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Recommendations Summary

T1DM: Diet Quality (2024)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    T1DM: Diet Quality

    In children and adolescents living with type 1 diabetes, we suggest having a registered dietitian nutritionist or an international equivalent provide individualized nutrition education that includes discussion on diet quality to manage glycemia.

    Rating: Level 2(D)
    Conditional

    • Risks/Harms of Implementing This Recommendation

      There are few adverse events reported with MNT interventions provided by RDNs for children and adolescents with T1DM. However, hypoglycemia, hyperglycemia or weight gain may result if the RDN does not select, or if the individuals with diabetes cannot implement, the appropriate carbohydrate management strategy. Potential harms such as financial costs (Sheils 1999), time spent at clinic visits, psychological concerns and potential for anxiety related to MNT provided by RDNs are relatively minimal compared with the potential benefits of improved nutrition status and decreased disease progression. 

      Access to RDN services may be limited by the number of professionals, the availability of these individuals and physical access to schedule. Families may experience burden due to the volume of appointments they are required to attend, despite the need/desire for the information provided by the service (and the support). Appointments may mean missing school (children/adolescents) and work (parents/caregivers) and lost wages. Also, increased travel costs, and childcare costs can be barriers to accessing care. Telehealth options can mitigate some of these issues.

      Recommendations focusing on dietary patterns, diet quality, and making appropriate changes in dietary intake without addressing food insecurity may inadvertently have potential risks and harms in some populations as implementation of this recommendation may not be accessible to underserved and vulnerable populations. Underserved and vulnerable populations are populations that face health, financial, educational, and/or housing disparities (Serving Vulnerable and Underserved Populations. Accessed January 17, 2023). Access to supermarkets and convenience stores that have a variety of foods is known to be limited in neighborhoods with high minority populations and low population density, which could limit access to lower, healthier food choices (Larson 2009). Underserved and vulnerable populations with limited health literacy may not have access to nutrition education and resources that would facilitate making this change. Food insecurity may also serve as a potential barrier to following this guideline, as provision of adequate food and nutrients may take priority. 

    • Conditions of Application

      RDNs should work within interdisciplinary teams to promote the implementation of nutrition care. Interdisciplinary team protocols should include nutrition screening and referral to RDNs for individualized MNT. Incorporation of nutrition screening and referral to an RDN requires coordination of administrators, and organizational policies and procedures. Issues like feasibility of implementation, values of interventions, and equity issues should be considered while developing care plans for clients.

      The primary goal of implementing these recommendations is improving client outcomes while individualizing care to your client’s preferences and health status. Although the costs of MNT sessions and reimbursement vary, MNT is significantly associated with improved client outcomes. MNT can be considered cost-effective when considering the benefits of nutrition interventions on the onset and progression of comorbidities versus the cost of the interventions. The dietary recommendation can be implemented in numerous ways and hence is easy to incorporate into practice. This recommendation can be incorporated into ongoing counseling sessions and does not require any extra resources. However, there can be some barriers to providing care and RDNs should consider these when planning interventions for their clients. Issues like lack of insurance or higher out-of-pocket costs are more likely to impact the ability of certain demographics/groups to obtain care. Diabetes complications, both short and long-term, could be more frequent for those who have access problems, costing more for the individual, family, and the health-care system as a whole. Limited services by RDNs in some areas (eg. rural) can also be a barrier.

      The RDN should work with both children and adolescents with T1DM and their parents/caregivers, as they play a critical part in self-management in youth. The treatment plan should focus on normal growth and development of the individual along with dietary management. RDNs should screen and assess the educational, psychological, emotional, behavioral, and access to food status of children and work with parents/caregivers to help implement the treatment plan.

      RDNs can play a central role in helping individuals obtain the skills needed to balance dietary intake, quality of life, and glycemic goals. Potential skills to assist with:

      • Identifying and quantifying carbohydrate foods.
      • Understanding average carbohydrate intake for age, weight, activity level.
      • Calculating insulin dosages based on carbohydrate intake from foods and beverages.
      • Quantifying carbohydrate quantities in foods when dining away from home.
      • Choosing foods on a limited budget.
      • Choosing foods to promote a healthy growth pattern.
      • Defining healthy eating attitudes and behaviors to reduce the risk of disordered or dysfunctional eating.
      • Managing hypoglycemia.
      • Understanding nutrition guidelines for sick days.
      • Understanding nutrition recommendations for religious/ethnic considerations (eg,  fasting, foods avoided, etc.).
      • Navigating eating and glycemic management while traveling.
      • Understanding nutrition recommendations for exercise and physical activity to optimize glycemic goals, prevent hypoglycemia, and optimize performance through nutrition.
      • For those interested in technology, introducing the use of apps to assist with tasks related to identifying & quantifying carbohydrate foods, tracking food intake, understanding the impact on different variables, including food, on blood glucose.
      • Understanding the use of continuous glucose monitoring, insulin smart pen, and/or insulin pump data as diabetes self-management tools to aid in optimal post-prandial glycemia, management of hypoglycemia, and sports performance.

    • Potential Costs Associated with Application

      The cost-benefit ratio of MNT provided by the RDN is unlikely to be very high and if MNT is successful, the benefits may outweigh the financial costs. Coverage for services varies by state, payor, etc, and this can lead to varying out-of-pocket costs. These costs would be anticipated to be less than the cost of continuing the reduced access/low number of RDNs. Cost is minimal compared to potential benefits, especially considering the long-term cost of ill-health to government, hospitals, etc. Prevention of additional illness could create moderate savings.

    • Recommendation Narrative

      Two cohort studies regarding diet quality in pediatric T1DM reported on glycemic outcomes and/or anthropometrics (Liese 2020; Nansel 2016). In one prospective cohort study (Liese 2020), dietary intake was assessed over two years using a food frequency questionnaire. Average diet quality was moderate to poor, with a mean score of 55 (HEI-2015, range 0–100) and there were no associations between dietary quality indices and measures of arterial stiffness and/or an interaction with levels of glycemic outcomes or BMI z-score.

      In one retrospective cohort study (Nansel 2016) as a secondary analysis of the Cultivating Healthy Environments in Families With Type 1 Diabetes (CHEF) randomized controlled trial, dietary intake was assessed through three-day diet records at six-time points over 18 months, and diet quality was measured by the Healthy Eating Index 2005 (HEI-2005). In subjects receiving an intervention designed to improve carbohydrate quality and whole plant food density, mean HEI-2005 scores were 64.6 + 2.0, compared to 57.4 + 1.6 in the control group. A1C was associated inversely with carbohydrate and natural sugar, and positively with protein and unsaturated fat. Greater glycemic targets as indicated by >1 continuous glucose monitoring variable were associated with higher HEI-2005, whole plant food density, fiber, carbohydrate, and natural sugar and lower glycemic index and unsaturated fat. In children and adolescents with T1DM, very low quality evidence indicates that improvements in diet quality [from an average Healthy Eating Index (HEI) score of 55/100 to a score of 65/100] were associated with better glycemic outcomes and certainty of evidence was very low quality.

    • Recommendation Strength Rationale

      The recommendation was based on Very Low quality evidence.

    • Minority Opinions

      None.