Dietary Recommendations for Children and Adolescents with Diabetes: An Implementation Paper

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Abstract
General Recommendations1. Children with diabetes mellitus have the same basic nutritional requirements as other children. 2. Dietary recommendations should be based on good eating habits for the whole family. Radical changes in diet involving unusual foods or eating patterns for the child with diabetes alone are not appropriate. 3. Energy requirements of children vary widely and the energy content of the diet should be based on what the child usually eats. The diet should be reviewed regularly to meet the changing needs of growth and physical exercise without obesity. 4. The insulin regimen should, as far as is possible, be chosen to fit the child's daily lifestyle and preferred eating habits. Insulin type, dose, and frequency should be reviewed with the diet as the child develops. 5. Regular distribution of meals and snacks throughout the day remains the most important way to avoid extremes of hyperglycaemia and hypoglycaemia. This distribution should be based on an exchange system, using handy measures and taking into account food and meal type, the particular insulin regimen and the child's exercise patterns and usual eating habits. Currently this exchange system is based on carbohydrate foods but in the future the energy and fat contents will need further consideration. 6. Most special ‘diabetic foods’ are unnecessary. Low calorie sweeteners, as used in low calorie fruit squashes and fizzy drinks, are useful. 7. Children with diabetes from specific ethnic minority groups, or on vegan diets or living in deprived circumstances require special dietary attention for their diabetes. Those with coexisting chronic disorders such as cystic fibrosis or coeliac disease, should receive dietary advice from professionals with specialist knowledge. 8. Translating the principles of diabetic dietary management into a varied diet, arranged readily by the parents and eaten by the child, is demanding. It can best be met by a skilled dietitian working in close co‐operation with child, parents, diabetes specialist nurse and doctor.Infancy9. The diet should not differ from that of infants without diabetes. Breast feeding should be encouraged or a standard infant formula‐feed used. Solids may be introduced from 3–6 months, but breast milk or a modified infant formula is encouraged as part of the increasingly mixed diet to at least the end of the first year. 10. Diabetes is rare in infancy so expert advice should be sought from dietitians experienced in paediatric diabetes.Under fives11. After 2 years of age the diet should slowly be changed to one relatively low in fats, with unrefined carbohydrate foods, fitting family customs and meeting energy needs. 12. Fully skimmed cow's milk contains insufficient vitamins A and D, too little fat and therefore energy for the under‐fives. However, semi‐skimmed milk can safely be included in a nutritionally adequate diet from the age of 2 years. 13. Vitamin supplementation may be given to children aged from 1 month to 5 years according to needs and local practice for all children. There are no specific additional requirements for the under‐fives with diabetes.School children14. Reduction of fat intake, especially of saturated fats, is expected to reduce risk of coronary heart disease and stroke in later life. After 5 years of age fat intake should be reduced to around 35–40 % of total energy. 15. Replacing energy from fat by eating half or more of the daily food energy as carbohydrate, principally from unrefined, fibre‐rich sources, may improve both short‐ and long‐term health. Dietary carbohydrate for the child with diabetes should never be restricted below the usual family intake (usual range 45–50% of calories). 16. School children should be encouraged to select their carbohydrate from sources that are rich in soluble fibre with physical structure intact (e.g. whole fruit, oats, porridge, peas, beans, and lentils). These have been shown to improve glycaemic control. 17. Consumption of rapidly absorbed carbohydrate in the form of simple sugar such as fruit juice and sweets or refined starch such as mashed potato in isolation, should be discouraged. However, when used in conjunction with other nutrients within a meal, simple sugars and refined starch improve palatability without worsening metabolic control. 18. The use of sugars to prevent or treat hypoglycaemia should be established on an individual basis. 19. The proportion of energy taken as protein should not be increased among children with diabetes compared with their normal peers. 20. Supplements of minerals and vitamins are not required where a good balance of foods is taken. 21. Regular exercise should be encouraged, and insulin dose reduced or extra dietary energy provided as indicated by individual blood glucose monitoring.