Diabetes in Pediatrics Understanding Type I and Type II Diabetes in Children and Adolescents By: Erica Glover

Type 1 vs. Type 2 DM-1 Insulin dependent No connection to family history Auto-immune disease DM-2 Not insulin dependent (hopefully) Family history Strong relation to obesity and IGT Insulin resistance Hyperinsulinemia

Goals of Medical Nutrition Therapy Maintenance of near-normal blood glucose (BG) levels by balancing food intake with insulin and activity levels Hypoglycemia: multiple events can cause impaired brain development in young children Intensive BG management NOT recommended under ages of 13 years old

Goals of Medical Nutrition Therapy Achievement of optimal lipid levels Begins with maintaining normal glucose levels Children at high risk lipid abnormalities should be screened and monitored Provision of adequate calories for normal growth and development Height and weight every 3-6 months Plot growth on NCHS growth chart Once calorie and nutrient needs are established, they can be adjusted to accommodate growth or prevent accelerated weight gain At diagnosis, children usually require additional calories to promote catch-up growth Regular physical activity should be encourage, esp. type 2

Goals of Medical Nutrition Therapy Prevention, delay, or treatment of nutrition-related risk factors and complications. The rule of 15 Improvement of overall health through optimal nutrition.

Meal Planning Approaches Carbohydrate Counting Specific calorie levels not generally recommended Usually based on the amount of CHO normally consumed Exchange List for Meal Planning Helpful in formulating meal plan for specific nutrition needs Simply not practical

Physical Activity Generally reduces insulin requirements Better to consume 15g CHO per hour of activity than to adjust insulin Decreases insulin resistance in type 2 Check BG levels!! May have lipid-lowering effect Hyper risk may be due to inadequate insulin, missed injections, or increased stress hormone levels, which promotes glycolysis Physical activity promotes slimming in overweight type 2’s and increased insulin sensitivity.

Insulin Regimens Conventional Multiple daily injections Insulin pump The child/adolescent must take more responsibility for additional BG testing and CHO counting

Initial Nutrition Education Food components that influence BG levels Meal timing and consistent CHO intake Meal plan Prevention & treatment of hypoglycemia BG control in illness

Secondary Nutrition Education Monitoring & discussion of growth Review & modify meal plan Use of BG monitoring to develop CHO to insulin ratios Problem-solving/troubleshooting Modifications based on changes in appetite or schedule, excess weight gain or loss

Age-specific: Toddlers Daily variation in meal patterns Typically graze with small, frequent meals Food jags, selective eating Sporadic activity

Age-specific: Toddlers Schedule adequate regular meals and snacks containing carbohydrate Suggest to parents alternate sources of CHO if food refusal occurs Avoid withholding food in hyperglycemia

Age-specific: Preschool and School-aged Children More consistent & predictable appetites Generally eat same amounts of CHO at same time each day More meals & snacks away from home Birthday parties Overnight parties

Age-specific: Preschool and School-aged Children Involve more in food preparation and meal planning Morning and afternoon snack encouraged Instruct parents on management during special occasions Review meal plan often to ensure meals and snacks correspond to changes in activity. During childhood, there is increased participation in sports and physical education. Structure of meals and activity dramatically changes from school days to holidays and summer break. Remind parents of adjustments that need to be made at that time.

Age-specific: Adolescents Variable meal schedules Work School activities Social activity More responsibility for food choices Inconsistent meal timing, frequency, and amounts of CHO

Age-specific: Adolescents Peer influence in food choices and timing Mismanagement of meal plan common Growth spurts and variation of appetite Sports become central in the lives of some adolescents.

Age-specific: Adolescents Assess involvement of activity on a regular basis Make suggestions for appropriate snacks & supplements Screen for insulin omission & eating disorders Instruct on the potential hypoglycemic effects of alcohol Frequent adjustments may need to be made in insulin regimen. Football season to weightlifting or basketball or wrestling to baseball. Appropriate snacks should be suggested to supplement activity and prevent hypoglycemia. Boys are likely to need appropriate information on protein supplements, energy drinks, and others that promote weight gain

Age-specific: Adolescents Instruct adolescents who drive on the importance of BG monitoring & carrying a source of CHO with them at all times. Provide practical knowledge as needed on alternative eating patterns (i.e. vegetarianism)

Eating Disorders in Adolescents with DM-1 Pubertal changes in body shape may cause development of unhealthy eating attitudes. Dx of DM-1 heightens awareness of dietary restraints, weight gain, and food preoccupation. Insulin misuse to lose weight

Eating Disorders in Adolescents with DM-1 Pay attention to those who express body dissatisfaction Lead them toward healthy weight control practices Screen regarding weight How concerned are you about your weight? Do you ever skip meals to lose or maintain weight? Remember eating disorders affect both boys and girls.

Eating Disorders in Adolescents with DM-1 In the past year have you ever tried to lose weight by vomiting, taking pills, using laxatives, skipping insulin, or modifying your insulin dose? Include Behavioral Health Counselor and Family

Practical Advice to Parents Parents can have trouble dealing with their child’s new diagnosis. Here are points to help: 1. Don’t Isolate Yourself Find support, lean on others Support groups, family, friends, place of worship Keep in mind all that parent have to learn upon diagnosis: how to use BG monitoring equipment, plan meals differently, and make more frequent doctor visits for check-ups.

Practical Advice to Parents 2. Ask for Help Bring a friend or relative to help you take notes when you talk to medical providers. 3. Don’t Blame yourself Remind yourself that BG monitoring and insulin shots are now a fact of life You didn’t give your child diabetes

Practical Advice to Parents 4. Mind your Marriage Make time for your spouse everyday, putting aside your child’s diabetes 5. Work with Your Ex Put aside negative feelings to work together for the sake of your child Seek counseling if needed. Don’t play good parent, bad parent to drive a wedge between child and other parent Good parent games (relaxed rules) can cause and immediate threat to the child’s health. Both should meet with the diabetes care team or healthcare provider.

Practical Advice to Parents 5. Be Consistent Routines make children feel secure 6. Educate Yourself Knowledge may help reduce anxiety 7. Consider counseling Sometimes you just need a little help 8. Take a break from diabetes Take care of Yourself!

Do you have questions for me? Clarifications? Cultural/Native American Differences? More Information?