ISPAD Clinical Practice Consensus Guidelines 2022: Nutritional management in children and adolescents with diabetes

Clinical significance of coefficient of variation in continuous glucose monitoring for glycemic management in children and adolescents with type 1 diabetes

AIMS/INTRODUCTION

Coefficient of variation (CV) is an indicator for glucose variability in continuous glucose monitoring (CGM), and the target threshold of %CV in type 1 diabetes is proposed to be ≤36%. This study aimed to evaluate the clinical significance of CV in children and adolescents with type 1 diabetes.

MATERIALS AND METHODS

Participants included 66 children with type 1 diabetes. A total of 48 participants were treated with multiple daily injections of insulin, and 18 with continues subcutaneous insulin infusion, using intermittently scanned CGM. The frequencies of the CGM metrics and glycosylated hemoglobin values were examined, and the significance of a threshold %CV of 36% was evaluated.

RESULTS

The mean frequencies in time in range (TIR), time below range, %CV and the mean glycosylated hemoglobin value were 59.3 ± 16.1, 4.0 ± 3.5, 39.3 ± 6.2 and 7.3 ± 0.8%, respectively. The frequencies of participants who achieved a TIR >70% and a %CV of ≤36% were 24.1 and 27.3%, respectively. A total of 18 participants with a %CV of ≤36% had significantly higher TIR, lower time below range and lower glycosylated hemoglobin than the 48 with a %CV of >36% (72.6 ± 12.6 vs 52.4 ± 13.6, 2.4 ± 1.9 vs 4.6 ± 3.6, 6.9 ± 0.8 vs 7.4 ± 0.7%, respectively).

CONCLUSIONS

Children and adolescents with type 1 diabetes using intermittently scanned CGM had difficulties in achieving the recommended targets of TIR and CV. However, the target %CV of ≤36% seems to be an appropriate indicator for assessing glycemic control and risk of hypoglycemia in pediatric patients with type 1 diabetes with any treatment.

A proposal for breakfast to improve the postprandial glucose response in children with type 1 diabetes - Preliminary results from a camp-based study

This study aimed to evaluate post - prandial glucose response (PPGR) after a traditional Italian breakfast and an alternative meal in children with type 1 diabetes (T1D). Preliminary findings showed that by replacing a small portion ofcarbohydrates with fats helpsimprovingPPGR after breakfast in children with T1D.

Nutritional status and extended metabolic screening in Egyptian children with uncomplicated type 1 diabetes

Nutritional status assessment, including amino acids, carnitine, and acylcarnitine profile, is an important component of diabetes care management, influencing growth and metabolic regulation. A designed case-control research included 100 Egyptian participants (50 T1DM and 50 healthy controls) aged 6 to 18 years old. The participants' nutritional status was assessed using the Body Mass Index (BMI) Z-score. Extended metabolic screening (EMS) was performed using a high-performance liquid chromatography-electrospray ionization-mass spectroscopy system to evaluate the levels of 14 amino acids, free carnitine, and 27 carnitine esters. T1DM children had considerably lower anthropometric Z-scores than the control group, with 16% undernutrition and 32% short stature. Total aromatic amino acids, phenylalanine, phenylalanine/tyrosine ratio, proline, arginine, leucine, isoleucine, free carnitine, and carnitine esters levels were considerably lower in the diabetic group, suggesting an altered amino acid and carnitine metabolism in type 1 diabetes. BMI Z-score showed a significant positive correlation with Leucine, Isoleucine, Phenylalanine, Citrulline, Tyrosine, Arginine, Proline, free carnitine, and some carnitine esters (Acetylcarnitine, Hydroxy-Isovalerylcarnitine, Hexanoylcarnitine, Methylglutarylcarnitine, Dodecanoylcarnitine, Tetradecanoylcarnitine, and Hexadecanoylcarnitine). HbA1c% had a significant negative correlation with Total aromatic amino acids, Branched-chain amino acid/Total aromatic amino acids ratio, Glutamic Acid, Citrulline, Tyrosine, Arginine, Proline, and certain carnitine esters (Propionylcarnitine, Methylglutarylcarnitine, Decanoylcarnitine, Octadecanoylcarnitine and Octadecenoylcarnitine), suggest that dysregulated amino acid and carnitine metabolism may be negatively affect the glycaemic control in children with TIDM. In conclusion, regular nutritional assessments including EMS of T1DM patients are critical in terms of diet quality and protein content for improved growth and glycemic management.

Psychological and Clinical Challenges in the Management of Type 1 Diabetes during Adolescence: A Narrative Review

Adolescence, a critical period of physical and psychological development, presents unique challenges in type 1 diabetes (T1D) management due to endocrinological changes, reduced therapeutic adherence, and elevated susceptibility to psychological issues such as depression, anxiety, and eating disorders. This narrative review explores the impact of psychological and behavioral factors on glycemic control in adolescents with T1D. We examine the prevalence and influence of mental health disorders, lifestyle factors, harmful behaviors, and social dynamics on diabetes management and glycemic outcomes. Strategies for improving metabolic control are also reviewed, including cognitive behavioral therapy, technological devices, and educational interventions. The importance of tailored psychological support, family involvement, and targeted interventions to improve adherence to treatment and glycemic control in adolescents with T1D should be emphasized.

Dietary recommendations for people with diabetes in special situations: a position statement report by Arabic Association for the Study of Diabetes and metabolism (AASD)

BACKGROUND

Diabetes is a significant global health concern. Regional factors play a crucial role in determining the appropriate diet for patients.

MAIN BODY

The Arabic Association for the Study of Diabetes and Metabolism has developed a position statement that addresses the dietary needs of patients in the context of low income and cultural dietary habits. This statement aims to explore the most suitable diet for Middle East and North Africa (MENA) region and provide guidance for physicians to overcome barriers in optimal care. While most dietary guidelines focus on uncomplicated diabetes, it's essential to recognize that diabetes often coexists with other common diseases in our region.

CONCLUSION

International guidelines cannot be directly applied to the Egypt and Arab countries due to cultural and dietary differences. Our position statement shares valuable insights into managing diabetes in special situations and diverse clinical settings within this region. These recommendations are flexible, considering personal, cultural, and traditional differences.

Low-carbohydrate diet in children and young people with type 1 diabetes: A randomized controlled trial with cross-over design

AIMS

We investigated whether a short period of tightly controlled low-carbohydrate diet (LCD) leads to higher time in range without increasing the associated risks in children and young people with diabetes (CYPwD).

METHODS

Thirty-five (CYPwD) were recruited into this randomized controlled cross-over study (20 female; 20 CSII; age 14.5 ± 2.9 years; HbA1c 48.9 ± 9.4 mmol/mol). The interventions were five and five weeks of ready-made food box deliveries of isocaloric diets in random order: either LCD (94.5 ± 4.7 g/day) or recommended carbohydrate diet (RCD) (191 ± 19.2 g/day). The outcomes were continuous glucose monitoring parameters, anthropometric, laboratory and quality of life (QoL) data.

RESULTS

Time in range was significantly higher in the LCD than in the RCD period (77.1 % vs. 73.8 %, P=0.008). Times in hyperglycemia and average glycaemia were significantly lower in the LCD. There was no difference between the diets in time in hypoglycemia or glycemic variability. The subjects' body weight and BMI were significantly lower during the LCD. There was no significant difference in the LDL-cholesterol levels. No significant differences were observed in the self-assessed QoL.

CONCLUSIONS

Short-term LCD led to an improvement of glycemic parameters without increasing time in hypoglycemia, disturbing the lipid profile or negatively affecting the quality of life of CYPwD.

Household food insecurity among child and adolescent athletics practitioners: A cross-sectional, descriptive, and exploratory study

OBJECTIVE

The aim of the study was to explore the prevalence of food insecurity among child and adolescent athletics practitioners and to investigate factors associated with exercise performance, dietary habits, body composition, sleep, and socioeconomic status based on food security status.

METHODS

This was a cross-sectional, descriptive, and exploratory study conducted in Campinas, São Paulo, Brazil, between June and July 2023. The convenience sample included children and adolescents (7-17 y old) of both sexes. We evaluated exercise performance, household food insecurity (HFI), dietary-related parameters, and other body composition, lifestyle, and social-related variables. Exercise performance was assessed using the counter movement jump (CMJ), squat jump (SJ), horizontal long jump (HLJ), 50-m sprint test (50-m ST) and throwing strength test (TST). The assessment of HFI was conducted using the food insecurity experience scale (FIES). Comparisons and associations were investigated based on food security status.

RESULTS

The total sample size was comprised of 138 children (n = 42; 30.4%) and adolescents (n = 96; 69.6%). We found an association between food security status and sex (X2(138,1) = 4.42; P = 0.036). SJ was higher in the food security group than in the HFI group (t(117) = 2.112; P = 0.037; ES = 0.39). Sleep- and dietary-related factors did not differ between the groups.

CONCLUSIONS

In summary, the prevalence of HFI among child and adolescent athletics participants was approximately 40%. Regarding exercise performance, SJ was better in the food security group than in the HFI group. Concerning dietary-related data, the HFI group had a lower number of meals per day than the food security group, and other dietary data did not differ between the groups. Body composition and sleep-related parameters were similar between the groups.

Does minimed 780GTM insulin pump system affect energy and nutrient intake?: long-term follow-up study

OBJECTIVE

We evaluate the energy and nutrient intake of children, adolescents, and young adults with type 1 diabetes (T1D) who started to use automated insulin delivery (AID) systems before the transition and during follow-up for 6 months in a real-world setting.

RESEARCH DESIGN AND METHODS

Twenty-nine people with T1D (PwD) who started to use MiniMed 780GTM participated in the study. Participants' 3-day food diaries and glycemic outcomes were analyzed at baseline and after (the 3rd and 6th month) switching to an advanced hybrid closed-loop system (a-HCL).

RESULTS

Mean carbohydrate, protein, and fat intake (energy %) at baseline were 49.1 ± 4.5, 17.8 ± 2.3, and 33.0 ± 3.9, respectively, and there were no statistically significant differences during the follow-up period. However, low fiber (<14 g/1000 kcal) and high saturated fat (>10 energy %) intake in PwD, both baseline and follow-up period. The median auto-correction bolus ratio was 14.0 (9.5)% at auto mode after 14 days, 18.0 (11.0)% at the 3rd month, and 19.0 (7.5)% at the 6th month (p < 0.05). A negative correlation was present between auto-correction boluses with TIR in both the 3rd (r:-0.747, p < 0.01) and 6th month (r:-0.395, p < 0.05). A negative correlation was present between auto-correction boluses with TIR in both the 3rd (r:-0.747, p < 0.01) and 6th month (r:-0.395, p < 0.05).

CONCLUSIONS

a-HCLS systems offer better glycemic control. Using the Minimed 780 GTM insulin pump system didn't change the energy and nutrient intake of PwD. This real-world follow-up study suggests that children, adolescents, and young adults with T1D consume saturated fat above and fiber intake lower than recommendations independent of the use of a-HCLS.

CLINICAL TRIALS REGISTRATION NUMBER

NCT05666596.

The Impact of Dietary Habits on Sleep Deprivation and Glucose Control in School-Aged Children with Type 1 Diabetes: A Cross-Sectional Study

Diet plays a crucial role in managing type 1 diabetes (T1DM). Background/Objectives:This study aimed to determine the impact of nutritional habits on sleep deprivation and glucose control in school-aged children with T1DM. Methods: In this cross-sectional study, nutritional habits and sleep deprivation were assessed in 100 school-aged children with T1DM, aged 7-13 years. The Dietary Habits Index and the Sleep Deprivation Scale for Children and Adolescents were used to evaluate nutritional habits and the level of sleep deprivation. Patients' sociodemographic and nutritional variables were collected through researcher-composed questionnaires. HbA1c levels over the past 6 months were obtained from the patient data system. Results: The study found a moderately strong positive correlation between the Dietary Habits Index score and HbA1c (p < 0.001), with 28% of the variation in HbA1c explained by changes in the Dietary Habits Index score. However, no correlation was found between the Dietary Habits Index score and the level of sleep deprivation. Conclusions: The nutritional habits of school-aged children with T1DM may affect glucose control and sleep deprivation. Therefore, it is important to educate children with T1DM on making healthy food choices to manage their condition effectively.

Dietary Components in the Pathogenesis and Prevention of Type 1 Diabetes in Children

BACKGROUND

Type 1 diabetes (T1D) is a disease closely linked to nutrition and modifications in various dietary components have been part of the effort to prevent or slow the progression of the disease even before the discovery of insulin.

SUMMARY

The scientific focus in the prevention or progression modification of T1D is mostly centered on four dietary compounds and their modifications - gluten and its omission, vitamin D supplementation, omega-3 fatty acids supplementation, and decreasing of the amount of ingested carbohydrates. The aim of this narrative review was to provide an overview of nutritional interventions studied in children either as preventive methods or as modifiers in the early stages of T1D from autoantibody positive individuals to persons with newly diagnosed T1D.

KEY MESSAGES

Our review shows that dietary modifications in various dietary components might be useful but none of them seems to provide universal effects in T1D prevention or progression modification. More research is therefore needed with focus on promising modes of action of individual dietary components.

Modifiable lifestyle risk factors for overweight and obesity in children and adolescents with type 1 diabetes: A systematic review

This review aims to identify and report epidemiological associations between modifiable lifestyle risk factors for overweight or obesity in children and adolescents with type 1 diabetes (T1D). A systematic literature search of medical databases from 1990 to 2023 was undertaken. Inclusion criteria were observational studies reporting on associations between dietary factors, disordered eating, physical activity, sedentary and sleep behaviours and measures of adiposity in children and adolescents (<18 years) with T1D. Thirty-seven studies met inclusion criteria. Studies were mostly cross-sectional (89 %), and 13 studies included adolescents up to 19 years which were included in this analysis. In adolescents with T1D, higher adiposity was positively associated with disordered eating behaviours (DEB) and a higher than recommended total fat and lower carbohydrate intake. A small amount of evidence suggested a positive association with skipping meals, and negative associations with diet quality and sleep stage. There were no published associations between overweight and physical activity, sedentary behaviours and eating disorders. Overall, the findings infer relationships between DEB, fat and carbohydrate intake and adiposity outcomes in people with T1D. Prospective studies are needed to determine causal relationships and to investigate sleep stages. High quality studies objectively measuring physical activity and include body composition outcomes are needed.

Psychometric Properties of the Revised Self-Efficacy for Diabetes Self-Management Scale among Spanish Children and Adolescents with Type 1 Diabetes

A longitudinal design was used to examine the psychometric properties of the Self-Efficacy for Diabetes Self-Management (SEDM) for children and adolescents with a diagnosis of type 1 diabetes (T1D). The SEDM was adapted to Spanish and the best factorial solution was selected to test the invariance of the measures of age and gender. Individuals between the ages of 10 and 19 years old with a diagnosis of T1D completed a self-reported questionnaire (167 at Time 1 [mean age = 14.49, SD = 2.76; 56.9% boys] and 122 at Time 2 [mean age = 14.77, SD = 2.58; 56.6% boys]). Two unifactorial solutions were tested. The psychometric properties of the scale were validated. The proposed validation obtained excellent reliability indices (χ2 (26) = 25.59, p > 0.49, RMSEA = 0.00, 95% CI [0.00, 0.07], CFI = 1.00, GFI = 0.96, AGFI = 0.92, TLI = 1.00, and CMIN = 0.98), and it appeared to be invariant for gender and for age groups. The Cronbach's α was 0.85. The test-retest reliability was high (r = 0.69 [p < 0.001]). Convergent, discriminant, and external validity were proven. The nine-item SEDM is a brief measure with satisfactory structural validity. From our knowledge, this study provides the first reliable tool to assess self-efficacy in the management of T1D for Spanish children and adolescents.

Exploring Family Perspectives on a Group-Based Hands-on Advanced Carbohydrate Counting Education Program for Children and Adolescents with Type 1 Diabetes: A Qualitative Study

The care needs of children and adolescents with type 1 diabetes and their families are frequently approached as if they were identical to those of adults, overlooking the distinct challenges young people may face. It has been stated that children and adolescents often find conventional conversations with diabetes specialists tiresome and unpleasant. The present study focuses on familial experiences of an advanced carbohydrate counting program tailored to children and adolescents. The data encompass semi-structured interviews with families who participated in a group-based child-centered advanced carbohydrate counting program. The analysis revealed five themes: (1) peer-to-peer interaction is an essential determinant of sharing and learning; (2) illness perception significantly influences dietary intake; (3) normalization of diabetes in everyday life eases the disease burden; (4) repetition of dietary knowledge is important for retention; and (5) creating a safe and playful learning environment is crucial to engaging children and adolescents in their own treatment. The present findings suggest that it would be beneficial to explore and consider alternative teaching approaches that are adapted to a more interactive and engaging learning environment that is specifically tailored to children and adolescents. This entails moving away from traditional individual approaches.

Severe growth retardation during carbohydrate restriction in type 1 diabetes mellitus: A case report

Carbohydrate restriction is not typically recommended for children with type 1 diabetes mellitus (T1DM) because of concerns regarding growth retardation, ketoacidosis, severe hypoglycemia, and dyslipidemia. There is no consensus regarding the effects of carbohydrate restriction on the growth of children with T1DM. However, some previously reported cases of T1DM exhibited growth retardation during carbohydrate restriction, whereas others showed no obvious impairment. A female child with T1DM exhibited severe height growth velocity impairment during carbohydrate restriction in early childhood. Her height standard deviation score (SDS) was 1.12 at the initial T1DM diagnosis (2 yr and 11 mo of age) and -1.33 at 4 yr and 8 mo of age. Her height velocity was only 1.7 cm/yr (SDS -7.02). Discontinuing carbohydrate restriction substantially improved her height growth velocity. Implementing a carbohydrate-restricted diet in children with T1DM can negatively affect height growth velocity.

Effects of Dietary Carbohydrate Concentration and Glycemic Index on Blood Glucose Variability and Free Fatty Acids in Individuals with Type 1 Diabetes

Monitoring glycemic control status is the cornerstone of diabetes management. This study aimed to reveal whether moderate-carbohydrate (CHO) diets increase the risk of free fatty acid (FFA) levels, and it presents the short-term effects of four different diet models on blood sugar, glycemic variability (GV), and FFA levels. This crossover study included 17 patients with type 1 diabetes mellitus to identify the effects of four diets with different CHO contents and glycemic index (GI) on GV and plasma FFA levels. Diet 1 (D1) contained 40% CHO with a low GI, diet 2 (D2) contained 40% CHO with a high GI, diet 3 (D3) contained 60% CHO with a low GI, and diet 4 (D4) contained 60% CHO with a high GI. Interventions were performed with sensor monitoring in four-day periods and completed in four weeks. No statistical difference was observed among the groups in terms of blood glucose area under the curve (p = 0.78), mean blood glucose levels (p = 0.28), GV (p = 0.59), and time in range (p = 0.567). FFA and total triglyceride levels were higher in the D1 group (p < 0.014 and p = 0.002, respectively). Different diets may increase the risk of cardiovascular diseases by affecting GI, FFA, and blood glucose levels.

Diabetes Management in Detention Facilities: A Statement of the American Diabetes Association

This statement provides guidance for diabetes care in detention facilities. It focuses on areas where the processes for delivery of care to people with diabetes in detention facilities may differ from those in the community, and key points are made at the end of each section. Areas of emphasis, which inform multiple aspects discussed in this statement, include 1) timely identification or diagnosis of diabetes treatment needs and continuity of care (at reception/intake, during transfers, and upon discharge), 2) nutrition and physical activity, 3) timely access to diabetes management tools (insulin, blood glucose monitoring, tracking data, current diabetes management technologies, etc.), and 4) treatment of the whole person with diabetes (self-management education, mental health support, monitoring and addressing long-term complications, specialty care, etc.).

Experiences With Outpatient Nutrition Services Among Caregivers of Youth With Type 1 Diabetes

Many children with type 1 diabetes do not meet nutritional guidelines. Little is known about how caregivers perceive the necessity of registered dietitian (RD) visits or how satisfied they are with nutrition care. This study aimed to evaluate nutrition experiences and perceptions of care among caregivers of children with type 1 diabetes at an academic medical center. We analyzed 159 survey responses. Using multivariable logistic regression, we assessed factors associated with the perception of need for annual nutrition visits, satisfaction with RD care, and encouragement from a nurse or doctor to meet with an RD. Covariates included age (<13 vs. ≥13 years), type 1 diabetes duration (≤3 vs. >3 years), sex, race/ethnicity, and insulin pump and continuous glucose monitoring use. More than half of caregivers (56%) considered annual visits necessary. Shorter type 1 diabetes duration (odds ratio [OR] 1.92, 95% CI 1.02-3.63) was associated with this finding. Less than half (46.5%) reported satisfaction with nutrition care; higher satisfaction was also correlated with shorter type 1 diabetes duration (OR 2.20, 95% CI 1.17-4.15). Although 42% reported meeting with an RD in the past year, less than two-thirds (62%) reported receiving a medical provider recommendation for nutrition care. Leading reasons for not meeting with an RD were "I am knowledgeable in nutrition and do not need to see an [RD]" (41%) and "I had a past visit with an [RD] that was not helpful" (40%). Our findings suggest that satisfaction with and perceived need for nutrition care may wane with longer type 1 diabetes duration. Improved strategies for therapeutic alliance between caregivers and RDs and engagement of families at later stages of type 1 diabetes are needed.

Basic carbohydrate counting and glycemia in young people with type 1 diabetes in India: A randomized controlled trial

OBJECTIVES

The aim of this study was to evaluate the effect on glycemic control and acceptability of basic carbohydrate counting (BCC) in children and young adults with type 1 diabetes (T1DM).

METHODS

Ninety-two children and young adults (6-25 y of age) with T1DM were randomized to receive either routine nutrition education (RNE), which addressed food groups, glycemic index, and effects of food and exercise on glycemia, or learn BCC with personalized portion size education. A continuous glucose monitoring study and glycosylated hemoglobin (HbA1c) were performed at baseline and after 12 wk. The primary outcome was a change in time-in-range from baseline through 12 wk. A questionnaire on the acceptability of BCC was administered.

RESULTS

At 12 wk, there was no significant difference in change in time-in-range between the two groups (BCC group: 1.2 ± 12.2; RNE group: 1.9 ± 12.3; P = 0.786). No significant changes were observed in the percentage of time that blood glucose was >180 or >250 mg/dL; <70 or <54 mg/dL; glycemic variability, percentage of nights with hypoglycemia and HbA1c. In subgroup analysis, there was a significant decrease in HbA1c in the BCC group among participants with higher maternal education (-0.5 versus 0.2, P = 0.042). The total score on the acceptability questionnaire was higher in the BCC group (P = 0.022).

CONCLUSION

Among children and young adults in our region with T1DM, BCC provided flexibility in food choices and perception of greater ease of insulin adjustment. Although BCC was equivalent to RNE in terms of glycemic control, larger studies may reveal benefit in outcomes in certain subgroups.

Postprandial glucose metabolism in children and adolescents with type 1 diabetes mellitus: potential targets for improvement

The main goal of therapeutic management of type 1 Diabetes Mellitus (T1DM) is to maintain optimal glycemic control to prevent acute and long-term diabetes complications and to enable a good quality of life. Postprandial glycemia makes a substantial contribution to overall glycemic control and variability in diabetes and, despite technological advancements in insulin treatments, optimal postprandial glycemia is difficult to achieve. Several factors influence postprandial blood glucose levels in children and adolescents with T1DM, including nutritional habits and adjustment of insulin doses according to meal composition. Additionally, hormone secretion, enteroendocrine axis dysfunction, altered gastrointestinal digestion and absorption, and physical activity play important roles. Meal-time routines, intake of appropriate ratios of macronutrients, and correct adjustment of the insulin dose for the meal composition have positive impacts on postprandial glycemic variability and long-term cardiometabolic health of the individual with T1DM. Further knowledge in the field is necessary for management of all these factors to be part of routine pediatric diabetes education and clinical practice. Thus, the aim of this report is to review the main factors that influence postprandial blood glucose levels and metabolism, focusing on macronutrients and other nutritional and lifestyle factors, to suggest potential targets for improving postprandial glycemia in the management of children and adolescents with T1DM.

Super Bolus-A Remedy for a High Glycemic Index Meal in Children with Type 1 Diabetes on Insulin Pump Therapy?-A Randomized, Double-Blind, Controlled Trial

BACKGROUND

This study aimed to compare whether a super bolus (SB) is a more efficient strategy than a normal bolus (NB) for high glycemic index (h-GI) meals in children with type 1 diabetes (T1D).

METHODS

A randomized, double-blind, crossover trial with an allocation ratio of 1:1, registered at ClinicalTrials.gov (NCT04019821). 72 children aged 10-18 years with T1D > 1 year, and on insulin pump therapy > 3 months were included. As an intervention, they ate a h-GI breakfast for the two following days and receive a prandial insulin bolus either in the form of SB or NB.

RESULTS

The SB group had lower glucose values during the observation time and lower glucose levels in 90th min (primary end point). The median time in range was also higher after SB. At the same time, more hypoglycemic episodes and a higher time below range were noted in this group. Almost 90% of them were the threshold value for initiating treatment for hypoglycemia and occurred near the end of observation period. More hyperglycemic episodes and over twice as much time in hyperglycemia were noted after NB.

CONCLUSIONS

Super bolus is an effective strategy to avoid postprandial hyperglycemia but the basal insulin suspension should be longer to avoid hypoglycemia (f.ex. 3 h).

Postprandial Glucose Variability Following Typical Meals in Youth Living with Type 1 Diabetes

We explored the association between macronutrient intake and postprandial glucose variability in a large sample of youth living with T1D and consuming free-living meals. In the Type 1 Diabetes Exercise Initiative Pediatric (T1DEXIP) Study, youth took photographs before and after their meals on 3 days during a 10 day observation period. We used the remote food photograph method to obtain the macronutrient content of youth's meals. We also collected physical activity, continuous glucose monitoring, and insulin use data. We measured glycemic variability using standard deviation (SD) and coefficient of variation (CV) of glucose for up to 3 h after meals. Our sample included 208 youth with T1D (mean age: 14 ± 2 years, mean HbA1c: 54 ± 14.2 mmol/mol [7.1 ± 1.3%]; 40% female). We observed greater postprandial glycemic variability (SD and CV) following meals with more carbohydrates. In contrast, we observed less postprandial variability following meals with more fat (SD and CV) and protein (SD only) after adjusting for carbohydrates. Insulin modality, exercise after meals, and exercise intensity did not influence associations between macronutrients and postprandial glycemic variability. To reduce postprandial glycemic variability in youth with T1D, clinicians should encourage diversified macronutrient meal content, with a goal to approximate dietary guidelines for suggested carbohydrate intake.

Mediterranean diet adherence and glycemic control in children and adolescents with type 1 diabetes

To effectively manage type 1 diabetes (T1D) insulin is essential, with dosages based on lifestyle. The Mediterranean diet has demonstrated its advantages in preventing and enhancing the management of chronic diseases. Our objective was to investigate the potential mediation of sensor activity on the relationship between adherence to the Mediterranean diet and glycemic control in children and adolescents. A total of 150 children and adolescents (mean age = 13.09, SD = 3.54; 44% female) with T1D were recruited. Adherence to the Mediterranean diet was assessed using the KIDMED questionnaire which evaluates 16 items and gives higher scores when adherence is higher. Glycemic control and the duration of sensor activity were evaluated with data from flash glucose monitoring. The data confirmed our hypothesis by revealing that adherence to the Mediterranean diet positively influenced glycemic control (direct effect = 1.505; P < 0.01) and that this relationship was mediated by the duration of sensor activity (indirect effect = 0.531; P < 0.01).  Conclusions: Our results support the increased utilization of glycemic control devices, as they contribute to improve glycemic control and mediate on the positive relationship between adherence to the Mediterranean diet and adequate glycemic control. Furthermore, our findings highlight the importance of incorporating Mediterranean diet recommendations to achieve better glycemic control in children and adolescents with T1D. What is Known: • The Mediterranean diet and glycemic control have proven benefits in improving cardiovascular health in the general population. Scarce evidence exists of these benefits among children and adolescents with T1D. What is New: • Adherence to the Mediterranean diet and greater use of glucose monitoring devices in children and adolescents with T1D are related to better glycemic control. These variables can be enhanced by psychoeducational interventions such as structured diabetes education programs or peer group-based sessions, which highlights the importance of focusing on these aspects.

Omega-3 fatty acids supplementation improves early-stage diabetic nephropathy and subclinical atherosclerosis in pediatric patients with type 1 diabetes: A randomized controlled trial

BACKGROUND

Numerous studies have evaluated the beneficial effects of omega-3 fatty acids on inflammatory, autoimmune and renal diseases. However, data about the effects of omega-3 fatty acids on diabetic kidney disease in type 1 diabetes mellitus (T1DM) are lacking.

OBJECTIVES

This randomized-controlled trial assessed the effect of oral omega-3 supplementation on glycemic control, lipid profile, albuminuria level, kidney injury molecule-1 (KIM-1) and carotid intima media thickness (CIMT) in pediatric patients with T1DM and diabetic nephropathy.

METHODS

Seventy T1DM patients and diabetic nephropathy were enrolled with a mean age 15.2 ± 1.96 years and median disease duration 7 years. Patients were randomly assigned into two groups; intervention group which received oral omega-3 fatty acids capsules (1 g daily). The other group received a matching placebo and served as a control group. Both groups were followed-up for 6 months with assessment of fasting blood glucose (FBG), HbA1c, fasting lipids, urinary albumin creatinine ratio (UACR), KIM-1 and CIMT.

RESULTS

After 6 months, omega-3 fatty acids adjuvant therapy for the intervention group resulted in a significant decrease in FBG, HbA1c, triglycerides, total cholesterol, LDL-cholesterol, UACR, KIM-1 and CIMT, whereas, HDL-cholesterol was significantly higher post-therapy compared with baseline levels and compared with the control group (p < 0.05). Baseline KIM-1 levels were positively correlated to HbA1c, UACR and CIMT. Supplementation with omega-3 fatty acids was safe and well-tolerated.

CONCLUSIONS

Omega-3 fatty acids as an adjuvant therapy in pediatric T1DM patients with diabetic nephropathy improved glycemic control, dyslipidemia and delayed disease progression and subclinical atherosclerosis among those patients. This trial was registered under ClinicalTrials.gov Identifier no. NCT05980026.

A Nutritional Approach to Optimizing Pump Therapy in Type 1 Diabetes Mellitus

Achieving optimal glucose control in individuals with type 1 diabetes (T1DM) continues to pose a significant challenge. While continuous insulin infusion systems have shown promise as an alternative to conventional insulin therapy, there remains a crucial need for greater awareness regarding the necessary adaptations for various special circumstances. Nutritional choices play an essential role in the efficacy of diabetes management and overall health status for patients with T1DM. Factors such as effective carbohydrate counting, assessment of the macronutrient composition of meals, and comprehending the concept of the glycemic index of foods are paramount in making informed pre-meal adjustments when utilizing insulin pumps. Furthermore, the ability to handle such situations as physical exercise, illness, pregnancy, and lactation by making appropriate adjustments in nutrition and pump settings should be cultivated within the patient-practitioner relationship. This review aims to provide healthcare practitioners with practical guidance on optimizing care for individuals living with T1DM. It includes recommendations on carbohydrate counting, managing mixed meals and the glycemic index, addressing exercise-related challenges, coping with illness, and managing nutritional needs during pregnancy and lactation. Additionally, considerations relating to closed-loop systems with regard to nutrition are addressed. By implementing these strategies, healthcare providers can better equip themselves to support individuals with T1DM in achieving improved diabetes management and enhanced quality of life.

Carbohydrate Counting, Empowerment and Glycemic Outcomes in Adolescents and Young Adults with Long Duration of Type 1 Diabetes

The complex treatment for diabetes type 1 (T1D) includes insulin dosing for every meal, which requires education and experience to achieve optimal outcomes. Advanced carbohydrate counting (ACC) is the recommended method. We studied ACC as part of a standard treatment with the aim to explore its associations with glycemic control and empowerment in adolescents and young adults. We used national registry data on glycemic outcomes, a study-specific questionnaire regarding the use of ACC and the Gothenburg Young Persons Empowerment Scale (GYPES) to measure empowerment. A total of 111 participants (10-28 years of age, diabetes duration >9 years, mean HbA1c of 55.4 mmol/mol) answered the questionnaire. We found that most participants (79.3%) who learn ACC, at onset or later, continue to use the method. A higher level of empowerment was associated with lower HbA1c (p = 0.021), making patient empowerment an important factor in achieving optimal glycemic outcomes. No associations were found between ACC and empowerment or glycemic outcomes. A mixed strategy, only using ACC sometimes when insulin dosing for meals, was associated with the lowest empowerment score and highest HbA1c and should warrant extra education and support from the diabetes team to reinforce a dosing strategy.

The Mediterranean Diet for Adolescents with Type 1 Diabetes: A Prospective Interventional Study

The Mediterranean diet (MED) is highly recommended. Medical nutrition therapy is the cornerstone of diabetes treatment. The primary outcome was to evaluate the change in micronutrient intake of youth with type 1 diabetes before and after a 6-month MED intervention; we also assessed adherence and glycemic control. Twenty adolescents, median age 18 years (interquartile range: 15.5-21), median diabetes duration 9 years (7-14), using continuous glucose monitoring devices, received personalized diet regimes based on MED. At 6 months post-intervention, the caloric intake remained unchanged; however, the carbohydrate proportion was lower (p = 0.058), and the intakes of some monounsaturated fats increased (p = 0.049). Sodium intake exceeded the recommended daily allowance by 250% (p = 0.653), before and after the intervention. For blood glucose, the percent TIR (time-in-range, 70-180 mg/dL) improved from 52% (38-60) to 63% (47-71) (p = 0.047). The total insulin dose decreased marginally, from 0.76 u/kg (0.64-0.97) to 0.72 u/kg (0.61-0.89) (p = 0.067). BMI z-score and waist circumference did not change (p = 0.316 and p = 0.161, respectively). Diastolic blood pressure percentile decreased from 73% (68-88) to 69% (50-79) (p = 0.028), and LDL cholesterol from 114 mg/dL (105-134) to 104 mg/dL (96-124) (p = 0.059). The Israeli Mediterranean diet screener score increased, from 8 (7-11) to 13 points (12-14) (p < 0.001). The MED-based intervention in youth with type 1 diabetes is feasible and leads to improvement in monounsaturated fat intake, TIR, and diastolic blood pressure. Other parameters show no change (caloric intake, BMI, and HbA1c).

Low-Carbohydrate Diets in Children and Adolescents With or at Risk for Diabetes

Carbohydrate restriction is increasingly popular as a weight loss strategy and for achieving better glycemic control in people with diabetes, including type 1 and type 2 diabetes. However, evidence to support low-carbohydrate diets in youth (children and adolescents 2-18 years of age) with obesity or diabetes is limited. There are no guidelines for restricting dietary carbohydrate consumption to reduce risk for diabetes or improve diabetes outcomes in youth. Thus, there is a need to provide practical recommendations for pediatricians regarding the use of low-carbohydrate diets in patients who elect to follow these diets, including those with type 1 diabetes and for patients with obesity, prediabetes, and type 2 diabetes. This clinical report will: Provide background on current dietary patterns in youth, describe how moderate-, low-, and very low-carbohydrate diets differ, and review safety concerns associated with the use of these dietary patternsReview the physiologic rationale for carbohydrate reduction in youth with type 1 diabetes and for youth with obesity, prediabetes, and type 2 diabetesReview the evidence for low-carbohydrate diets in the management of youth with type 1 diabetesReview the evidence for low-carbohydrate diets in the management of youth with obesity, prediabetes, and type 2 diabetesProvide practical information for pediatricians counseling families and youth on carbohydrate recommendations for type 1 diabetes and for obesity, prediabetes, and type 2 diabetes.

Poor glycemic control and its associated factors among children with type 1 diabetes mellitus in Harar, eastern Ethiopia: A cross-sectional study

BACKGROUND

Poor glycemic control increases the risk of acute metabolic derangements and long-term consequences, which are the main causes of morbidity and mortality. Maintaining adequate glycemic control is challenging for children with diabetes, particularly in resource-limited settings. There is a paucity of data on the magnitude of poor glycemic control and its predisposing factors in Ethiopian particularly in this study setting. Hence, we aimed to assess the magnitude of poor glycemic control and its associated factors among children and adolescents with type 1 diabetic mellitus in Jugol and Hiwot Fana Compressive Specialized University Hospitals in Harar, eastern Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among 231 children and adolescents with type 1 diabetes mellitus in Jugol and Hiwot Fana Compressive Specialized University Hospitals. Participants were included consecutively in the follow-up clinic from November 15, 2022 to January 15, 2023. Data were collected through an interviewer-administered structured questionnaire and a review of medical records. A binary logistic regression model with an adjusted odds ratio (aOR) and a 95% confidence interval (CI) was used to identify the factors associated with poor glycemic control. Statistical significance was set at p < 0.05.

RESULT

A total of 231 children and adolescents with type 1 diabetes mellitus were included. The magnitude of poor glycemic control was 166 (71.9%) with 95% CI 66.0-77.7%). In multivariable analysis, the age of the child (aOR = 0.19, 95% CI: 0.05-0.83), education of the caregiver (aOR = 4.13;95% CI: 1.82-9.46), meal frequency less than three (aOR = 3.28; 95% CI: 1.25-8.62), and consumption of forbidden foods (aOR = 3.17; 95% CI: 1.21-8.29) were factors significantly associated with poor glycemic control.

CONCLUSION

Two-thirds of participants had poor glycemic control. There was a statistically significant association between the age of the child, education of the caregiver, meal frequency, and forbidden foods with poor glycemic control. To improve glycemic control, diabetes education on meal use and selection should be conducted during follow-up along with parent education.

An Overview of Diet and Physical Activity for Healthy Weight in Adolescents and Young Adults with Type 1 Diabetes: Lessons Learned from the ACT1ON Consortium

The prevalence of overweight and obesity in young people with type 1 diabetes (T1D) now parallels that of the general population. Excess adiposity increases the risk of cardiovascular disease, which is already elevated up to 10-fold in T1D, underscoring a compelling need to address weight management as part of routine T1D care. Sustainable weight management requires both diet and physical activity (PA). Diet and PA approaches must be optimized towards the underlying metabolic and behavioral challenges unique to T1D to support glycemic control throughout the day. Diet strategies for people with T1D need to take into consideration glycemic management, metabolic status, clinical goals, personal preferences, and sociocultural considerations. A major barrier to weight management in this high-risk population is the challenge of integrating regular PA with day-to-day management of T1D. Specifically, exercise poses a substantial challenge due to the increased risk of hypoglycemia and/or hyperglycemia. Indeed, about two-thirds of individuals with T1D do not engage in the recommended amount of PA. Hypoglycemia presents a serious health risk, yet prevention and treatment often necessitates the consumption of additional calories, which may prohibit weight loss over time. Exercising safely is a concern and challenge with weight management and maintaining cardiometabolic health for individuals living with T1D and many healthcare professionals. Thus, a tremendous opportunity exists to improve exercise participation and cardiometabolic outcomes in this population. This article will review dietary strategies, the role of combined PA and diet for weight management, current resources for PA and glucose management, barriers to PA adherence in adults with T1D, as well as findings and lessons learned from the Advancing Care for Type 1 Diabetes and Obesity Network (ACT1ON).