Review Articles

Practical dietetic management of diabetic children

Alison Johnston BSC SRD Senior 7 Dietitian, Royal Hospital for Sick Children, Yorkhill, Glasgow

Introduction Theoretical recommendations (Ref 1) have recently been made revising the dietary prescriptions appropriate for diabetic persons. These are broad guide- lines covering many aspects of the diet and are designed to apply to the popula- tion as a whole. No advice has been given however for certain groups within the population, in particular geriatric and paediatric patients.

Can one assume that these recommen- dations apply to the entire spectrum of people who suffer from diabetes?

When the practicalities of nutritional therapy in diabetic children are investi- gated it is clear that some modification of these recommendations should be made to incorporate particular paediatric con- siderations.

Dietary aims Children with diabetes mellitus have

the same basic nutritional requirements as their non-diabetic counterparts, and any dietary recommendations to this group should be based on good eating habits for the whole family and not on radical changes, with diets involving unusual foods or abnormal eating patterns, for diabetic children alone.

The dietary aims for the child with diabetes are:

The diet should contribute to opti- mising blood sugars and avoid swings between hyper- and hypo- glycaemia. Therefore the distribu- tion of carbohydrate through the day is important, and should balance the effects of injected insulin. A preprandial blood glu- cose of 4-6 mmol/l is ideal. Any dietary modification must ensure normal growth and development in children. Energy should be sufficient for growth and development, allowing for variable exercise patterns without provok- ing obesity. Children should have their height and weight measured at each clinic appointment and the results plotted on growth centile charts. Growth velocity charts are also useful, particularly for antici- pating the onset of obesity or stunting. If children lose ground in their physical development, poor diabetic control should be con- sidered because growth can be a useful indicator of control.

Obesity is not such a problem in diabetic children as it is in diabetic adults but if children do gain weight disproportionately to their height, suitable dietetic advice should be given, sooner rather than later. Particular care should be taken to monitor the height and weight of adolescent girls as this group is most prone to obesity (Ref 2).

(3) The diet should be tailor-made for the individual child, bearing in mind the child’s social and cultural background because this will give the most favourable conditions for compliance.

(4) The psychological, social and emo- tional implications of eating should also be borne in mind. A dietary regimen must not be so rigid that it has a detrimental effect on the psychological development of a child. It should be as near to the normal eating habits of the family as possible.

Current recommendations Nutrition and health have become

topical subjects in the last decade, not only for the general population, but also for those with chronic conditions such as diabetes. Dietitians have welcomed this interest, which has resulted in the public- ation of two major nutritional reports.

In 1980, ‘Dietary recommendations for diabetics in the 1980s’ a report of the Nutrition Sub-committee of the Medical Advisory Committee of the British Diabetic Association (BDA) (Ref 1) was issued. In 1983, the National Advisory Committee on Nutrition Education (NACNE) published a discussion paper on ‘Proposals for nutritional guidelines for the general population’ (Ref 3).

The recommendations from each are similar, both proposing an increase in dietary carbohydrate and reducing dietary fat. Thus theemphasis has shifted from the traditional restriction and regulation of carbohydrate alone, to paying attention to all the components of the diabetic diet. In particular the reports advocate a reduction in dietary fat and an increase in dietary fibre. These publica- tions suggest that attention to the energy content of the diet in relation to individual energy requirements is of major importance for long-term good health.

The decrease in fat and increase in high fibre carbohydrates not only applies to the diabetic population, but to the popu- lation as a whole, and is now considered to be ‘sensible eating’ (Table I).

Carbohydrate The BDA states that at least 50% of a

diabetic’s total energy intake should be derived from carbohydrate. This carbo- hydrate should be in the form of poly- saccharides (eg bread, potatoes, cereals, beans) and those rich in fibre should be encouraged. Rapidly absorbed mono and disaccharides should be excluded where possible.

This new carbohydrate recommenda- tion differs from the old formulae whereby children were prescribed lOOg carbohydrate + log for every year of life which resulted in only 35-40’70 of their total daily energy requirement being car- bohydrate (Table 2 overltwfi.

It should be noted at this point that UK recommended energy and nutrient in- takes (Ref 4) were not designed for indivi- duals but for groups of people and no allowance was made for a child’s actual body weight or activity. Individual child-

Table 1 Recommended amounts of nutrients

NACNE3 for BDA’ for General Pop” Diabetic Pop”

% energy recommended from each:

Carbohydrate 50% >SO% Sugar 72% 1 Fat 30-34 % 35 % Protein 7 1 % 72-75% Fibre 25-3 Og/da y >25-30g/day

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Review Articles Practical dietetic management of diabetic children

l a ble 2 Diabetic diet

g.CHO daily Recommended g.CHO daily to from formulae

daily energy provide 50% total lOOg + 70s for Age intake4 energy from CHO every year of life ClRlS

2 I300 160 120 7 1900 240 170

5 1740 220 150 10 2280 290 200

BOYS

ren’s energy requirements may vary dramatically and recommended intakes for groups of people should not be used as the basis to compute an individual’s ideal diet.

To put the new recommendations into perspective, a five year old boy might have 220g carbohydrate and a two year old girl 16Og carbohydrate. This com- pares with the old dietary formulae of 150g and 120g carbohydrate respectively (Table 2, Fig I) . These figures are derived using the grouped means as the basis for recommendations and are for the pur- poses of example only.

The majority of paediatric dietitians have found from practical experience that it is impossible to get the younger children who have small stomach capa- cities to eat the large amounts of carbohy- drate advised, particularly if it has to be in the form of bulky unrefined sources. Moreover if these diets are prescribed, caution should be exerted in the pre- school child as these foods have a high satiety value, and are not energy dense. Young children on a low fat, high

Figure 1 Five- year-old diabetic with 220g carbohydrate foods. ( 1 980 BOA

recommendations)

carbohydrate diet with small appetites may not be able to consume this amount of food and consequently may not receive adequate energy for growth.

Ideally at least 40% of the total energy in the diet should come from carbohy- drate but the exact amount prescribed should only be made after due consider- ation of each individual’s capacity for unrefined carbohydrate. As the child grows older the percentage of carbohy- drate can be increased gradually to pro- vide 50% of the total energy and a reciprocal reduction in dietary fat made. Regular and continual dietetic guidance should be given.

Fat Children can easily reduce their dietary

(a) Taking grilled and baked foods in preference to fried, and cutting off any visible fat on meat.

(b) Encouraging fish and poultry instead of red meat.

(c) Cutting down the intake of crisps to 2-3 bags per week though often it is only possible to reduce them to one bag per day.

(d) Encouraging lower fat varieties of cheese. We have found from experience that cottage cheese is not popular with children so it seems more realistid to discourage the higher fat content varieties.

(e) Using skimmed milk instead of full cream milk in the over five age group. Children under five years old should only drink full cream milk, not skimmed milk (Ref 5), as they derive a substantial propor- tion of their energy from milk. The sodium: calorie ratio is also signifi- cantly higher in skimmed milk and could predispose to hypernatrae- mia in babies (Ref 6).

fat intake by:

children’s fibre intake although a figure of 7g fibre per lo00 calories has been

. tentatively suggested. High intakes can impair the absorption of vitamins and minerals due to the high level of phytate in high fibre foods although it can be argued that these foods themselves have a higher vitamin and mineral content than the lower fibre foods.

High fibre foods contain less energy per gram than refined carbohydrates therefore the child‘s total energy intake may be compromised if the diet has too high a fibre content. Children can how- ever include a number of high fibre foods in their diet, ie Weetabix, high fibre baking, baked beans and the majority will eat brown bread instead of white bread, although some will only have it toasted, as they are put off by the colour of brown food. A large proportion of children will eat at least one piece of fruit per day if it is offered to them.

Children are notorious for not being fond of vegetables although often raw vegetables are preferred to cooked. A child should frequently be offered vege- tables and have them included in soups and stews. Usually, in time, they acquire a taste for them. Efforts to force children to eat vegetables will only result in food being adamantly refused.

The high fibre pulses (Ref 7) would appear to be particularly beneficial but it can be an uphill struggle to tempt children to eat those other than in the form of baked beans in tomato sauce, peas and lentil soup.

Sugar Over 50% of carbohydrate is taken as

simple sugars by normal individuals eating the usual western diet, and replac- ing these with polysaccharides high in dietary fibre results in a considerable increase in the volume or bulk of food eaten. For this reason it is hard for

Figure 2 Four-month-old diabetic child,

diagnosed diabetic at two weeks.

Fibre A total daily fibre intake has been

recommended but in children it should surely relate to their body weight or total energy requirement. No official recom- mendation has yet been made regarding

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Review Art i c I es P radical dietetic management of diabetic children

diabetic children t o increase the propor- tion of energy eaten as dietary carbo- hydrate.

Prohibition of sugar has been the corner-stone of diabetic dietary manage- ment although many studies (Refs 7-9) are bringing to light the fact that the sparing use of sucrose taken as part of a mixed meal may help non-obese insulin- dependent, well controlled diabetics to comply with their diet while maintaining good blood glucose control.

Slama (Ref 8) 1984 states: ‘The inges- tion of sucrose may result in the same or lower plasma glucose concentrations than ingestion of an equivalent amount of either glucose or starch. The simple sugars vary widely in their rates of absorption. The rate depends on, among other factors, the type of sugar, the pre- sence or absence of dietary fibre, the simultaneous absorption of starch, fat and protein and the fluidity of the ali- mentary bolus’.

This has been reassuring to most pae- diatric dietitians who have always allowed controlled amounts of sweets and simple sugars, not only for illness or hypoglycaemia, but also before or after heavy or prolonged exercise. These carbohydrate foods may be given prior to exercise when extra carbohydrate is required. It should be pointed out that the extra carbohydrate before exercise need not be given as simple sugars and standard exchanges may be used although these are not often preferred by the children. The amount of additional car- bohydrate required before exercise will depend on the individual child, the type of exercise and how prolonged it is going to be. The rapidly absorbed carbo- hydrates may also be used as part of the dietary allowance at the end of a main meal, eg ice cream, given when the glycaemic response is lower, or on a special occasion.

The inclusion of these ‘sugary’ foods can serve numerous purposes:

(1) It makes the children feel more akin to their non-diabetic peer groups.

(2) Increases dietary compliance. (3) Increases palatability and variety. (4) Discourages the use of diabetic

products which are expensive, may contain the laxative sorbitol, and moreover are usually unpalatable.

Practical points

Diabetes mellitus occurs rarely in infants under a year old, perhaps one in every 50,000. It is uncommon in pre- school children, approximately one out of every 1,500-2,000 children. The over- all incidence of diabetes in the child population 0-16 years is 1 5 0 0 (Ref 10).

Translating the principles of diabetic

122

dietary management into a varied diet managed happily by the parents and eaten by the child is a formidable challenge. A diet history frqm the newly diagnosed diabetic is valuable, if only t o find out their present eating pattern.

Parents of these children are generally deeply shocked by the diagnosis and should be allowed to accept the condition before dietary instruction can begin. Frequent and short sessions are prefer- able with the whole family. Most families have little knowledge of nutrition and even less of what constitutes a diabetic diet. Those who have encountered the diabetic diet usually have experience of an aged relation and fear that their child is committed to a life-time of rich tea biscuits.

Parents may feel isolated and need much support from the diabetic team before dietary education is effective. The use of educational equipment including visual aids and computer tapes can help to engage the attention of the child and parents (Appendix i, ii, iii, iv, v). The British Diabetic Association also has a role to play and produces useful publications. The local parents group branch can help by allowing families in a similar situation to meet and feel more at ease.

Diabetic babies

Diabetic infants need particular con- cern. Any dietary modification must allow for growth which is a particularly important consideration for this age group (Figure 2 previous page). The carbohy- drate allowance should be based on their milk requirement, the principal source of nutrition. Mothers should be encouraged to continue breast feeding. Whether breast or bottle fed, the usual feeding pattern of frequent and regular feeds is ideal for the diabetic dietary regimen. A baby’s average requirement for milk up to nine months old is 150-200mls per kg per day (1501111 of breast and modified cows milk contains approximately log carbohydrate). If growth and develop- ment is normal the daily carbohydrate intake should be based on the baby’s usual feeding pattern with the insulin dose tailored appropriately.

Weaning usually starts around four months. Non-carbohydrate foods may be used initially eg 1-2 teaspoons of pureed vegetables, which will not affect the carbohydrate intake from milk. This allows the baby to become accustomed to solids without any anxiety being generated by food refusal. Once the child has become used t o a spoon and the amounts taken have been increased, carbohydrate exchances can be intro- duced. At first 5g carbohydrate exchanges are useful where only small quantities are being taken, eg !h oz of baby rice, Y2 rusk, 1 oz potato.

In the second six months the carbohy- drate from solids is gradually increased and by a year old up to about 90g may be taken, the remainder of the child’s carbohydrate allowance being given as milk. The carbohydrate should be evenly distributed throughout the day. Water and dilute low calorie squashes can be given to drink between foods.

Naturally, mothers do worry about hypoglycaemia which can be hard to recognise in babies. Advice should be given on how to recognise and treat hypos, with extra milk, Delrosa, Ribena or sweetened fruit juice. Nocturnal hypo- glycaemia is a great fear and to avoid this, milk and carbohydrate-based cereal should be given before the baby is put down for the night.

Weaning is an anxious and worrying time for any mother and this anxiety is heightened if any dietary modification has also to be observed. Tension about food must be relieved as a baby may refuse solids completely if hidher mother is worrying or fussing overduly.

Diabetic toddlers Small children cannot understand the

importance of their diet, so parents and health professionals must learn to be flexible and compromise as much as is practical. Toddler food strikes are com- mon in many children between 2-4 years. Most families manage to cope with the ‘food refusal syndrome’ without being manipulated by the child but the diabetic toddler poses a very real problem and with hypoglycaemia always a possibility, food refusal can become a powerful weapon. Parents should be advised not to force-feed, and to rely on the child’s falling blood sugar to cause hunger and a desire to eat. Lucozade or some other simple sugar may have to be given if breakfast is refused after the insulin injection.

In addition to the food strikes, many young diabetic children complain of con- stant hunger. Measurement of height, and weight, and dietary monitoring at each clinic visit should be done at this stage to assess the child’s intake and re- assure anxious parents that adequate nutrition is being maintained. The BDA Babysitting Notes (Appendix vi) are particularly useful for this age group.

School children The BDA school pack (Appendix vii) is

useful and should be given to each child’s school teacher. It explains in clear terms about diabetes and hypoglycaemia and how to treat it.

Diabetic children are recommended to carry glucose tablets at all times and the child’s school teachers should be equip- ped with a glucose drink in case of hypo- glycaemia. Some children fake hypogly-

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Review Articles Practical dietetic management of diabetic children

caemia to get extra dextrosol or Lucozade, but the thought of doing extra blood sugars a t the time of a suspected hypo is usually enough to dispel this idea.

Physical education teachers need to realise the need for extra carbohydrate before exercise and to check that children are carrying carbohydrate on cross country runs, for example. Pockets may be sewn into running shorts for this pur- pose. School dinners can, but should not, present a problem. It is not always possible for a child to go home for lunch and they may prefer to dine with their friends. Older children with a good grasp of their diet can have a n ordinary school lunch, counting the pudding as 30g of carbohydrate and the remainder of their allowance made up with potato at the main course. The most frequent use of cafeteria style canteens allows a flexible choice of food. The organisation and provision of diabetic meals can vary from area to area but a special school lunch may be arranged through the local com- munity medicine specialist, or by contact- ing the local authority catering service directly. We have found in practice that the child can be made to sit apart from his friends to eat his ‘special diet’ or that the caterer’s idea of a diabetic diet is to avoid carbohydrate totally. Advice should be given about suitable packed lunches.

School is a den of temptation for many children as non-diabetic children are con- stantly eating sweets. It can be predicted with certainty that a child will want to share these. The best attitude is to use positive reinforcement when a child is doing well. If persistent cheating is a pro- blem a 20g sweet allowance can be given daily. As soon as sweets are allowed they often lose their appeal and most children ask to have the allowance stopped within a few months. If the sweet allowance is not effective and habitual bingeing is causing frequent hospital admissions or poor diabetic control, the services of a child psychologist may be useful as ‘bingeing’ suggests underlying distress.

Parties and eating out All parties are highlights in children’s

lives and advice should be given so that the diabetic child can enjoy the party as

much as everyone else. Diabetic children can usually eat most of the varieties of party fare. It is important to ensure additional carbohydrate is eaten to com- pensate for the extra activity and excite- ment. Usually the host can be recommen- ded to provide low calorie juices for all the party guests.

As a child reaches adolescence, eating out in the evening with friends is com- mon. The carbohydrate content of foods available in popular eating places and published by the BDA is available (Appendix viii, ix). Children should be educated about their diet as soon as possible so that they are able to manage their diabetes independently. Parents should gradually allow them more inde- pendence- supervised if appropriate, so that their diabetic child is not cushioned from the realities of the world. Hospital admission of older children, for any reason, gives the diabetic team an oppor- tunity to teach the child about his con- dition.

Conclusion The dietary principles for adults are

also applicable to children but the inter- pretation will vary. Diabetic children require dietary advice suited to their own particular needs and, as they grow older, must have their diet adapted accordingly in order to optimise blood sugars and, as far as possible, avoid the long term com- plications of a poor diet and diabetes.

Acknowledgement Thanks are due to Mrs Brenda Clark,

Chief Dietitian, Royal Hospital for Sick Children, for her kind and valuable assis- tance.

References 1. Report of the Nutrition Subcommittee of the

Medical Advisory Committee of the British Diabetic Associalion. Dietary recommendations for diabetics for the 1980s. Human Nufritrun: Applied Nulrition, 1982, 36A: 378-94.

2. Jackson R. Growth and maturation of children with insulin dependent diabetes mellitus. The Paedrarric Clinics of North America. Philadelphia. Saunders Co. June 1984.31: 3,545-67.

3 . James WPT. A discussion paper on proposals for nutritional guidelines for health education. Sept. 1983. The Health Education Council. National Advisory Committee on Nutrition Education.

4. DHSS Committee on Medical Aspects of Food Policy. Recommended daily amounts of food energy and nutrients for groups of people in the United Kingdom. London, HM Stationery Office. 1979.

5 . The Committee on Medical Aspects of Food Policy. Diet and cardiovascular disease. London, HM Stationery Office, 1984.

6. Yeung 0. Pennell M. Leung M el a/ . The effect of 2% milk intake on infant nutrition. Nufrilion Research, 1982, 2 : 651-60. USA.

7. Mann J. What carbohydrate foods should dia- betics eat? Brit Med J . 7 April 1984. 288: 1025-6.

8. Slama G, Haardt M. Jean Joseph P er a/ . Sucrose taken during mixed meal has no additional hypoglycaemic action over isocaloric amounts of starch in well controlled diabetics. The Lancer. 12 July 1984, 122-4.

9. Jenkins D. Wolever T. Jenkins A el al. The glycaemic response to carbohydrate foods. The Lancet, 18 August 1984, 388-91.

10. Swift P. Babies and infants with diabetes. British Diabetic Association, 1986. Available from BDA.

Appendix Useful Aids and Publications

(i) Diet Teaching Aid, Standard Version, British Diabetic Association, 10 Queen Anne Street, London W l M OBP. Price f20.

(ii) Diet Teaching Aid, Ethnic Version, British Diabetic Association. Price f20.

(iii) The Diabetes Handbook -Insulin Dependent Dia- betes, Dr John L Day, Thorsons Publishing Group, New York, 1986.

(iv) I have Diabetes by Athea Dinosaur Publications, 1983.

(v) ‘Diabetes’, Computer Tape Dunitz Software, Martin Dunitz Ltd, 1983.

(vi) Baby Sitting Notes, British Diabetic Association.

(vii) School Pack, British Diabetic Association.

(viii) Carbohydrate Countdown, British Diabetic Association. Price f3.95.

(ix) Fast Food Carbohydrate/ Calories Check List. British Diabetic Association, Lilly Diabetes Care Programme. Eli Lilly & Co Ltd. Basing- stoke, Hampshire.

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