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Recommendations Summary

T1DM: Dietary Patterns (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: Dietary Patterns

    For all children and adolescents living with type 1 diabetes, it is reasonable for the registered dietitian nutritionist or international equivalent to consider advising a dietary pattern, individualized for dietary preferences, nutrient needs, and available resources that promotes consumption of nutrient-dense foods.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      There are few adverse events reported with MNT interventions provided by an RDN 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, time spent at clinic visits, psychological concerns and potential for anxiety related to MNT provided by an RDN are relatively minimal compared with the potential benefits of improved nutrition status and decreased disease progression. 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.

    • Conditions of Application

      Barriers to Implementing

      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. 

      Acceptability

      There is limited research on the acceptability of MNT provided by an RDN among children and adolescents with T1DM. However, this limited evidence indicates that children and adolescents living with T1DM understand that food plays a central role in the management of diabetes (Ye 2017). Stakeholders for these recommendations included children and adolescents with diabetes, families, caregivers, RDNs, health professionals, educators, and support services. Findings from Yes 2017 mention that teens are not only concerned about outcomes like management of their blood glucose, but also their interactions with peers, and emotional well-being, to name a few. Based on the results from these articles, it is clear that children and adolescents living with T1DM and their parents/caregivers do value MNT from RDNs and understand that dietary knowledge and behavior are important for management of their blood glucose. Chalmers 2022 indicated that developing social media related tools or education materials to discuss T1DM might be helpful. Overall, evidence indicates that stakeholders desired a personalized approach, not just focusing on A1C management but also other outcomes like emotional and physical well-being, access to dietetic services, and a shared decision-making relationship with the RDN. 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. 

      Implementation Considerations

      RDNs should work within interdisciplinary teams to promote the implementation of nutrition care. Interdisciplinary team protocols should include nutrition screening and referral to an RDN for individualized MNT. Incorporation of nutrition screening and referral to RDNs 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. The RDN 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.

      Additional information to consider when determining the best methods of implementing recommendations:

      • Consider client's age, socio-economic status, cultural membership, psychological and mental health status, health history, and other individual and health conditions.
      • Dietary pattern-focused interventions may have small to moderate benefits for individuals with diabetes and little to no harm. Benefits would include changes in diet that show an improvement in A1C and quality of life. Secondary benefits could be seen with improvements in lipid profiles, blood pressure, and optimizing of BMI through growth and development. 
      • Changes in diet quality or intake may result in hypoglycemia. Thus, practitioners must ensure families know how to treat low blood glucose and discuss insulin adjustments should there be a pattern of hypoglycemia. Insulin adjustments should always be considered before making suggestions.
      • While providing counseling and care for individuals regarding dietary interventions, the RDN should evaluate for signs of disordered eating.
      • At present there are no guidelines for best practice recommendations on vitamin D supplementation. Practitioners should use their own clinical expertise and individualize based on patients’ needs. 
      • Consider all types of learning in teaching methods, including visual, kinesthetic, audible, and written, and include demonstrations and teaching back skills when appropriate.
      • The Academy has developed Implementing Evidence: from Guidelines to Daily Practice, a new resource which aims to assist nutrition and dietetics practitioners with implementing evidence-based practice recommendations and clinical practice innovations into daily practice.

      RDNs are encouraged to incorporate inclusion, diversity, equity, and access (IDEA) in their practice when working with individuals living with T1DM. Addressing health inequities extends beyond providing individualized advice that considers social determinants of health and other barriers to healthy lifestyle behaviors. The Academy’s membership website, eatrightPRO.org, includes a section titled “IDEA Hub” that provides resources for RDN’s aiming to advance IDEA principles in their practices and professions. For example, providing dietary counseling on diet quality would probably create more equity quality, as some cultures do not value fruit, vegetables, and high fiber in the diet. Providing this education could help to improve overall health for all populations, thus improving health equity.

    • Potential Costs Associated with Application

      Potential harms such as financial costs, time spent at clinic visits, psychological concerns and potential for anxiety related to MNT provided by an RDN are relatively minimal compared with the potential benefits of improved nutrition status and decreased disease progression. 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

      Four articles (Barnes et al, 2013; Costacou et al, 2018; Sauder et al, 2020; Zhong et al, 2016) from the SEARCH cohort study regarding dietary patterns in pediatric T1DM reported on glycemic outcomes and anthropometrics.

      Mediterranean Dietary Pattern

      Two cohort studies report no significant effects of the Mediterranean diet on glycemic and/or anthropometric outcomes. Costacou  2018 reported no significant associations were observed for diet quality characterized by Mediterranean mKIDMED indices in SEARCH cohort participants over five years of follow-up. Costacou 2018 is a prospective cohort study based on SEARCH cohort study to investigate diet quality and microalbuminuria using Mediterranean diet score (mKIDMED), DASH, and healthy eating index (HEI). Results indicated that adherence to higher-quality diets in this sample was low based on mKIDMED and DASH scores.  Reported scores for HEI were better compared to mKIDMED or DASH, and greater adherence to HEI may be beneficial for kidney health.

      Zhong 2016 reported that in SEARCH participants, only 3% had high Mediterranean diet scores, which was not associated with BMI z score or waist circumference, and a two-point increase in mKIDMED score was associated with 0.01% lower log-A1C (P=0.07, NS). Zhong 2016 conducted an association study of the Mediterranean diet and glycemic management and other cardiovascular risk factors in participants of SEARCH ancillary study (n=793). Adherence to a Mediterranean type of diet was assessed with the KIDMED index score, based on the SEARCH FFQ. At baseline, the results of the study indicated that only 2.8% of the participants had high Mediterranean diet scores, 45.8% had median score and 51.5% had a low score. These scores did not change much at 1-year and 5-year follow-up visits. Cross-sectional analysis of the data indicated higher Mediterranean diet scores were associated with lower A1C and an improved lipid profile. Both studies reported low adherence of the prescribed dietary pattern and no actual dietary intake was assessed.

      DASH Dietary Pattern 

      In one prospective cohort study (class B evidence, Barnes 2013), an increase in DASH diet score was significantly associated with a decrease in A1C (beta = -0.20, P-value = 0.0063) but there were no significant associations between DASH diet score and BMI z-score or waist circumference. However, Costacou 2018 reported no significant associations were observed for diet quality characterized by DASH indices in SEARCH cohort participants over five years of follow-up. Barnes 2013 used SEARCH cohort study’s longitudinal data to investigate if changes in DASH diet score are associated with change in cardiovascular disease (CVD) risk factors. A total of 617 youths with T1DM were followed over 60 months. There was very little change in DASH score at the 60-month visit compared to baseline score (-0.41 ± 11.2), however, several CVD risks factors did significantly increase at 60-month visit compared to baseline (diastolic BP 65.4 ± 9.2 vs 71.5 ± 8.3 mmHg; Systolic BP 105.2 ± 10.4 vs 110.7 ± 9.1 mmHg; total cholesterol 161.3 ± ±31.8 vs 172.0 ± 37.4; triglycerides 71.6 ± 41.5 vs 111.6 ± 143.0 mg/dl; and A1c 7.97 ± 1.71 vs 9.31 ± 2.17). Major limitations of this study were the small sample size and poor adherence to the DASH dietary pattern and this did not change much over time.

      Glycemic Index 

      In a prospective cohort study (class B evidence, Sauder 2020), for choosing low glycemic index foods, mean A1C was 0.3% to 0.6% lower among those who often, started, or sometimes used this strategy compared to those who stopped or never used it. A1C was lower among those who sometimes chose low glycemic index foods (−0.5%, P = .02) compared to those with less use. Sauder 2020 conducted a cross-sectional analysis of dietary strategies used by SEARCH participants (n=1558) over 5.5 years. Ten different dietary strategies were assessed using a questionnaire. Results indicated that participants who tracked calories, often counted carbohydrates, or often chose low glycemic index foods compared to those who used less of these strategies had lower A1C. However, due to the nature of the study design, there are some limitations eg,  limited power, confounding between strategies used, sustained versus variable use of dietary strategies. 

      Overall, in children and adolescents with T1DM, effects of dietary patterns like Mediterranean, DASH, and low glycemic index on glycemic outcomes are inconclusive and the certainty of evidence is very low quality.

    • Recommendation Strength Rationale

      The recommendation is rated conditional as the quality of supporting evidence ranges from very low to low.

    • Minority Opinions

      None.