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Recommendations Summary

T1DM: Vitamin D (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: Vitamin D

    In children and adolescents living with type 1 diabetes,  we suggest prescribing Vitamin D supplementation in the form of cholecalciferol or ergocalciferol to correct 25(OH)D deficiency/insufficiency.

    Rating: Level 2(C)
    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 (Sheils 1999),  time spent at clinic visits, psychological concerns and potential for anxiety related to MNT 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, RDN’s, health professionals, educators, and support services. Findings from Ye 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.

      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 RDNs 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 (e.g. 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 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 (e.g. 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 and 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 suggesting.
      • 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 demonstration 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 member website, eatrightPRO.org, includes a section titled “IDEA Hub” that provides resources for RDNs 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.

      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 T1DM, families, caregivers, RDNs, health professionals, educators, and support services. Findings from Ye 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 an RDN 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.

    • 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 RDNs 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

      Six studies regarding vitamin D supplementation in children and adolescents living with T1DM reported on glycemic targets and/or anthropometrics (Giri et al, 2017; Nafei et al, 2017; Panjiyar et al, 2018; Sharma et al, 2017; Shih et al, 2016; Treiber et al, 2015). Of the six included studies, only two studies (Giri 2017 and Shih 2016) stratified their subjects by serum vitamin D levels of sufficient, insufficient, and deficient. The remaining four studies (Nafei 2017, Panjiyar 2018, Sharma 2017, Treiber 2015) pooled the results of supplementing their vitamin D-sufficient, insufficient, and deficient patients and/or used different cutoffs to determine which patients were sufficient, insufficient or deficient. Furthermore, all studies used varying dosages and durations of vitamin D supplementation, with some studies basing it on body weight: 400 – 6, 000 IU per day, 20, 000 IU per week, or 60, 000-120, 000 IU per month, for periods of three months to one year. All of these issues present challenges to synthesizing the evidence. 

      Glycemic Outcomes 

      In one randomized controlled trial (Nafei 2017), children were randomized into three groups: Group 1 of newly diagnosed children receiving 2000 IU vitamin D3 per day combined with a daily insulin regimen for three months; Group 2 of newly diagnosed children receiving a daily insulin regimen only for three months; and Group 3 of healthy children receiving no intervention. Serum levels of vitamin D at baseline were lower in Groups 1 and 2 compared to healthy children in Group 3. After three months, Group 1 patients treated with vitamin D3 had significant decreases in A1C levels (P>.01) compared with pre-treatment values.

      In a second randomized controlled trial (Sharma 2017), children and adolescents received cholecalciferol supplementation once per month for six months, with the dosage depending on age (1-3 years: 60, 000 IU, 4-8 years: 90, 000 IU, 9-18 years: 120, 000 IU) or standard insulin therapy only. Vitamin D deficiency was present in 33 subjects (63.5%). At six months, there was no significant difference in A1C between groups.

      In a third randomized controlled trial (Shih 2016), 63% of an adolescent cohort with T1DM was vitamin D deficient and randomized to vitamin D supplementation or delayed treatment. Subjects received 20, 000 IU/week vitamin D3 for six months, either immediately or after six months of observation; this increased serum levels of 25-OH vitamin D but did not affect A1C.

      In a fourth randomized placebo-controlled trial (Treiber 2015), children and adolescents in the Cholecalciferol Supplementation Group received 140 IU/kg BW/day for one month and 70 IU/kg BW/day for eleven months. Approximately 63% of subjects had a serum 25(OH)D level in the vitamin D deficient (<50 nmol/L) or insufficient (50-75 nmol/L) range. Over 12 months, serum 25(OH)D levels increased significantly in the treatment group and remained higher than the levels in the placebo group (p<.001) but A1C remained similar between groups.

      In a retrospective cohort study (Giri 2017), 14.8% of the whole cohort (n= 271) were vitamin D deficient [25(OH)D <30 nmol/L)] and 31% were insufficient [25(OH)D 30–50 nmol/L)]. Medical charts of 73 participants were reviewed; 43 vitamin D insufficient patients received 400 units of cholecalciferol per day and 30 vitamin D deficient patients received 6, 000 units of cholecalciferol per day for three months. Baseline A1C was 73.5(±14.9 mmol/mol and after three months it decreased to 65±11.2 mmol/mol (P < 0.001). Children with higher pre-treatment A1C had a greater reduction in A1C (P < 0.001) and those with a lower 25(OH)D concentration showed higher reduction in A1C (P= 0.004) after treatment. Low 25(OH)D concentrations are fairly prevalent in children and adolescents with T1DM and treatment with cholecalciferol can potentially improve glycemic management.

      In a non-randomized controlled study (Panjiyar 2018), children in the intervention group received 3000 IU cholecalciferol per day for 12 months, while those in the control group received no supplementation. The mean total 25-(OH)D concentrations were similar in the two groups at baseline but increased in the intervention group after supplementation and remained in the sufficiency range (>30 ng/mL) at all visits, while levels decreased in the control group during the 12-month follow-up. The mean decrease in A1C between the groups reached statistical significance at 12 months (P=0.04).

      Of the included studies, three studies reported c-peptide levels. Some data suggests that the vitamin D system plays an important role in the regulation of tolerance of self-antigens such as those displayed by the beta cells. Vitamin D deficiency may be related to a loss of self-tolerance to the antigens displayed by the pancreatic beta cells. Vitamin D supplementation improved c-peptide levels in newly-diagnosed youth with T1DM (Atai-Jafari 2013). While some study results suggest vitamin D supplementation may preserve beta-cell function, it is not clear how long this effect lasts. Preserving residual beta-cell function may contribute to lower incidence of hypoglycemia and reduced complication rates. However, these relationships are associations only and inconclusive whether this is only a short-term effect. 

      Overall, low certainty of evidence indicates that in youth with T1DM, vitamin D insufficiency (defined as serum 25-hydroxyvitamin D [25(OH)D] concentrations of 30–50 nmol/L or 12–20 ng/mL) and/or deficiency (defined as serum 25-hydroxyvitamin D [25(OH)D] concentrations of <30 nmol/L or <12 ng/mL) are common, affecting as many as 63% of patients. Vitamin D supplementation repletes vitamin deficiency, but its effect on glycemic management is inconclusive.

    • Recommendation Strength Rationale

      The evidence supporting the recommendation is based on C (Low) quality evidence.

    • Minority Opinions

      None.