Current

Paediatrics

(I 999) 9, 164-l

68

8 1999 Harcourt Publishers Ltd

Symposium: Diabetes

Diabetic diets: which one?

N. Harding

Dietary advice given to families of children with diabetes has changed considerably over the last 70 years from strict carbohydrate prescriptions to a more liberal 10 g exchange system and now to the unrestricted healthy-eating advice that has become more common today. Although there is consensus throughout most diabetes centres on the fundamental nutritional requirements for children with diabetes there still remain considerable areas of controversy on the advice surrounding carbohydrate intake. This mainly surrounds quantification of carbohydrate versus a more liberal approach based on healthy-eating principles, the emphasis on other nutrients such as fat and fibre plus psychosocial implications of dietary control. This has resulted in a lack of consistency between teaching methods within the UK.

In practice, achieving all of the above can pose challenges to the health professional due to complex external factors which can include: 0 Varying social circumstances l Family eating patterns and practices l Education abilities l Parental attitude and peer pressure.

EVOLUTION

OF DIABETIC

DIETS

AIMS OF DIETARY

INTERVENTION

The primary goal of dietary modification is to minimize blood glucose variation through providing sufficient dietary carbohydrate to match the patients daily insulin dose. In attempting to achieve the primary goal the following additional factors have to be considered:
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Avoidance of extremes of hyper/hypoglycaemia the child Maintenance of ideal body weight and normal growth and development Minimization of the risks of long-term micro/macrovascular disease Maintenance of normal social functioning.

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Nicky Harding BSc, SRD, Paediatric Dietitian, Department of Nutrition and Dietetics, Southampton General Hospital, Southampton SO16 6YD, UK. Correspondence and requests for offprints to NH.

Historically evidence shows that dietary modification has played a key role in the control of diabetes for over 200 years. Before the widespread use of insulin therapy in the 1920s a starvation diet was typically prescribed to relieve the symptoms of diabetes. If the primary effect of this treatment was to delay death from ketoacidosis, death would nevertheless result from malnutrition. By the 1920s the use of insulin therapy was widespread within the UK and accepted as the primary treatment for diabetes. This led to the further development of diabetic diets to ensure sufficient carbohydrate intake to balance the insulin dose. This was achieved through rules such as the red/black line system established in the mid 1920s. These rules were designed specifically to restrict energy intake from carbohydrate to exceptionally low levels of around 20%. This inevitably resulted in fat energy intake levels of up to 70%, which conflicts with the 30-35X now recommended with the well-understood risks of high-fat intake and cardiovascular complications of diabetes. Counted diets evolved over the next 50 years becoming more flexible and thereby allowing patients to eat more normal diets, but still restricting the quantity of carbohydrate consumed. An individuals carbohydrate requirement would be calculated based on their average calorie intake. It is then divided into portions, usually 10 g, and distributed into meals and

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Diabetic diets: which one? snacks throughout the day. The individual would then be supplied with a prescription and compose their daily diet with the help of exchange lists and weighing scales. Alongside the development of diets such as the exchange system came increasing research into both diabetes and its complications which started to highlight some difficulties. These included: . Increasing knowledge of effects of high-fat diet Increasing understanding of the effects of different types of carbohydrate on blood glucose Difficulties in patients complying with rigid rules Emphasis on long-term control of complications as people with diabetes lived longer.
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Table Year

I %B Energy from carbohydrate %I Energy Diet 70 40 35 35 30-35 from fat

Pre-insulin 1921 1950 1971 1985 1996

Starvation 20 40 45 50 50-55

and insulin injections. This less strict dietary regime can reduce potential anxiety for parents when trying to get to grips with the medical routine.

The further evolution of dietary knowledge gradually reversed the emphasis on carbohydrate and fat (Table I). By 1975 Truswell et al reported that dietary advice was varying widely, particularly between different hospital teams, with respect to the type and quantity of fat and methods of quantifying carbohydrate. Toeller and Lion also confirmed this by their survey of the management of diet in 26 European centres.

THE CURRENT

EVIDENCE

WHAT IS THE QUALITATIVE

APPROACH?

A qualitative diet is based on the healthy-eating advice promoted for the population as a whole. This consists of a low sugar, low fat and high fibre diet with an emphasis on regular meals and snacks containing starchy carbohydrate with the aim of avoiding large variations in carbohydrate intake. Although sounding simpler than an exchange diet, a qualitative diet is not a completely free diet and does impose some forms of restriction, particularly regarding sugar and fat intake. The individual appetite primarily controls the amount of starchy carbohydrate (CHO) at each meal and snack. However, the child is encouraged to eat similar-sized portions of this type of CHO from day to day, only allowing for extra when there is an increase in activity. Parents and children may experience some difficulties in judging equal CHO portion sizes and to help this a portion system is sometimes used. This can be particularly useful for an overweight child when all feasible steps have been taken to reduce dietary fat intake, a portion system for carbohydrate can assist in the management of overall calorie intake. A qualitative diet is based on starchy carbohydrates, which are both bulky, filling and nutrientdense. A secondary benefit is that overall energy intake tends to be well regulated. This can prevent excessive hunger and therefore can help to distract the childs attention away from high-fat and sugary foods. A non-counted qualitative diet is less restrictive for the child and family allowing a more normal lifestyle to continue amongst the regime of blood tests

The Diabetes Control and Complications Trial4 showed that any sustained improvement in long-term glycaemic control is associated with lower risk of long-term complications. The 1993 5th National Symposium on Childhood Diabetes, Loughborough demonstrated that there was still a range of dietary teaching methods between diabetes teams.5 A national survey of paediatric dietetic practice on the same subject also reported this variation but with little evaluation of the effectiveness of practice.6 Results showed that 86% taught a quantitative system with the remainder using healthy-eating advice. The authors concluded that further research was needed into dietary counselling. Dietary compliance Studies have shown that patients in general are unable to or unwilling to follow a strict regime of counting exchanges. Many families who were taught exchanges at diagnosis were found to have reverted to a more liberal eating pattern to fit in with their lifestyle. The study showed that some who failed to grasp the concept became disillusioned and returned to their original eating habits Conversely, others determined to make the system work, doggedly adhered to the prescription to the extent where they felt unable to allow their child to eat out with friends for the fear of loss of control of the diet. It was shown that this over-restriction, which ignored the childs natural appetite, was detrimental to growth and development. McCulloch et al* reported that parents and children found exchange lists difficult to understand and Hackett et al9 found children varying their carbohydrate level from their prescribed levels by an average of 5 1 g. This variation was found to be related to factors such as exercise, activity and social events. It was noticed particularly in adolescents who have even less predictable lifestyles and hence a more marked daily variation in carbohydrate. Variability in carbohydrate intake coincided with deterioration in diabetic control.

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Lorenz et allo showed that even health professionals had difficulty in quantifying carbohydrate content of mixed meals and concluded that it was likely that the average child would experience similar difficulties. A child with well-controlled diabetes will have the same nutritional requirements as his non-diabetic peers. Price et al found that their unrestricted diet group had very similar diets to their non-diabetic peers, although the majority of the children perceived their diet to be considerably different to their friends. This is an important consideration to compliance, particularly in the adolescent group. Psycho-social impacts of quantitative diets It is generally accepted that personal eating patterns are complex and have strong psychosocial elements that can be particularly complex in children. Counting grams of carbohydrate for the diabetic child within the family may involve preparation of separate meals causing isolation and resentment for that individual. Despite the importance of good blood sugar control, strict dietary prescription can have the following psychosocial implications:
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Swift et al7 showed that, without regular dietary review when on an exchange diet, there was potential for overall nutrient intake to be insufficient to meet changing growth demands. Price et al found no significant difference in nutrient intake between prescribed carbohydrate and unrestricted groups. Both groups had approximately 45/ of total energy as carbohydrate and an unacceptably high 40% energy contribution from fat. Comparative studies In the last 20 years several studies have been performed to evaluate the effectiveness of carbohydrate restriction versus a more liberal diet based on healthyeating principles. In the early 1980s there was little alternative to the exchange system. A non-traditional qualitative diet was compared to the traditional exchange system. Results showed a reduction in glycosylated haemoglobin (HbAlc) for both groups and concluded both diets were equally effective at controlling diabetes.13 Since then WalkerlJ. Price et al and Mitchell et alIs have all performed similar comparative studies. They all concluded that there is no advantage to be gained by restricting diabetic children to a counted diet and that the traditional 10 g exchange system was not always necessary to achieve good glycaemic control. Other nutrient influences Although the theory of quantifying carbohydrate with a fixed dose of insulin appears an easy method of achieving good blood glucose control. it is now accepted that the digestion of other nutrients such as fat, protein and fibre also have a significant effect in the absorption of carbohydrate. It had been well recognized that fat and protein delay gastric emptying, affecting blood glucose response, but more recently variations in blood glucose response from different forms of carbohydrate have also been identified. A study by Jenkins et alI6 investigated the effects of digestion of different forms of carbohydrate on blood glucose response and found a large variability in how different forms of carbohydrate are handled. As a result of this work a glycaemic index was developed which allowed the relative effects of different foods on blood glucose response to be quantified based on a reference food. (Blood glucose response of test food) Glycaemic Index = (Blood glucose response of reference food)

The negative effects of peer pressure Potential development of eating disorders Possible feelings of guilt and inadequacy in the event of non-compliance Rebellion against dietary restraint with negative consequences for diabetic control.

Swift et al7 looked at the effect of differing advice between diabetes teams. They reported on the mother of a diabetic child who described vividly her feelings of inadequacy at relearning a different set of dietary principles having perfected the exchange system. She felt guilty she had not been doing the best for her child despite the good intentions and faith in the original education. There is now a greater appreciation of the psychological effects of strict dietary regimens and the onset of eating disorders. The evidence shows that anxieties can result from carbohydrate restriction resulting in disordered eating patterns, bingeing on forbidden foods and thus upsetting glycaemic control. A sense of failure and low self-esteem can be caused by an inability to adhere to the regime, compounded by fear of reprimand by their Diabetes Team resulting in nonattendance of clinic appointments. Increasing awareness of these factors mean that dietary education has had to change accordingly. Physiological consequences Studies have suggested that there can be physiological consequences of restricting carbohydrate. Waldron reported an increased fat and protein intake resulting from an inadequate carbohydrate allowance. This increased fat intake is generally accepted to have implications for raised lipids in the child.

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This research highlighted some of the difficulties of the 10 g exchange diet where glycaemic response of food is assumed to be solely a function of carbohydrate without allowing for differences in glycaemic response of carbohydrate types.14

Diabetic diets: which one? For example, beans and pulses were found to have a low blood glucose response due to their soluble dietary fibre content. Not all types of fibre have this response. Removal of insoluble fibre from bread, pasta and rice has very little effect on the glycaemic response. Furthermore, some starchy foods such as boiled potato produce a similar glycaemic response to glucose and the response of cornflakes and bread is higher than sucrose. Jenkins et alI6 concluded that, based on the glycaemic index, small amounts of sucrose could be consumed with fibre rich foods with no effect on the glycaemic response. The theory of quantifying carbohydrate to suit a prescribed dose of insulin may initially seem attractive but evidence shows that there are many other factors which affect blood glucose control. Dietary fibre

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Once a meal pattern and routine have been established, high-fibre starchy foods should be encouraged aiming for 2 g fibre/lOOKcaUday for school-age children. In particular, foods containing soluble fibre (beans, fruit and oats) with a lower glycaemic index should be encouraged. This is not so applicable in the younger age group (O-5 year olds) where insufficient energy intake may result from a bulky, low-sugar, high-fibre diet. Fat The BDA recommendations advise that school-age children with diabetes can adopt a low-fat diet as recommended for adults. Many parents are now aware of the health messages to reduce fat intake and so it is important to distinguish between the effects of fat and sugar on diabetes. Parents can easily become too caught up with buying low-fat foods whilst forgetting that a low-sugar diet is necessary for good glycaemic control. There are many popular foods now such as ice cream, cake bars and biscuits which are heavily marketed as lower-fat alternatives. In most cases, the fat has been substituted with additional sugar but they are still perceived as being allowed more freely within the context of a healthy diet. It is therefore important that the family is taught how to understand food labelling and to be able to make their own decisions on whether products are suitable. Sweeteners Artificially sweetened foods are now very much part of our culture with the increasing promotion of healthy eating. Non-nutritive sweeteners such as Aspartame and Acesulfame K are used widely and provide a considerable choice of low-sugar products for people with diabetes. Polyols (sorbitol, mannitol) and fructose have no advantage over small quantities of sucrose. They may cause osmotic diarrhoea and therefore are recommended to be limited to ~25 g/day. Diabetic foods are not recommended as they are often expensive and high in fat and calories. Exercise Many parents, in the initial stages, will anxiously overcompensate on snacks and meals to avoid hypoglycaemia, particularly before exercise. Together with additional starchy carbohydrate, refined carbohydrate should be given just before a period of strenuous activity. The more experienced parent and child will have learnt to judge the right amount of carbohydrate to cope with different occasions. Families should also be made aware of the risk of hypoglycaemia up to several hours after exercise and may need to compensate with a larger bedtime snack.

THE CURRENT

RECOMMENDATIONS

Current recommendations emphasize the need to establish eating habits which optimise glycaemic control within the familys normal diet. Carbohydrate distribution Regular amounts of unrefined carbohydrate at each meal and snack are the basis of the current BDA guidelines of diet for children and adolescents. They recommend, for school-age children, that at least 50% of calorie intake should be from carbohydrate sources and fat intake be reduced to 30%-35%.7 Parents need to be warned about the childs greatly increased appetite as weight is regained following diagnosis. Parents are often concerned having grown accustomed to their childs progressive malaise prior to the diagnosis. Therefore, advice should emphasize starchy filling carbohydrate at meals and snacks, preferably high in fibre. When the appetite has settled, parents need to be reassured that snacks are not additional to overall food intake but help to distribute carbohydrate more evenly throughout the day. Meal portions may need to be adjusted in order that the child has sufficient appetite for snacks and vice versa. A portion system is often used, as a rough guideline, to compare the amounts of carbohydrate and help meal planning.5 Food photographs and models make education of this system more effective. There are many misconceptions surrounding the diet for diabetes and the initial meeting with the Dietitian at diagnosis often solely requires reassuring the parent and dispelling the myths. Parents and children are often relieved to learn that the diet is not completely sugar-free. Recommendations allow up to 25 g of added sucrose within the context of a highfibre diet resulting in little difference in post-prandial blood glucose levels. * This may improve compliance in keeping children interested in food by allowing some treats.

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Current Paediatrics

CONCLUSIONS Quantitative diets have played an important role in the control of diabetes since the introduction of insulin in the 1920s. However, current research has shown that the success of quantitative dietary approaches in children can be limited by a number of factors: Childrens ability to comply with strict dietary prescription Psychosocial factors associated with rigid food disciplines Other nutrient interactions such as fat and fibre intake Physiological consequences of restricted dietary practice. The development of the glycaemic index has given a better understanding of the effects of different form CHO and allowed some flexibility within the diet to include more sucrose. There is a danger that it could be used as another rule-based diet. However, the principles of promoting high-soluble fibre foods should be incorporated into the healthy-diet approach to help reduce glycaemic response Any type of dietary modification needs to be treated sensitively. Families need reassurance in their abilities to manage their childs diet and may resent their existing methods being challenged. Whichever type of diet is used, the ultimate aim must be to keep the advice simple, practical and tailored to their lifestyle. Sensitivity to social factors as well as age, education and level of motivation along with the diabetics teams ability to establish a rapport with child and family also helps successful dietary modification. Despite considerable evidence indicating that qualitative methods of dietary control can allow children and parents to lead a more normal lifestyle whilst still maintaining good glycaemic control, the most recent surveys suggest that quantifying carbohydrate remains the most popular method within paediatric diabetes teams. The current trend to allow children with diabetes to lead normal lives to the greatest

extent possible means that further encouragement and education is required to promote the more widespread adoption of qualitative diabetic dietary concepts.
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Waldron S. Current controversies in the dietary management of diabetes in childhood and adolescence. Br J Hosp Med 1996; 56(9): 450455. Truswell AS, Thomas BJ, Brown AM Survey of dietary policy and management in British diabetic clinics. BMJ 1975; 4: 7-l I. Toeller M Lion S Survey of the management of diet in 26 diabetes centres in Europe. Diabetic Med 1987; 4: 129-134. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med 1993; 329: 977-986. Waldron S. Childhood diabetes -current dietary management. Current Pdediatrics 1993; 3: 138-141. Waldron S, Swift PGF. The diatetic management of children with diabetes. Diabetes Med 1994; I I (Supp 2): 55. Swift PGE Waldron S, Glass C. A child with diabetes: distress, discrepancies and dietetic debate. Pratt Diabetes Int 1995; I2 (2): 59-62. MC Culloch DK, Mitchell RD Ambler J. Influence or imaginative teaching of diet on compliance and metabolic control in insulin-dependent diabetes. BMJ 1983: 287: 1858-1861. Hackett AF. Court S, McGowan C, Parkin JM. Dietary variation in diabetics. Arch Dis Child 1988; 63: 794798. Lorenz RA. Christensen NK, Pichert RD. MS, JW. Dietrelated knowledge, skill and adherence among children with insulin-dependent diabetes. Paediatrics 1985: 75: 872-876. Price KJ. Lang C, Eiser C, Tripp JH. Prescribed versus unrestricted carbohydrate diets in children with type I diabetes. Diabetic Med 1993; IO: 962-967. Marcus MD, Wing RR, Jawad A. Orchard TJ. Eating disorders symptomology in a registry-based sample of women with insulin-dependent diabetes mellitus. Int J Eat Disord 1992; 12: 425430. Chandler C, Moore R, Leichter S, Lyttle S, Lexington JJ. Traditional vs. non-traditional diet methods. Diabetes 1993; 32 (Suppl): l8A. Walker L. Counted diet versus non-counted diet in the management of insulin-dependent diabetes in children. Diabetes in General Practice 1992; Winter. Mitchell RD. Nowakowska JA. Hurst AJ. Comparison of the official IO g carbohydrate exchange system with simplified dietary advice in insulin dependent diabetics. J Hum Nutr Dietetics 1990; 3: 19-26. Jenkins DJA. Jenkins AL, Wolever TMS, Josse RG Wong GS. The glycaemic response to carbohydrate foods. Lancet 1984; (ii): 388-39 I. British Diabetic Association The chequered history of diets. Balance for Beginners, 1995-1996.