diet Quality in Families of Youth with Type 1 Diabetes Participating in a Randomized Controlled Behavioral Nutrition Intervention Trial in Boston, MA (2010-2013): A Secondary Data Analysis

BACKGROUND

Parent-child diet quality resemblance is unknown in families of youth with type 1 diabetes, for whom nutrition is central to disease management.

OBJECTIVE

Examine diet quality resemblance in families of youth with type 1 diabetes participating in a behavioral nutrition intervention trial and investigate whether treatment assignment or family meal frequency modifies resemblance.

DESIGN

This is a secondary data analysis from an 18-month randomized controlled trial conducted August 2010 to May 2013.

PARTICIPANTS/SETTING

Parent-youth dyads (N=136, child age=12.3±2.5 years) were recruited from a northeast US diabetes center.

MAIN OUTCOME MEASURES

Parent and child Healthy Eating Index-2005 (HEI-2005, reflecting adherence to 2005 Dietary Guidelines for Americans) and whole plant food density (WPFD, reflecting intervention target foods) were calculated from 3-day food records collected every 6 months.

STATISTICAL ANALYSIS

Linear random effects models adjusting for demographics and disease characteristics investigated parent-child diet quality resemblance. Separate models examined whether treatment assignment or family meal frequency modified resemblance. Three-way interaction terms examined whether resemblance changed over time by treatment assignment.

RESULTS

Time-varying parent and child HEI-2005 and WPFD were positively associated (P<0.001), and there were no interactions with family meals. Parent-child HEI-2005 resemblance was similar across treatment groups; however, parent-child WPFD resemblance was stronger in the intervention (β±standard error [SE]=.30±.06) vs control families (β±SE=.12±.05). Parent-child HEI-2005 resemblance was similar over time by treatment assignment, whereas parent-child WPFD resemblance increased over time for families in the intervention group (three-way interaction term β±SE=.03±.01).

CONCLUSIONS

Parent and youth diet quality were positively correlated in families of youth with type 1 diabetes. Resemblance was stronger in the intervention group for target foods, but not for a general measure of diet quality. The lack of effect modification by family meal frequency suggests that family diet quality resemblance is not contingent on shared meals.

Dietary intake and eating patterns of young children with type 1 diabetes achieving glycemic targets

INTRODUCTION

Young children with type 1 diabetes (T1D) consume more saturated fat and less fruit and vegetables than recommended. A common challenge in this age group is unpredictable appetite potentially impacting the way parents manage diabetes cares at mealtimes. This small study aimed to assess nutritional intake and mealtime routines of young children with T1D in a clinic where the majority of children were achieving glycemic targets. A secondary aim was to explore association of eating pattern with HbA1c.

METHODS

A retrospective, cross-sectional review of children aged less than 7.0 years with T1D attending a pediatric diabetes service in Australia was performed (n=24). Baseline characteristics, glycated hemoglobin (HbA1c), a 3-day weighed food diary and a mealtime management survey were collected.

RESULTS

Twenty-two children (55% male) were included aged 4.9±1.3 years (mean±SD), HbA1c 47±10 mmol/mol (6.4%±0.9%), body mass index Z-score 0.8±0.9 and diabetes duration 1.7±1.1 years. Preprandial insulin use was reported in 95% of children. Macronutrient distribution (% energy intake) was carbohydrate (48%±4%), protein (16%±2%) and fat (33%±5%) with saturated fat (15%±3%). The majority of children did not meet vegetable and lean meat/protein intake recommendations (0% and 28%, respectively). HbA1c was not correlated with daily total carbohydrate, protein or fat intake (p>0.05). HbA1c was significantly higher in children offered food in a grazing pattern compared with those offered regular meals (mean 61 mmol/mol vs 43 mmol/mol (7.7% vs 6.1%), p=0.01).

CONCLUSIONS

Dietary quality is a concern in young children with T1D with excessive saturated fat and inadequate vegetable intake. Our results suggest that young children meeting glycemic targets give insulin before meals and follow a routine eating pattern.

A Time-Friendly, Feasible Measure of Nutrition Knowledge in Type 1 Diabetes: The Electronic Nutrition and Carbohydrate Counting Quiz (eNCQ)

BACKGROUND

Greater knowledge about nutrition and carbohydrate counting are associated with improved glycemic control and quality of life in youth with type 1 diabetes (T1D). However, limited assessments of nutrition and carbohydrate knowledge have been developed, and existing measures can be time-consuming, overly broad, or not conducive to routine clinical use. To fill this gap, we developed and examined the feasibility of administering the electronic Nutrition and Carbohydrate Counting Quiz (eNCQ).

METHOD

Ninety-two caregivers and 70 youth with T1D (mean age 12.5 years; mean time since diagnosis 5 years; English speaking) completed the 19-item eNCQ via tablet during a routine clinical visit. Completion time and item completion rates were used to assess feasibility. Relationships between eNCQ scores and patient demographics, diabetes management, and health outcomes were examined.

RESULTS

Participants took 10 minutes, on average, to complete the eNCQ. Total and Carbohydrate subscale scores (youth report) were negatively correlated with youth hemoglobin A1c (total r = -.38, carbohydrate r = -.38, Ps < .05), indicating that greater nutrition knowledge related to better glycemic control. Nutrition knowledge scores were generally high, but knowledge was negatively related to time since diabetes diagnosis ( r = -.276, P < .05).

CONCLUSIONS

Findings support feasibility of the eNCQ to assess nutrition knowledge in routine clinical care. Following additional acceptability and validity testing, the eNCQ may identify families in need of further nutrition education. Nutrition assessment is particularly indicated for youth over one year since T1D diagnosis, as these families displayed lower nutrition knowledge and may need continuing education to maintain diabetes-specific nutrition knowledge over time.

A randomized comparison of three prandial insulin dosing algorithms for children and adolescents with Type 1 diabetes

AIM

To compare systematically the impact of two novel insulin-dosing algorithms (the Pankowska Equation and the Food Insulin Index) with carbohydrate counting on postprandial glucose excursions following a high fat and a high protein meal.

METHODS

A randomized, crossover trial at two Paediatric Diabetes centres was conducted. On each day, participants consumed a high protein or high fat meal with similar carbohydrate amounts. Insulin was delivered according to carbohydrate counting, the Pankowska Equation or the Food Insulin Index. Subjects fasted for 5 h following the test meal and physical activity was standardized. Postprandial glycaemia was measured for 300 min using continuous glucose monitoring.

RESULTS

33 children participated in the study. When compared to carbohydrate counting, the Pankowska Equation resulted in lower glycaemic excursion for 90-240 min after the high protein meal (p < 0.05) and lower peak glycaemic excursion (p < 0.05). The risk of hypoglycaemia was significantly lower for carbohydrate counting and the Food Insulin Index compared to the Pankowska Equation (OR 0.76 carbohydrate counting vs. the Pankowska Equation and 0.81 the Food Insulin Index vs. the Pankowska Equation). There was no significant difference in glycaemic excursions when carbohydrate counting was compared to the Food Insulin Index.

CONCLUSION

The Pankowska Equation resulted in reduced postprandial hyperglycaemia at the expense of an increase in hypoglycaemia. There were no significant differences when carbohydrate counting was compared to the Food Insulin Index. Further research is required to optimize prandial insulin dosing.

Obesity in Type 1 Diabetes: Pathophysiology, Clinical Impact, and Mechanisms

There has been an alarming increase in the prevalence of obesity in people with type 1 diabetes in recent years. Although obesity has long been recognized as a major risk factor for the development of type 2 diabetes and a catalyst for complications, much less is known about the role of obesity in the initiation and pathogenesis of type 1 diabetes. Emerging evidence suggests that obesity contributes to insulin resistance, dyslipidemia, and cardiometabolic complications in type 1 diabetes. Unique therapeutic strategies may be required to address these comorbidities within the context of intensive insulin therapy, which promotes weight gain. There is an urgent need for clinical guidelines for the prevention and management of obesity in type 1 diabetes. The development of these recommendations will require a transdisciplinary research strategy addressing metabolism, molecular mechanisms, lifestyle, neuropsychology, and novel therapeutics. In this review, the prevalence, clinical impact, energy balance physiology, and potential mechanisms of obesity in type 1 diabetes are described, with a special focus on the substantial gaps in knowledge in this field. Our goal is to provide a framework for the evidence base needed to develop type 1 diabetes-specific weight management recommendations that account for the competing outcomes of glycemic control and weight management.

Commentary on the Impact of Obesity on PediatricDiabetes

While conventionally most children diagnosed with diabetes are thought to have type 1 diabetes mellitus (T1DM), with the increased prevalence of obesity, more are being affected by type 2 (T2) DM. Obesity leads to increased insulin resistance, which over time can lead to progressive β-cell failure and ultimately T2DM. However, patients developing T1DM may also be obese, making both the proper classification and management of diabetes in children more challenging. In this commentary, the authors discuss the impact ofobesity on the presentation of pediatric diabetes, how to differentiate between T1DM and T2DM, and the proper management of both diseases.

The influence of food order on postprandial glucose levels in children with type 1 diabetes

OBJECTIVE

To evaluate the effect of the order of intake of carbohydrates, protein, and fat on postprandial glucose levels in children with type 1 diabetes (T1D). Our hypothesis was that postprandial glucose levels would be lower when fat and protein are consumed prior to carbohydrates, compared to a meal where all macronutrients are combined.

METHODS

A randomized, open-label, within-subject crossover study was conducted. Twenty patients aged 7 to 17 years diagnosed with T1D for >1 year consumed 2 isocaloric meals (with similar composition) in random order. In 1 meal, the protein and fat part was consumed 15 minutes prior to the carbohydrates (test meal). In the other meal, all macronutrients were consumed together (standard meal). Capillary blood glucose measurements and continuous glucose monitoring system were used to assess multiple glucose levels during a 3-hour postprandial period.

RESULTS

Overall, mean glucose levels were 1 mmol/L lower following the test meal compared to the standard meal (9.30 ± 3.20 vs 10.24 ± 3.35 mmol/L; P < .001). No significant difference in peak glucose was found. Glucose excursions were 1.5 and 1 mmol/L lower at 30 and 120 minutes following the test meal. A reduction in the total time period in which glucose levels exceeded 10 and 12 mmol/L of 28.7 (P = .001) and 22.3 minutes (P = .004), respectively, after the test meal was found.

CONCLUSIONS

This study shows that consumption of protein and fat prior to carbohydrates results in lower postprandial glucose levels and reduced glycemic variability in children with T1D.

Infant-juvenile type 2 diabetes

In recent years, we have witnessed an increase in the number of cases of type 2 diabetes mellitus (DM2) in children and adolescents, which has paralleled the increase in the worldwide prevalence of obesity. Although screening the general population does not appear to be cost-effective, special attention should be paid to children with excess weight, obesity or other factors that predispose them to a state of insulin resistance. When faced with the diagnosis of childhood DM2, the presence of comorbidities (such as hypertension, dyslipidemia and microalbuminuria) should be assessed, and appropriate treatment and follow-up should be administered to prevent the onset of complications, given that the DM2 in this population group will last longer than that started in adulthood.

The effect of 12 weeks carnosine supplementation on renal functional integrity and oxidative stress in pediatric patients with diabetic nephropathy: a randomized placebo-controlled trial

BACKGROUND AND OBJECTIVES

Oxidative stress is a significant contributor to the pathogenesis of diabetic nephropathy. Carnosine is a natural radical oxygen species scavenger. We investigated the effect of carnosine as an adjuvant therapy on urinary albumin excretion (UAE), the tubular damage marker alpha 1-microglobulin (A1M), and oxidative stress in pediatric patients with type 1 diabetes and nephropathy.

METHODS

This randomized placebo-controlled trial included 90 patients with diabetic nephropathy, despite oral angiotensin-converting enzyme inhibitors (ACE-Is), who were randomly assigned to receive either 12 weeks of carnosine 1 g/day (n = 45), or matching placebo (n = 45). Both groups were followed-up with assessment of hemoglobin A1c (HbA1c), UAE, A1M, total antioxidant capacity (TAC) and malondialdhyde (MDA).

RESULTS

Baseline clinical and laboratory parameters were consistent between carnosine and placebo groups (P > .05). After 12 weeks, carnosine treatment resulted in significant decrease of HbA1c (8.2 ± 2.1% vs 7.4 ± 1.3%), UAE (91.7 vs 38.5 mg/g creatinine), A1M (16.5 ± 6.8 mg/L vs 9.3 ± 6.6 mg/L), MDA levels (25.5 ± 8.1 vs 18.2 ± 7.7 nmol/mL) while TAC levels were increased compared with baseline levels (P < .001) and compared with placebo (P < .001). No adverse reactions due to carnosine supplementation were reported. Baseline TAC was inversely correlated to HbA1c (r = -0.58, P = .04) and A1M (r = -0.682, P = .015) among carnosine group.

CONCLUSIONS

Oral supplementation with L-Carnosine for 12 weeks resulted in a significant improvement of oxidative stress, glycemic control and renal function. Thus, carnosine could be a safe and effective strategy for treatment of pediatric patients with diabetic nephropathy.

Targeting postprandial glycaemia in children with diabetes: Opportunities and challenges

Postprandial glycaemia makes a substantial contribution to overall glycaemic control in diabetes, particularly in patients whose preprandial glycaemia is relatively well controlled and glycated haemoglobin (HbA1c) only modestly elevated. Our review addresses the determinants of postprandial glycaemia and how it may be targeted therapeutically in children with diabetes. Postprandial glycaemia is influenced by preprandial glycaemia, macronutrients and their absorption, insulin delivery and sensitivity, the action of the enteroendocrine system, and the rate of gastric emptying. Contemporary continuous glucose monitoring systems reveal patterns of post prandial glycaemia and allow management to be guided more precisely. Delays in blood glucose determination, insulin delivery and its absorption remain challenges in the rapidly evolving closed loop continuous subcutaneous insulin and glucagon delivery systems developed for children with type 1 diabetes. Augmentation of the incretin system through nutritional preloads or incretin mimetics targets postprandial glycaemia by slowing gastric emptying as well as insulinotropic and glucagonostatic effects. These treatments are of particular relevance to children with type 2 diabetes. Following the development of targeted therapies in adults, postprandial blood glucose control will now be increasingly targeted in the treatment of diabetes in children.

Diabetes in Childhood and Adolescence

BACKGROUND

The incidence of type 1 diabetes mellitus in childhood and adolescence is steadily rising and now stands at 22.9 new cases per year per 100 000 persons up to age 15.

METHODS

This review is based on pertinent publications retrieved by a selective literature search, with special attention to the current German S3 guideline on diabetes in childhood and adolescence.

RESULTS

Polydipsia, polyuria, and weight loss are the characteristic presenting symptoms of diabetes mellitus. The acutely presenting patient needs immediate stabilization because of the danger of rapid metabolic decompensation (risk of keto - acidosis, 21.1%). Long-term insulin therapy can be delivered either by subcutaneous injection or by an insulin pump. The goals of treatment are the near-normalization of glucose metabolism (HbA1c <7.5%), the avoidance of acute complications (hypoglycemia and ketoacidosis), the reduction of diabetes-specific sequelae (retinopathy, nephropathy, neuropathy, hypertension, and hyperlipidemia), unrestricted participation in age-appropriate everyday activities, and normal physical and psychosocial development. Children and adolescents with diabetes need individualized treatment with frequent adjustments and holistic overall care so that these goals can be effectively met.

CONCLUSION

Every physician must be able to diagnose the initial presentation of diabetes and to initiate the first steps in its management. The patient should be referred as soon as possible to a diabetes team that has experience in the treatment of children and adolescents.

Maternal Experiences of Transitioning Their Emerging Adult With Type 1 Diabetes to College

Purpose The purpose of this study was to gain a deeper understanding about mothers' experiences of transitioning their emerging adult with type 1 diabetes mellitus to college. Methods A descriptive, qualitative study was conducted with 9 mothers of high school seniors with type 1 diabetes (T1DM) using semi-structured questions via recorded telephone interviews. Results Among the 9 participants, 8 had daughters, and 1 had a son. The thematic analysis resulted in 4 themes: (1) concern for health and safety at college, (2) evolving roles of the parent and emerging adult dyad, (3) communication dynamics, and (4) social support systems. Conclusions Results indicate that mothers of emerging adults with T1DM experience heightened levels of concern during the college transition. These concerns are above and beyond those that are experienced by mothers of emerging adults without T1DM. Findings indicated that increasing levels of support for both parents as well as emerging adults with T1DM during the college transition may serve to decrease maternal stress and enhance the development of preparedness for diabetes self-management. Recommendations for diabetes educators in clinical practice include a family-centered approach focusing on the transition before the late adolescent period, interventions from colleges to promote a smooth transition, and interventions that address concerns of both the emerging adult with T1DM and the parent. Further research is necessary to identify barriers and facilitators to support parent/emerging adult dyads during the college transition period.

Endocrine and metabolic consequences due to restrictive carbohydrate diets in children with type 1 diabetes: An illustrative case series

Low carbohydrate diets for the management of type 1 diabetes have been popularised by social media. The promotion of a low carbohydrate diet in lay media is in contrast to published pediatric diabetes guidelines that endorse a balanced diet from a variety of foods for optimal growth and development in children with type 1 diabetes. This can be a source of conflict in clinical practice. We describe a series of 6 cases where adoption of a low carbohydrate diet in children impacted growth and cardiovascular risk factors with potential long-term sequelae. These cases support current clinical guidelines for children with diabetes that promote a diet where total energy intake is derived from balanced macronutrient sources.

Dietary sodium intake relates to vascular health in children with type 1 diabetes

BACKGROUND AND OBJECTIVE

Children with type 1 diabetes (T1D) have vascular dysfunction and frequently struggle to adhere to dietary recommendations. Limited data exist for the vascular consequences of poor diet quality in children. We aimed to evaluate the association between dietary components and vascular function in children with T1D.

METHODS

Cross-sectional study including 90 children (13.6 [3.5] years, 41 boys) with T1D. They had evaluation of dietary micro and macronutrients (Australian Child and Adolescent Eating Survey), vascular endothelial and smooth muscle function (flow-mediated dilatation and glyceryl trinitrate mediated dilatation [GTN], respectively), clinical and biochemical variables.

RESULTS

Children had a sodium intake of 3.013 (0.76) (mean [SD]) g/day. Vascular smooth muscle dysfunction, as measured by GTN, related to higher daily sodium intake (r = -0.31, P = .003), independent of the inverse relationships between GTN and total energy (r = -0.30, P = .005) and fat intake (r = -0.28, P = .007). Multiregression model showed that an increase in 1 g of daily sodium intake was independently associated with a deterioration of 3 percentage units in GTN (95% CI -4.3, -0.9; P = .003). There was an association between sodium intake and systolic blood pressure after adjustment for age and gender (regression coefficient 2.4; 95% CI 0.5, 4.3; P = .01).

CONCLUSIONS

High dietary sodium intake in children with T1D is common and relates to vascular dysfunction, independently of other dietary intake, blood pressure, and glycemic control.

Carbohydrate Counting in Children and Adolescents with Type 1 Diabetes

Carbohydrate counting (CC) is a meal-planning tool for patients with type 1 diabetes (T1D) treated with a basal bolus insulin regimen by means of multiple daily injections or continuous subcutaneous insulin infusion. It is based on an awareness of foods that contain carbohydrates and their effect on blood glucose. The bolus insulin dose needed is obtained from the total amount of carbohydrates consumed at each meal and the insulin-to-carbohydrate ratio. Evidence suggests that CC may have positive effects on metabolic control and on reducing glycosylated haemoglobin concentration (HbA1c). Moreover, CC might reduce the frequency of hypoglycaemia. In addition, with CC the flexibility of meals and snacks allows children and teenagers to manage their T1D more effectively within their own lifestyles. CC and the bolus calculator can have possible beneficial effects in improving post-meal glucose, with a higher percentage of values within the target. Moreover, CC might be integrated with the counting of fat and protein to more accurately calculate the insulin bolus. In conclusion, in children and adolescents with T1D, CC may have a positive effect on metabolic control, might reduce hypoglycaemia events, improves quality of life, and seems to do so without influencing body mass index; however, more high-quality clinical trials are needed to confirm this positive impact.