Feature Article / Carbohydrate Counting in Adolescents

Background and Objectives Youth with type 1 diabetes do not count carbohydrates (CHOs) accurately, yet it is an important strategy in blood glucose control. The study objective was to determine whether a nutrition education intervention would improve CHO counting accuracy and glycemic control. Design Randomized, controlled, nutrition intervention trial recruited February 2009 to February 2010. Participants and Methods Youth (12-18 years, n=101) with type 1 diabetes were screened to identify those with poor CHO counting accuracy, using a previously developed CHO counting accuracy test covering commonly consumed foods and beverage items presented in six mixed meals and two snacks. All participants (n=66, age=15 ± 3 yrs, 41 male, diabetes duration=6 ± 4 yrs, HbA1c=8.3 ± 1.1%) were randomized to the control or intervention group at the baseline visit. The intervention group attended a 90 minute class with a RD/CDE and twice kept three-day food records, which were used to review CHO counting progress. Main Outcome Measures CHO counting accuracy (measured as described above) and HbA1c were evaluated at baseline and three months to determine the effectiveness of the intervention. Statistical Analyses T-tests, Spearman correlations, and repeated measures models were used. Results At baseline, CHO content was over and underestimated in 16 and five of 29 food items, respectively. When foods were presented as mixed meals, participants either significantly over or underestimated 10 of the nine meals and four snacks. After three months of follow-up, HbA1c decreased in both the intervention and control groups by −0.19 ± 0.12% (p=0.12) and −0.08 ± 0.11% (p=0.51) respectively; however, the overall intervention effect was not statistically significant for change in HbA1c or CHO counting accuracy. Conclusions More intensive intervention may be required to improve adolescents’ CHO counting accuracy and nutrition management of type 1 diabetes. Further research is needed to translate nutrition education into improved health outcomes.

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Objectives Low‐carbohydrate and ketogenic diets are becoming increasingly popular choices for people with type 1 diabetes (T1D) aiming to achieve optimal glycemic control. A carbohydrate‐restricted diet in children has been associated with negative health effects including poor linear growth and inadequate bone mineralization. Guidelines for monitoring children and adolescents choosing to follow a carbohydrate‐restricted diet do not exist. We aimed to create a clinical protocol outlining how to clinically and biochemically follow patients choosing a carbohydrate‐restricted diet with the goal of medical safety. Methods An interdisciplinary committee was formed and reviewed current consensus guidelines for pediatric patients on carbohydrate‐restricted diets for epilepsy and metabolic disorders. A literature search was done to determine management strategies for children with T1D on a low‐carbohydrate or ketogenic diet. Key health parameters that require monitoring were identified: growth, glycemic control, bone health, cardiometabolic health, and nutritional status. These health outcomes were used to develop a protocol for monitoring children on carbohydrate‐restricted diets. Results A one‐page protocol for medical providers and educational materials for families interested in following a low‐carbohydrate or ketogenic diet were developed and successfully implemented into clinical care. Conclusion Implementing a protocol for children on carbohydrate‐restricted diets in clinic allows medical providers to ensure medical safety while being open to discussing a family's dietary preferences. Following children in the protocol over time will lead to informed clinical guidelines for patients with T1D who choose to follow a carbohydrate‐restricted diet.