Pediatric, Adolescent, and Young-Adult Nutrition Issues in IDDM

Although insulin is life sustaining for patients with insulin-dependent diabetes mellitus (IDDM), the meal plan is of critical importance for avoiding hyperglycemia, preventing hypoglycemia, and maintaining metabolic balance. Consistency, timing, composition, and caloric content of food intake and physical activity, age, sex, growth, and pubertal status alter meal-plan needs. Self-monitoring of blood glucose should be used to individualize the meal plan. The general American Diabetes Association recommendations suggest that 50–65% of total calories be from carbohydrates from foods with a lower glycemic index and/or high fiber content. Protein should contribute 12–20% of total calories and fat <30%, with <10% saturated fat and <300 mg/day cholesterol. More severe fat restriction should be considered in individuals with persistent lipid abnormalities when compared with sex- and ageadjusted values. Calories should be sufficient for growth and development, with growth data obtained several times a year and plotted on standardized weight, height, and velocity charts. Blood pressure should be similarly plotted on age- and sex-standardized curves. All meal plans should be individualized, but certain circumstances require special attention in IDDM patients: 1) lack of minerals or vitamins in a youngster who is a picky eater; 2) eating disorders (i.e., obesity, bulimia, anorexia nervosa); 3) specific gastrointestinal diseases (i.e., Crohn's disease, celiac disease, giardiasis, or IgA deficiency); 4) low iron stores because of associated achlorhydria and positive gastroparietal antibodies; 5) alternative sweeteners, especially in pregnant women and very young children; 6) mineral balance changes that may occur with increased soluble fiber intake and episodes of hyperglycemia with or without ketosis/ketoacidosis; 7) changes in physical activity that require nutritional counterbalancing; and 8) intensified insulin therapy (including multidose insulin and continuous subcutaneous insulin infusion) associated with more frequent hypoglycemia and increased risk of obesity—both conditions potentially amenable to appropriate nutrition counseling.