“Does my son need to be on a special diet for diabetes?”
My 14-year-old son was just diagnosed with type 1 diabetes, and it's really been a whirlwind of emotions since his diagnosis. He is starting to manage it with injections. But, should he also be on a special diet for type 1 diabetes?
3 Answers
Education in diabetes is essential for Type 1 kids. You and your son need to have a lengthy conversation with your Pediatrician, Endocrinologist, and Nutritionist.
Diet for diabetes:
The dietary recommendations for children are based on diet that mainly relies on fruits and vegetables, whole grains, low-fat and nonfat dairy products, beans, fish, and lean meat, to support growth and development and maintain a healthy cardiovascular system.
These guidelines advocate the intake of:
1) Low saturated and trans fat.
2) Low cholesterol
3) lower added sugar to <10% of daily calories. Reduce added sugars, including sugar-sweetened drinks and juices
4) Low salt <3 grams per day, including salt from processed foods
5) Low intake of energy drinks
6) Physical activity appropriate for age and gender.
7) Maintenance ideal weight for height.( <85 percentile)
8) Adequate intake of vitamins and minerals.
9) consumption of appropriate amount of fat, protein, carbohydrates and vegetables daily.
10) Perform moderate to vigorous physical activity at least an hour a day with strength and balance activity at least 3 times a week to maintain normal growth.
11) Eat vegetables and fruits daily, while limiting juice intake.
12) Use vegetable oils and soft margarines low in saturated fat and trans fatty acids and avoid butter or most other animal fats in the diet.
13) Eat whole-grain breads and cereals rather than refined-grain products
Reduce the intake of sugar-sweetened beverages and foods
14) Use nonfat (skim) or low-fat milk and dairy products daily. Use only lean cuts of meat and reduced-fat meat products. Remove the skin from poultry before eating.
15) Eat more fish, especially oily fish, broiled or baked.
16) Use fresh, frozen, and canned vegetables and fruits and serve at every meal; be careful with added sauces and sugar
17) Use recommended portion sizes on food labels when preparing and serving food.
The daily calorie requirement is different for different age groups and gender. Male expend more calorie than women. In general adult males require about 2000-3000 calories a day. Adult females will require a bout 1600-2000 calories a day depending on their activity level. Younger children <8 years old will require about 1000-2000 calories a day. While older children will require 1400-3200 calories a day. Those who a sedentary life style require the list amount of calories. While moderate activity and vigorous physical activity requires additional calories in some cases up to 800 calories more than sedentary people. A 14 years old may require 2400 to 3200 calories for boys when they are physically active. And girls of that age require from 2200-2800 calories depending on their physically active.
Sedentary life is considered when activity is only performed to maintain independent living such as doing house chores, cooking etc. Moderate physical activity is when walking a bout 1.5 to 3 miles per day at 3-4 miles an hour in addition to independent living (sedentary) activity. Active life style is when walking more than 3 miles a day at 3-4 miles an hour in addition to sedentary activity to support independent living.
Children should be active (moderate or /and vigorous) for at least an hour a day with muscle strengthening as part of the 60 minutes and bone strengthening (running, jumping rope, and lifting weights) and flexibility activity as part of the 60 minutes at least 3 times a week.
A typical 14 years old boy should consume about 2200 calories when sedentary and about 3200 calories when he is active. He will require about 325-400 grams carbohydrates a day (50% of the calories) depending his physical activity. Added sugars including from processed food, should be less than 10% of the total carbohydrate intake. Fructose based syrups should be avoided if possible.
His protein requirement will be 125 grams of protein (20%) of his daily calories. His fat intake should be bout 90 grams a day (30% of daily calories) daily. Saturated fats and trans fats should be less than 10% of the daily fat intake (<10 grams).
A 14 years old or older boy should consume around 1-3 cups of milk, 2 cups of fruits, 3 cups of vegetables and 7 ounces of grains a day. He needs about 30-40 grams of fiber a day.
His daily mineral requirement are as follow: Calcium 1200 mg, Sodium <2300 mg, potassium 4700 mg, phosphorus 1250m mg, Magnesium 410 mg, Iron 11 mg.
A typical 14 years old require vitamins as follows:
Vitamin D 600 units (15 microgram)
Vitamin A 900 mg
Vitamin C 75 mg
Vitamin B-12 2.4 mg.
Dietary recommendations are revised by USDA every 5 years. A group of expert panel and dieticians revise the nutritional guidelines sponsored by the United states department of agriculture (USAD). Currently the Choose My Plate method is available since 2010. It was revised in 2015. The next revision will be in 2020. In 1992 the USAD set a nutritional guideline called the food pyramid. In 2005 the food pyramid was replaced by the MyPyramid. Since most people would not be able to quantify foods in ounces and grams the USDA developed choose MyPlate method for children based on the recommendation of scientists and dieticians, based on the current scientific information on nutrition. The Myplate method is divided into five sections of approximately 30 percent grains, 30 percent vegetables, 20 percent fruits and 20 percent protein, and a glass of dairy product such as low fat or skim milk. It is color codded for simplicity so the families with children will understand it. The Choose Myplate method was simpler with out measuring the grams and ounce but visualizing the plate proportions. Half the plate should consist of fruits and vegetables, while the other half is divided between whole grains and lean sources of protein. The dairy is represented by a glass of skim or 1% milk or other nonfat or low fat dairy products. The general guidelines for macronutrients are similar to that of none diabetic population.
The choose Myplate method is colored as follows.
1.Vegetables is green
2.Fruits. Like veggies, fruits have vitamins, minerals, and fiber
3.Grains. The orange section of MyPlate is about one quarter of the plate.
4.Protein. High-protein foods help the body build and maintain its tissues.
5.A glass of dairy products such as low fat milk. Fats are not considered here because people use oil to cook and some of the food have enough fat or oil to support the nutritional requirement of a growing child..
A 14 years old with type 1 diabetes may require about 40-60 units of insulin daily in divided doses, depending on his insulin sensitivity. As time goes by his insulin sensitivity may diminish and may require much more insulin. The typical insulin to carbohydrate ratio will be 1 unit for 10 grams in the beginning but may require more insulin later on. As time goes by 1 unit of insulin to 5 grams of carbohydrates is common. This is specially true as the honeymoon period passes. His insulin sensitivity may be about 1 unit for every 30-50 mg/dl of glucose above the target blood sugar. Most target blood sugars are 100-120 mg/dl.
The nutritional requirement for diabetic patients are similar to those that healthy individuals with out diabetes as discussed above. However diabetes involves blood sugar testing, insulin adjustment, and carbohydrate counting.
Dietary guidelines should be incorporate into diabetic patients lifestyle to maintain good glycemic control, promote growth and development and support cardiovascular health. There are no set of especial nutritional recommendations set for diabetic patient other than to pay special attention to insulin regimen and carbohydrate, insulin and carbohydrate requirements during physical activity and illness. diabetes patients should follow dietary guide. These should be individualized, and accepted by the diabetic patient in order to be effective.
This involves a team effort of a dietician, and diabetic team approach not of a single diet sheet or a hand out approach. These include instruction on nutrition therapy and diabetes self-management education.
The nutritional goal for diabetic patients is:
1) To promote and support healthful eating patterns, with nutrient dense foods and appropriate portion sizes.
2 Improve glycemic control
3) maintain normal blood pressure, and lipid goals.
For children with type 1 diabetes, participation in an intensive flexible insulin therapy education program using the carbohydrate counting meal planning approach can result in improved glycemic control. This can be done with either multiple daily insulin injections of a fast acting insulin for meals and corrections and a long acting insulin (bolus/basal principle) or using continuous subcutaneous insulin infusion (insulin pump) therapy.
In a non-diabetic patient insulin is made in the pancreatic beta cells and is released continuously (basal or background insulin) and in response to food, mainly carbohydrates. The insulin produced in the pancreas, goes through the liver, and, 85% of it is destroyed by the liver before it goes to the systemic circulation (blood) to mediate glucose transport to the tissues to be consumed for energy. The remaining 15% travels in the systemic circulation and is deactivated in a short period of time. The half life of insulin is about 5 minute in the blood and in 3 half lives (15 minutes) insulin dissipates completely so that we do not experience hypoglycemia afterwards.
In patient with insulin dependent diabetes, insulin is not made in the pancreas but given under the skin by injection and stays minimum of 3-4 hours not 15 minutes as in a none diabetic person.
It is therefore important to recognize that in diabetic patients insulin is given AT THE WRONG PLACE, AT THE WRONG TIME, AND IN THE WRONG DOSE. This causes a huge problem in managing insulin dependent diabetic patients. Insulin given under the skin leads to greater unpredictability. Unlike non diabetic persons, where insulin is controlled tightly and blood sugars are maintained in a narrow normal range, insulin dependent diabetic patients experience blood sugar variability (excursions). Hypoglycemia and hyperglycemia are very common in insulin dependent patients.
During illness in non-diabetic patients the pancreas make more insulin (20-30% more insulin) due to the stress hormones with out causing hypoglycemia or hyperglycemia. In insulin dependent diabetic patients during stress the body makes stress hormones leading to high blood sugars necessitating increase in insulin requirement by 20-30%.
Diabetic patients have similar nutritional requirement to the non diabetic patients. However since insulin is given at the wrong site ( not coming from the pancreas to the liver), at the wrong time (30-10 before meals) and in the wrong dose ( bigger dose that lasts at least 3-5 hours instead of 15 minutes) compared to what the body does. Therefore special attention should be taken regarding the following considerations:
1) Insulin management and timing of Insulin and Meals
2) Carbohydrate counting:
3) Prevention of hypoglycemia
4) Sick Day Management
5) Treatment of hypoglycemia guidelines
6) Exercise and diabetes
A) insulin dosing and timing of insulin and meals: Insulin doses should be determined for the amount of food to be consumed and for correction for high blood sugars. Insulin to carbohydrate ratio and sensitivity factor should be established and adjusted as needed. The amount of carbohydrate for each meal should be decided if the patient is on fixed insulin therapy. The amount of carbohydrates for each meal and snacks should be kept constantly to avoid high or low blood sugars. The amount and timing of insulin for each meals and snacks should be reasonable to avoid mismatch between the food consumed and the amount of insulin given. In flexible insulin therapy either via the insulin pump or multiple daily injections of fast acting insulin with a long acting insulin the amount of carbohydrates can be varied as needed with out affecting blood sugars as the amount of insulin is matched to the amount of carbohydrate consumed. However the timing of insulin boluses should be constant. Flexible insulin therapy is superior to fixed insulin therapy, though in good hands they will all do reasonably well.
B) Carbohydrate counting: The primary goal in the management of diabetes is to achieve a reasonable fasting and postprandial ) blood glucose. This assumes over 50% of blood sugars should be in the desirable range of 70-140 mg/dl with little blood glucose variability. Maintaining an A1c of <7.5% is ideal. It is important to pay attention to the type and amount of carbohydrate in a food because they can influence overall glucose control. This means that the type and the total amount of carbohydrate eaten strongest the glycemic response.
Most patients with type 1 diabetes get about 50% of their total energy intake from carbohydrates. The rest of the 50% is derived from proteins and fats (oils). With type 1 diabetics estimating the total grams of carbohydrates by either experience based estimation or actual carbohydrate counting, is useful in achieving reasonable blood glucose control.
Most carbohydrate should be consumed from vegetables, fruits, whole grains, legumes, and dairy products with out added sugars, fats or salt.
Diabetic should choose low–glycemic load foods for better glycemic control. If substitutions are required with sucrose based products it should be done without compromising nutrient dense food choices.
Type 1 diabetic patients should also consume about 30- 40 grams of fiber a day similar recommendation to the general population. Dietary fiber is defined as the carbohydrate and lignin found in plants that is not digested by the stomach or absorbed in the gastrointestinal tract.
Some of the high fiber containing carbohydrate that should be consumed daily include whole fruits and vegetables, whole grain breads, legumes, and cereals. At least over 50% of grains should be whole grain and fruits and vegetables should be fresh unprocessed products.
Processed foods and high fructose based products should be avoided. Added sugars should be limited to <10% of the total carbohydrate intake.
C) Prevention of hypoglycemia:
Type 1 diabetic patients must take insulin to control their blood sugars. Since subcutaneous insulin injection does not follow the natural insulin production in the pancreas (wrong site, wrong dose and wrong time) hypoglycemia and hyperglycemia are very common. When blood sugars are low (<70 mg/dl) the person can develop autonomic symptoms of hypoglycemia such as dizziness, weakness hunger, anxiety, irritability, light-headedness, sweating, pale face, tremor, heart palpitations, rapid or irregular heart rate, trembling, or shaking. When hypoglycemia is sever (<30 mg/dl) neuroglycopenia will sett in leading to stupor, unconsciousness seizures and coma. Chronic hypoglycemia will also lead to detrimental health out come.
Diabetics on insulin or oral hypoglycemic agents therapy need to prevent hypoglycemia from happening. Some of the following guidelines may be helpful in preventing hypoglycemia.
1) Learn how subcutaneous insulin works. Understanding the what the duration of action of fast acting insulin and long acting insulin are (the time it takes for the injected insulin to dissipate completely). Understanding when insulin starts to work after admitted under the skin or when bolused through the insulin pump (onset of action), and when the maximum of action takes place (peak of action). Understanding how certain insulin behaves will help you to determine whether you need to increase or decrease the insulin dose in the future.
2) Monitor blood sugars before meals and after meals or at least 4 times a day including at bed time. Occasional, testing blood sugars in the middle of the night will be helpful in management your diabetes better.
3) During moderate to vigorous physical activity insulin doses and food intake should be adjusted to correlate with the level of physical activity. Increasing the level or duration of physical activity can lead to significantly low blood sugars. During moderate or vigorous physical activity, insulin dose may need to decrease by about 20-30%, depending on person’s insulin sensitivity.
4) Diabetic patients on insulin therapy or oral hypoglycemic agents should not skip, significantly alter, or delay the amount of meals or snacks without changing the insulin dose. similarly the timing of meals and insulin injections should be maintained appropriately.
5) Document any occurrences of low blood sugars and hypoglycemic symptoms. This can be helpful in determining the cause of hypoglycemia and find ways to prevent them.
6) Every patient with insulin dependent diabetes should carry some form of diabetes identification such necklace or bracelet and wallet card in case of emergency.
D)Treatment of Hypoglycemia:
Any blood glucose level ≤70 mg/dL is considered hypoglycemia. Symptoms Regardless of the symptoms of hypoglycemia, the low blood sugars must be treated promptly with fast acting sugars such as juice, milk, soda, life savers , etc. Usually the rule of 15/15 rule: That is 15 gms of fast acting carbohydrate increase blood glucose by 30-45 mg/dL within 15 minutes. Blood sugars should be checked in 15-20 minutes. If blood glucose is still < 70 mg/dL, another round of fast acting carbohydrates should be given. This can be repeated every 15-30 minutes until blood glucose increases >70 mg/dl persistently and symptoms of hypoglycemia resolve. About 4 ozs of fruit juice, regular (not diet) soft drink, 4 glucose tablets, 2 table spoon of raisins and a cup of skim milk will raise the blood sugars by a bout 30-40 mg/dl in 15 minutes. if the next meal is at least an hour away, eating a small snack will be helpful.
If the patient can not take any thing by mouth or if the patients is not conscious or have a seize do not use fast acting sugars as this will lead to aspiration. Glucagon emergency kit should be used in caser of emergency give 1 mg of glucagon intramuscularly and emergency medical services should be activated by calling 911.
If the patient is sick but can not take by mouth due to vomiting or diarrhea glucagon can be used to raise the blood sugar. In this case subcutaneous glucagon of 10-15 units can be given using a diabetes syringe similar to insulin injection every 30 minutes as needed. Glucagon should raise blood glucose level by 30-40 mg/dl in 30 minute. This can be repeated several times as needed or need to go to the emergency room. If the patient is spilling ketones glucagon is not recommended since the glycogen in the liver may be depleted.
During hypoglycemic episodes high fat foods should not be given to correct blood sugars, as these will delay blood glucose raise from carbohydrate intake.
E) Sick Day Management
During illness the body makes stress hormones such as adrenalin and cortisol. These stress hormones cause insulin resistance leading to 20-30% in insulin requirement. Occasionally when patients get sick they develop hypoglycemia especially if they have diarrhea and vomiting. However most of the time diabetic develop high blood sugars due to the stress hormones. Some times diabetic ketoacidosis can develop if enough insulin is not taken or when the patient is not well hydrated. More often many patients omit their insulin doses and develop diabetes ketoacidosis.
The most important things to remember during illness are;
1) Self-monitor blood glucose as often as possible.
2)Continue to take insulin
3) increase your insulin doses 20-30% until the illness resolves.
4) give insulin corrections as often as possible every 2-3 hours.
5) keep blood sugars <150 mg/dl by giving multiple injections
6) you should drink enough fluid to keep hydrated. With out hydration insulin can not be absorbed from the skin and does to work no matter how much insulin you give. Hydration, Hydration, Hydration, Hydration, Hydration,
7) Eat the usual amount of carbohydrate, divided into smaller meals and snacks if necessary. Eat foods that are easy-on-the-stomach such as yogurt, soups, non-diet gelatin, crackers, and applesauce. If blood sugars are > 250 mg/dL the usual amount of carbohydrate may not be necessary until the blood sugars come down. It is essential to consume at least about 2/3 or 40-60 grams of carbohydrate every three to four hours.
8) Test urine ketones:
If ketones are negative you may correct your blood sugars every 2-3 hrs. with insulin in addition to your usual insulin dose. Push for hydration.
If ketones are mild you can increase your usual insulin by 5-10% and give insulin corrections every 2-3 hours. Push for hydration.
If ketones are moderate increase your insulin regimen by 10-20%. Correct blood sugars every 2-3 hours. Push for hydration. Consult with you diabetes educators.
If ketones are large, increase your insulin regimen by up to 30%. Push for hydration. call your diabetes educators and go to emergency room for intravenous hydration.
Patients on insulin pump should consider giving insulin by injection when blood sugars are not coming down or the ketones are moderate or large. Change the pump site and continue to give insulin boluses every 2-3 hours by injection. Also hydration, hydration and hydration.
F) Exercise has many benefits to our cardiovascular health. The recommendations for aerobic activity for diabetic patients is similar to persons with out diabetes. Adolescents should spent over an hour a day in moderate to vigorous physical activity. Sports activity brings special challenges in managing the blood sugars of diabetics on medications, especially for those on insulin and oral hypoglycemic agents. Physical activity affects blood glucose response. The duration of activity, the amount and intensity of exercise, timing and type of the previous meal, timing and type of the insulin injection all affect blood glucose repose. In general moderate to vigorous physical activity significantly lowers blood glucose levels. Snacks of about 15 grams should be consumed every 30-60 minutes depending on the individuals blood sugar response to physical activity.
Monitoring blood sugars before during and after physical activity and adjusting insulin and carbohydrate snack will be vital in preventing or treating hypoglycemia. Some patients may develop high blood sugars during sports activity. As long as they are not sick or they are not spilling ketones, they can administer at least 1/2 of their boluses if their blood sugars are above 250 mg/dl.
If the patient is sick or have ketones with or with out illness participation in sports activity should be avoided.
In summary the nutritional requirement of a diabetic person is similar to a non diabetic person. However since insulin is given under the skin and it acts completely different from the normal physiology of insulin in a non diabetic patient, controlling the blood sugars to near normal becomes a great challenge. In insulin dependent diabetes blood sugar excursions are very common. episodes of high and low blood sugars are not easily avoidable. Diet, exercise and illness significantly affect the blood sugars of diabetic patients. It becomes a great task to be able to balance all these variables in order to prevent hypoglycemia, hyperglycemia, diabetes ketoacidosis, and long term complications of diabetes. A balanced diet with adequate macro and micro nutrients will help not only in maintaining good glycemic control but also in maintaining good cardiovascular health. Understanding insulin, and the effect of carbohydrates, physical activity and illness on blood sugars will significantly enhance your ability to manage insulin dependent diabetes better.
Going back to your child:
You have a newly diagnosed son with type 1 diabetes. In the beginning managing a new onset diabetes is overwhelming, but eventually you will be comfortable in managing it. In the begging, too much information will confuse you. Things need to be taken slowly step by step. The first step it to be able to test blood sugars frequently, administer his insulin for each meals and correct high blood sugars if necessary, and understand low blood sugars and take appropriate action. The second step is to understand how insulin works and how carbohydrates affect the blood sugars. The next step is to learn carbohydrate counting or at least be able to estimate the gram of carbohydrates from a given food. Once you have a reasonable understanding of these issues, you could move on with learning about adjusting insulin and carbohydrate during physical activity, in sick days, understand acute and chronic complications of diabetes and treatment of hypoglycemia so that you can prevent them ahead before they ever happen. You will need a team of diabetes educators and dietician for these to be successful. Start it with simple steps and proceed to complex issues slowly. These take time, but you will be very comfortable as the time goes by.
There is no special nutrition for diabetic patients on insulin except that especial considerations should be given to the ones mentioned above. The general nutritional recommendations for children applies to type 1 diabetics as well. I have summarized them in more detail above. You may be overwhelmed now but with time you will have a good handle of it. The most important issue here is paying special attention to insulin requirement for each meals, adjusting insulin as needed and preventing or treating low blood sugars as needed. Talk to your diabetes educator and dietician. You should work as a team and get any help you can, and, use any resource available to you.
Good luck
Reading references:
1) https://health.gov/dietaryguidelines/2015/guidelines/#subnav-4;
2) Nutritional Recommendations for Individuals with Diabetes
Alison Gray, RD, MBA.
Author Information
Alison Gray, RD, MBA
Senior Clinical Research Scientist, Lilly USA LLC; DC 2231
Last Update: May 31, 2015.
3 )Pediatrics; February 2006, VOLUME 117 / ISSUE 2
AMERICAN ACADEMY OF PEDIATRICS
4) https://www.fns.usda.gov/tn/myplate
The dietary recommendations for children are based on diet that mainly relies on fruits and vegetables, whole grains, low-fat and nonfat dairy products, beans, fish, and lean meat, to support growth and development and maintain a healthy cardiovascular system.
These guidelines advocate the intake of:
1) Low saturated and trans fat.
2) Low cholesterol
3) lower added sugar to <10% of daily calories. Reduce added sugars, including sugar-sweetened drinks and juices
4) Low salt <3 grams per day, including salt from processed foods
5) Low intake of energy drinks
6) Physical activity appropriate for age and gender.
7) Maintenance ideal weight for height.( <85 percentile)
8) Adequate intake of vitamins and minerals.
9) consumption of appropriate amount of fat, protein, carbohydrates and vegetables daily.
10) Perform moderate to vigorous physical activity at least an hour a day with strength and balance activity at least 3 times a week to maintain normal growth.
11) Eat vegetables and fruits daily, while limiting juice intake.
12) Use vegetable oils and soft margarines low in saturated fat and trans fatty acids and avoid butter or most other animal fats in the diet.
13) Eat whole-grain breads and cereals rather than refined-grain products
Reduce the intake of sugar-sweetened beverages and foods
14) Use nonfat (skim) or low-fat milk and dairy products daily. Use only lean cuts of meat and reduced-fat meat products. Remove the skin from poultry before eating.
15) Eat more fish, especially oily fish, broiled or baked.
16) Use fresh, frozen, and canned vegetables and fruits and serve at every meal; be careful with added sauces and sugar
17) Use recommended portion sizes on food labels when preparing and serving food.
The daily calorie requirement is different for different age groups and gender. Male expend more calorie than women. In general adult males require about 2000-3000 calories a day. Adult females will require a bout 1600-2000 calories a day depending on their activity level. Younger children <8 years old will require about 1000-2000 calories a day. While older children will require 1400-3200 calories a day. Those who a sedentary life style require the list amount of calories. While moderate activity and vigorous physical activity requires additional calories in some cases up to 800 calories more than sedentary people. A 14 years old may require 2400 to 3200 calories for boys when they are physically active. And girls of that age require from 2200-2800 calories depending on their physically active.
Sedentary life is considered when activity is only performed to maintain independent living such as doing house chores, cooking etc. Moderate physical activity is when walking a bout 1.5 to 3 miles per day at 3-4 miles an hour in addition to independent living (sedentary) activity. Active life style is when walking more than 3 miles a day at 3-4 miles an hour in addition to sedentary activity to support independent living.
Children should be active (moderate or /and vigorous) for at least an hour a day with muscle strengthening as part of the 60 minutes and bone strengthening (running, jumping rope, and lifting weights) and flexibility activity as part of the 60 minutes at least 3 times a week.
A typical 14 years old boy should consume about 2200 calories when sedentary and about 3200 calories when he is active. He will require about 325-400 grams carbohydrates a day (50% of the calories) depending his physical activity. Added sugars including from processed food, should be less than 10% of the total carbohydrate intake. Fructose based syrups should be avoided if possible.
His protein requirement will be 125 grams of protein (20%) of his daily calories. His fat intake should be bout 90 grams a day (30% of daily calories) daily. Saturated fats and trans fats should be less than 10% of the daily fat intake (<10 grams).
A 14 years old or older boy should consume around 1-3 cups of milk, 2 cups of fruits, 3 cups of vegetables and 7 ounces of grains a day. He needs about 30-40 grams of fiber a day.
His daily mineral requirement are as follow: Calcium 1200 mg, Sodium <2300 mg, potassium 4700 mg, phosphorus 1250m mg, Magnesium 410 mg, Iron 11 mg.
A typical 14 years old require vitamins as follows:
Vitamin D 600 units (15 microgram)
Vitamin A 900 mg
Vitamin C 75 mg
Vitamin B-12 2.4 mg.
Dietary recommendations are revised by USDA every 5 years. A group of expert panel and dieticians revise the nutritional guidelines sponsored by the United states department of agriculture (USAD). Currently the Choose My Plate method is available since 2010. It was revised in 2015. The next revision will be in 2020. In 1992 the USAD set a nutritional guideline called the food pyramid. In 2005 the food pyramid was replaced by the MyPyramid. Since most people would not be able to quantify foods in ounces and grams the USDA developed choose MyPlate method for children based on the recommendation of scientists and dieticians, based on the current scientific information on nutrition. The Myplate method is divided into five sections of approximately 30 percent grains, 30 percent vegetables, 20 percent fruits and 20 percent protein, and a glass of dairy product such as low fat or skim milk. It is color codded for simplicity so the families with children will understand it. The Choose Myplate method was simpler with out measuring the grams and ounce but visualizing the plate proportions. Half the plate should consist of fruits and vegetables, while the other half is divided between whole grains and lean sources of protein. The dairy is represented by a glass of skim or 1% milk or other nonfat or low fat dairy products. The general guidelines for macronutrients are similar to that of none diabetic population.
The choose Myplate method is colored as follows.
1.Vegetables is green
2.Fruits. Like veggies, fruits have vitamins, minerals, and fiber
3.Grains. The orange section of MyPlate is about one quarter of the plate.
4.Protein. High-protein foods help the body build and maintain its tissues.
5.A glass of dairy products such as low fat milk. Fats are not considered here because people use oil to cook and some of the food have enough fat or oil to support the nutritional requirement of a growing child..
A 14 years old with type 1 diabetes may require about 40-60 units of insulin daily in divided doses, depending on his insulin sensitivity. As time goes by his insulin sensitivity may diminish and may require much more insulin. The typical insulin to carbohydrate ratio will be 1 unit for 10 grams in the beginning but may require more insulin later on. As time goes by 1 unit of insulin to 5 grams of carbohydrates is common. This is specially true as the honeymoon period passes. His insulin sensitivity may be about 1 unit for every 30-50 mg/dl of glucose above the target blood sugar. Most target blood sugars are 100-120 mg/dl.
The nutritional requirement for diabetic patients are similar to those that healthy individuals with out diabetes as discussed above. However diabetes involves blood sugar testing, insulin adjustment, and carbohydrate counting.
Dietary guidelines should be incorporate into diabetic patients lifestyle to maintain good glycemic control, promote growth and development and support cardiovascular health. There are no set of especial nutritional recommendations set for diabetic patient other than to pay special attention to insulin regimen and carbohydrate, insulin and carbohydrate requirements during physical activity and illness. diabetes patients should follow dietary guide. These should be individualized, and accepted by the diabetic patient in order to be effective.
This involves a team effort of a dietician, and diabetic team approach not of a single diet sheet or a hand out approach. These include instruction on nutrition therapy and diabetes self-management education.
The nutritional goal for diabetic patients is:
1) To promote and support healthful eating patterns, with nutrient dense foods and appropriate portion sizes.
2 Improve glycemic control
3) maintain normal blood pressure, and lipid goals.
For children with type 1 diabetes, participation in an intensive flexible insulin therapy education program using the carbohydrate counting meal planning approach can result in improved glycemic control. This can be done with either multiple daily insulin injections of a fast acting insulin for meals and corrections and a long acting insulin (bolus/basal principle) or using continuous subcutaneous insulin infusion (insulin pump) therapy.
In a non-diabetic patient insulin is made in the pancreatic beta cells and is released continuously (basal or background insulin) and in response to food, mainly carbohydrates. The insulin produced in the pancreas, goes through the liver, and, 85% of it is destroyed by the liver before it goes to the systemic circulation (blood) to mediate glucose transport to the tissues to be consumed for energy. The remaining 15% travels in the systemic circulation and is deactivated in a short period of time. The half life of insulin is about 5 minute in the blood and in 3 half lives (15 minutes) insulin dissipates completely so that we do not experience hypoglycemia afterwards.
In patient with insulin dependent diabetes, insulin is not made in the pancreas but given under the skin by injection and stays minimum of 3-4 hours not 15 minutes as in a none diabetic person.
It is therefore important to recognize that in diabetic patients insulin is given AT THE WRONG PLACE, AT THE WRONG TIME, AND IN THE WRONG DOSE. This causes a huge problem in managing insulin dependent diabetic patients. Insulin given under the skin leads to greater unpredictability. Unlike non diabetic persons, where insulin is controlled tightly and blood sugars are maintained in a narrow normal range, insulin dependent diabetic patients experience blood sugar variability (excursions). Hypoglycemia and hyperglycemia are very common in insulin dependent patients.
During illness in non-diabetic patients the pancreas make more insulin (20-30% more insulin) due to the stress hormones with out causing hypoglycemia or hyperglycemia. In insulin dependent diabetic patients during stress the body makes stress hormones leading to high blood sugars necessitating increase in insulin requirement by 20-30%.
Diabetic patients have similar nutritional requirement to the non diabetic patients. However since insulin is given at the wrong site ( not coming from the pancreas to the liver), at the wrong time (30-10 before meals) and in the wrong dose ( bigger dose that lasts at least 3-5 hours instead of 15 minutes) compared to what the body does. Therefore special attention should be taken regarding the following considerations:
1) Insulin management and timing of Insulin and Meals
2) Carbohydrate counting:
3) Prevention of hypoglycemia
4) Sick Day Management
5) Treatment of hypoglycemia guidelines
6) Exercise and diabetes
A) insulin dosing and timing of insulin and meals: Insulin doses should be determined for the amount of food to be consumed and for correction for high blood sugars. Insulin to carbohydrate ratio and sensitivity factor should be established and adjusted as needed. The amount of carbohydrate for each meal should be decided if the patient is on fixed insulin therapy. The amount of carbohydrates for each meal and snacks should be kept constantly to avoid high or low blood sugars. The amount and timing of insulin for each meals and snacks should be reasonable to avoid mismatch between the food consumed and the amount of insulin given. In flexible insulin therapy either via the insulin pump or multiple daily injections of fast acting insulin with a long acting insulin the amount of carbohydrates can be varied as needed with out affecting blood sugars as the amount of insulin is matched to the amount of carbohydrate consumed. However the timing of insulin boluses should be constant. Flexible insulin therapy is superior to fixed insulin therapy, though in good hands they will all do reasonably well.
B) Carbohydrate counting: The primary goal in the management of diabetes is to achieve a reasonable fasting and postprandial ) blood glucose. This assumes over 50% of blood sugars should be in the desirable range of 70-140 mg/dl with little blood glucose variability. Maintaining an A1c of <7.5% is ideal. It is important to pay attention to the type and amount of carbohydrate in a food because they can influence overall glucose control. This means that the type and the total amount of carbohydrate eaten strongest the glycemic response.
Most patients with type 1 diabetes get about 50% of their total energy intake from carbohydrates. The rest of the 50% is derived from proteins and fats (oils). With type 1 diabetics estimating the total grams of carbohydrates by either experience based estimation or actual carbohydrate counting, is useful in achieving reasonable blood glucose control.
Most carbohydrate should be consumed from vegetables, fruits, whole grains, legumes, and dairy products with out added sugars, fats or salt.
Diabetic should choose low–glycemic load foods for better glycemic control. If substitutions are required with sucrose based products it should be done without compromising nutrient dense food choices.
Type 1 diabetic patients should also consume about 30- 40 grams of fiber a day similar recommendation to the general population. Dietary fiber is defined as the carbohydrate and lignin found in plants that is not digested by the stomach or absorbed in the gastrointestinal tract.
Some of the high fiber containing carbohydrate that should be consumed daily include whole fruits and vegetables, whole grain breads, legumes, and cereals. At least over 50% of grains should be whole grain and fruits and vegetables should be fresh unprocessed products.
Processed foods and high fructose based products should be avoided. Added sugars should be limited to <10% of the total carbohydrate intake.
C) Prevention of hypoglycemia:
Type 1 diabetic patients must take insulin to control their blood sugars. Since subcutaneous insulin injection does not follow the natural insulin production in the pancreas (wrong site, wrong dose and wrong time) hypoglycemia and hyperglycemia are very common. When blood sugars are low (<70 mg/dl) the person can develop autonomic symptoms of hypoglycemia such as dizziness, weakness hunger, anxiety, irritability, light-headedness, sweating, pale face, tremor, heart palpitations, rapid or irregular heart rate, trembling, or shaking. When hypoglycemia is sever (<30 mg/dl) neuroglycopenia will sett in leading to stupor, unconsciousness seizures and coma. Chronic hypoglycemia will also lead to detrimental health out come.
Diabetics on insulin or oral hypoglycemic agents therapy need to prevent hypoglycemia from happening. Some of the following guidelines may be helpful in preventing hypoglycemia.
1) Learn how subcutaneous insulin works. Understanding the what the duration of action of fast acting insulin and long acting insulin are (the time it takes for the injected insulin to dissipate completely). Understanding when insulin starts to work after admitted under the skin or when bolused through the insulin pump (onset of action), and when the maximum of action takes place (peak of action). Understanding how certain insulin behaves will help you to determine whether you need to increase or decrease the insulin dose in the future.
2) Monitor blood sugars before meals and after meals or at least 4 times a day including at bed time. Occasional, testing blood sugars in the middle of the night will be helpful in management your diabetes better.
3) During moderate to vigorous physical activity insulin doses and food intake should be adjusted to correlate with the level of physical activity. Increasing the level or duration of physical activity can lead to significantly low blood sugars. During moderate or vigorous physical activity, insulin dose may need to decrease by about 20-30%, depending on person’s insulin sensitivity.
4) Diabetic patients on insulin therapy or oral hypoglycemic agents should not skip, significantly alter, or delay the amount of meals or snacks without changing the insulin dose. similarly the timing of meals and insulin injections should be maintained appropriately.
5) Document any occurrences of low blood sugars and hypoglycemic symptoms. This can be helpful in determining the cause of hypoglycemia and find ways to prevent them.
6) Every patient with insulin dependent diabetes should carry some form of diabetes identification such necklace or bracelet and wallet card in case of emergency.
D)Treatment of Hypoglycemia:
Any blood glucose level ≤70 mg/dL is considered hypoglycemia. Symptoms Regardless of the symptoms of hypoglycemia, the low blood sugars must be treated promptly with fast acting sugars such as juice, milk, soda, life savers , etc. Usually the rule of 15/15 rule: That is 15 gms of fast acting carbohydrate increase blood glucose by 30-45 mg/dL within 15 minutes. Blood sugars should be checked in 15-20 minutes. If blood glucose is still < 70 mg/dL, another round of fast acting carbohydrates should be given. This can be repeated every 15-30 minutes until blood glucose increases >70 mg/dl persistently and symptoms of hypoglycemia resolve. About 4 ozs of fruit juice, regular (not diet) soft drink, 4 glucose tablets, 2 table spoon of raisins and a cup of skim milk will raise the blood sugars by a bout 30-40 mg/dl in 15 minutes. if the next meal is at least an hour away, eating a small snack will be helpful.
If the patient can not take any thing by mouth or if the patients is not conscious or have a seize do not use fast acting sugars as this will lead to aspiration. Glucagon emergency kit should be used in caser of emergency give 1 mg of glucagon intramuscularly and emergency medical services should be activated by calling 911.
If the patient is sick but can not take by mouth due to vomiting or diarrhea glucagon can be used to raise the blood sugar. In this case subcutaneous glucagon of 10-15 units can be given using a diabetes syringe similar to insulin injection every 30 minutes as needed. Glucagon should raise blood glucose level by 30-40 mg/dl in 30 minute. This can be repeated several times as needed or need to go to the emergency room. If the patient is spilling ketones glucagon is not recommended since the glycogen in the liver may be depleted.
During hypoglycemic episodes high fat foods should not be given to correct blood sugars, as these will delay blood glucose raise from carbohydrate intake.
E) Sick Day Management
During illness the body makes stress hormones such as adrenalin and cortisol. These stress hormones cause insulin resistance leading to 20-30% in insulin requirement. Occasionally when patients get sick they develop hypoglycemia especially if they have diarrhea and vomiting. However most of the time diabetic develop high blood sugars due to the stress hormones. Some times diabetic ketoacidosis can develop if enough insulin is not taken or when the patient is not well hydrated. More often many patients omit their insulin doses and develop diabetes ketoacidosis.
The most important things to remember during illness are;
1) Self-monitor blood glucose as often as possible.
2)Continue to take insulin
3) increase your insulin doses 20-30% until the illness resolves.
4) give insulin corrections as often as possible every 2-3 hours.
5) keep blood sugars <150 mg/dl by giving multiple injections
6) you should drink enough fluid to keep hydrated. With out hydration insulin can not be absorbed from the skin and does to work no matter how much insulin you give. Hydration, Hydration, Hydration, Hydration, Hydration,
7) Eat the usual amount of carbohydrate, divided into smaller meals and snacks if necessary. Eat foods that are easy-on-the-stomach such as yogurt, soups, non-diet gelatin, crackers, and applesauce. If blood sugars are > 250 mg/dL the usual amount of carbohydrate may not be necessary until the blood sugars come down. It is essential to consume at least about 2/3 or 40-60 grams of carbohydrate every three to four hours.
8) Test urine ketones:
If ketones are negative you may correct your blood sugars every 2-3 hrs. with insulin in addition to your usual insulin dose. Push for hydration.
If ketones are mild you can increase your usual insulin by 5-10% and give insulin corrections every 2-3 hours. Push for hydration.
If ketones are moderate increase your insulin regimen by 10-20%. Correct blood sugars every 2-3 hours. Push for hydration. Consult with you diabetes educators.
If ketones are large, increase your insulin regimen by up to 30%. Push for hydration. call your diabetes educators and go to emergency room for intravenous hydration.
Patients on insulin pump should consider giving insulin by injection when blood sugars are not coming down or the ketones are moderate or large. Change the pump site and continue to give insulin boluses every 2-3 hours by injection. Also hydration, hydration and hydration.
F) Exercise has many benefits to our cardiovascular health. The recommendations for aerobic activity for diabetic patients is similar to persons with out diabetes. Adolescents should spent over an hour a day in moderate to vigorous physical activity. Sports activity brings special challenges in managing the blood sugars of diabetics on medications, especially for those on insulin and oral hypoglycemic agents. Physical activity affects blood glucose response. The duration of activity, the amount and intensity of exercise, timing and type of the previous meal, timing and type of the insulin injection all affect blood glucose repose. In general moderate to vigorous physical activity significantly lowers blood glucose levels. Snacks of about 15 grams should be consumed every 30-60 minutes depending on the individuals blood sugar response to physical activity.
Monitoring blood sugars before during and after physical activity and adjusting insulin and carbohydrate snack will be vital in preventing or treating hypoglycemia. Some patients may develop high blood sugars during sports activity. As long as they are not sick or they are not spilling ketones, they can administer at least 1/2 of their boluses if their blood sugars are above 250 mg/dl.
If the patient is sick or have ketones with or with out illness participation in sports activity should be avoided.
In summary the nutritional requirement of a diabetic person is similar to a non diabetic person. However since insulin is given under the skin and it acts completely different from the normal physiology of insulin in a non diabetic patient, controlling the blood sugars to near normal becomes a great challenge. In insulin dependent diabetes blood sugar excursions are very common. episodes of high and low blood sugars are not easily avoidable. Diet, exercise and illness significantly affect the blood sugars of diabetic patients. It becomes a great task to be able to balance all these variables in order to prevent hypoglycemia, hyperglycemia, diabetes ketoacidosis, and long term complications of diabetes. A balanced diet with adequate macro and micro nutrients will help not only in maintaining good glycemic control but also in maintaining good cardiovascular health. Understanding insulin, and the effect of carbohydrates, physical activity and illness on blood sugars will significantly enhance your ability to manage insulin dependent diabetes better.
Going back to your child:
You have a newly diagnosed son with type 1 diabetes. In the beginning managing a new onset diabetes is overwhelming, but eventually you will be comfortable in managing it. In the begging, too much information will confuse you. Things need to be taken slowly step by step. The first step it to be able to test blood sugars frequently, administer his insulin for each meals and correct high blood sugars if necessary, and understand low blood sugars and take appropriate action. The second step is to understand how insulin works and how carbohydrates affect the blood sugars. The next step is to learn carbohydrate counting or at least be able to estimate the gram of carbohydrates from a given food. Once you have a reasonable understanding of these issues, you could move on with learning about adjusting insulin and carbohydrate during physical activity, in sick days, understand acute and chronic complications of diabetes and treatment of hypoglycemia so that you can prevent them ahead before they ever happen. You will need a team of diabetes educators and dietician for these to be successful. Start it with simple steps and proceed to complex issues slowly. These take time, but you will be very comfortable as the time goes by.
There is no special nutrition for diabetic patients on insulin except that especial considerations should be given to the ones mentioned above. The general nutritional recommendations for children applies to type 1 diabetics as well. I have summarized them in more detail above. You may be overwhelmed now but with time you will have a good handle of it. The most important issue here is paying special attention to insulin requirement for each meals, adjusting insulin as needed and preventing or treating low blood sugars as needed. Talk to your diabetes educator and dietician. You should work as a team and get any help you can, and, use any resource available to you.
Good luck
Reading references:
1) https://health.gov/dietaryguidelines/2015/guidelines/#subnav-4;
2) Nutritional Recommendations for Individuals with Diabetes
Alison Gray, RD, MBA.
Author Information
Alison Gray, RD, MBA
Senior Clinical Research Scientist, Lilly USA LLC; DC 2231
Last Update: May 31, 2015.
3 )Pediatrics; February 2006, VOLUME 117 / ISSUE 2
AMERICAN ACADEMY OF PEDIATRICS
4) https://www.fns.usda.gov/tn/myplate
He should be on a low-carb diet with the amount of carbs per meal and snacks dictated by his endocrinologist. The number will depend on his current state of nutrition and how many carbs his body uses per unit of insulin. It is very important that he eat the meals and snacks recommended or the blood sugar can go very low.
