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Diabetes Education

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Q:What is the role of the dietitian on our child's team? I understand how to count carbs from a food label, so what help can I expect this person to offer?

A: As a vital member of a child’s diabetes care team, a Registered Dietitian® (RD) is a medical professional who has experience and training in pediatric nutrition. A parent’s first contact with their child’s RD is typically an initial education period shortly after the child’s diagnosis. Working with your child’s RD can help you develop a meal plan that takes into account your child’s nutrient needs for growth, family lifestyle and dietary preferences, insulin regimen, and your child’s activity levels. The initial education will include learning about reading food labels, “counting carbs” in foods, safe use of sweeteners, easy snack and meal ideas, planning foods for sick days, and many other topics.

Following that initial contact with your RD, you will likely stay in touch as food-related questions come up, and then meet formally once a year to look more in-depth at your child’s diet. The American Academy of Pediatrics, American Diabetes Association, and the American Association of Diabetes Educators all recommend that children with diabetes have an annual “nutrition review” with a Registered Dietitian because food needs change as children grow, and nutrition guidelines for diabetes change as we learn more about both nutrition and diabetes.

During the annual nutrition review, you can expect your RD to:

  • Review the child’s growth to assure that the child is growing and gaining weight appropriately.  Using pediatric growth charts, the RD will evaluate the child’s height, weight, and BMI (Body Mass Index). Because energy requirements change as children grow, your RD may revise your child’s meal plan based on his/her appetite, level of physical activity, and growth needs.
  • Review the basics of carbohydrate counting and reading of food labels to assure competency. You RD can also provide more advanced carbohydrate counting instruction if your child progresses to a more flexible insulin regimen, such as insulin pump therapy.
  • Help your family to facilitate your child taking on an appropriate level of control over his or her meal plan and diabetes, thus encouraging independence in diabetes care. If a child was diagnosed as toddler or preschooler, the initial education was focused toward the adult caregiver. However, as the child gets older, the healthcare team wants to make sure he or she receives education regarding diabetes and how to best manage it. The team’s RD is part of these efforts.
  • Address any other nutritional problems that may need to be factored into the meal plan, including celiac disease and the need to follow a gluten-free diet, elevated lipids, and high blood pressure.

In short, it’s much more than only reading food labels! What may be most important for you to know right now is that your RD is a valuable source of information for any questions you have that relate to food and nutrition. If you’re having trouble coming up with breakfast ideas that your peaky eater will actually eat, or are wondering how to navigate going out to eat for the first time after diabetes, this is the person on your care team to turn to for help.  

Source - Darcy de la Rosa, MPH, RD/LD-N, CDE, Florida Center for Pediatric Endocrinology at Florida Hospital for Children

Q:What are some easy foods to feed a child on sick days? When he's sick with a cold or stomach bug, it's really difficult to get him to eat, which just makes everything worse.

A: Sick days can be extra-challenging when it’s a child with diabetes who comes down with the inevitable cold or stomach bug. The most important thing for parents to remember is to NEVER stop using insulin during sick days for a child with type 1 diabetes, even if it seems like he isn’t keeping much food down. Just be prepared that insulin doses may need to be changed depending on your child’s glucose levels when he’s sick. Your care team can help you determine the appropriate adjustments if you’re not sure how to do this.

Carbohydrate intake is also important to prevent lows when using insulin. On sick days, it’s generally recommended for kids to try to stick as closely as possible to regular meal and snack times and carbohydrate goals. If your child does not feel like eating normal foods, try substituting soup and other comfort foods that tend to be easy to keep down. For some easy ideas of what to serve, the following foods/beverages each contain about 15 grams (or 1 serving) of carbohydrate:

  • 1 cup Gatorade sports drink
  • ½ cup fruit juice
  • 1 double-stick popsicle (not sugar-free)
  • ½ cup regular soft drink (not diet)
  • 6 saltine crackers
  • ½ cup regular ice cream
  • 1/3 cup frozen yogurt
  • 5 vanilla wafers
  • ½ cup custard
  • 4 Lifesavers hard candies
  • ½ cup mashed potatoes
  • 3 graham crackers
  • ½ cup sherbet
  • 1 slice dry toast (not light bread)
  • ¼ cup regular pudding
  • ½ cup regular Jell-O (not sugar-free)
  • ½ cup cooked cereal

In addition to these foods, encourage your child drink plenty of fluids throughout the day, including water and other non-caffeinated drinks. It's easy to run low on fluids when you are vomiting or have a fever or diarrhea, so have a supply of both calorie-free liquids available for when blood glucose readings might be high and calorie-containing liquids if glucose readings seem to be falling low.

Extra fluids also help to get rid of extra glucose (and possibly ketones) in the blood. If your child stops taking in fluids, especially when his blood sugar is high, contact your diabetes team or doctor, as dehydration and diabetic ketoacidosis can occur. If you haven’t already, ask your care team for a list of signs (excessive vomiting, high fever, etc.) that mean you should give them a call.

What else can help? Don’t forget Grandma’s favorite cold remedy! A one-cup serving of canned chicken soup contains approximately 16 grams of carbohydrates.

Source - Darcy de la Rosa, MPH, RD/LD-N, CDE, Florida Center for Pediatric Endocrinology at Florida Hospital for Children

Q: When our son has football practice on the field, his blood sugar tends to

go low, but when it's game time, it spikes pretty high. Why is this and how do we respond?

A: Playing a team sport is a wonderful way for kids, including kids with diabetes, to keep fit and stay active. However, as you’ve already picked up on, managing blood glucose can be tricky depending on whether it’s practice or game time. Fortunately, there are some basic explanations as to why these kinds of highs and lows happen and many practical steps you can take to help your son keep his numbers within range.

For starters, when kids engage in moderate physical activity, such as after school sports practice or gym class, blood glucose can drop low during or just after exercising because physical activity at this level tends to increase insulin sensitivity, which in turn, makes the body more efficient at using glucose. This is one of the reasons why it’s important for a child with type 1 to check his or her blood sugar before starting sports practice and have access to snacks and low blood sugar supplies.

When children with diabetes are physically activity for prolonged periods, another drop in blood glucose can occur about 8 hours after exercising. On your part, this means keeping a closer watch on your son’s blood sugars overnight. Many parents have learned to plan for these kinds of blood sugar drops by increasing their child’s carbohydrate intake or reducing insulin dose prior to exercising -- or just after. Your care team can give you guidance on what measures are appropriate for your child.

When it’s game time, competitive sports can cause some interesting blood sugar changes that require special handling. There seem to be two factors in play here. First, short bursts of intense exercise, such as sprinting towards the end zone in a football game, have been shown to increase glucose blood glucose levels and cause an increased need for insulin. In a person who doesn't have diabetes, the body simply releases more insulin to help transfer glucose into the muscle cells. In a person with type 1 diabetes, the internal insulin response isn't available and so blood glucose levels tend to climb, often quite dramatically. 

It’s also normal for kids feel keyed up and excited on game days. Most us have heard of the "fight or flight" stress response that occurs in our bodies when the brain perceives a challenge. The adrenaline released in those situations causes more fuel (glucose) to be made available for handling that challenge, sometimes even before starting the exercise. Again, in a child without diabetes, the body can simply release more insulin to handle this surge. In a child with diabetes, blood sugars can run higher.

Considering all the factors at play when kids engage in sports, trying to dose insulin correctly in these situations can be a challenge. High blood sugar corrections may ultimately drop the blood sugar very low, but allowing blood sugars to run really high during a game situation isn’t a great idea either! Extra fluids and small insulin adjustments may help. If your child wears an insulin pump during a game, making adjustments to the basal rates may be indicated. Again, it’s important to talk these situations over with the diabetes team.

Whatever plan you come up with, expect that some trial and error may be necessary, along with lots of blood glucose monitoring before during, and after (including overnight) exercise and sports before you figure out what works for your child. Wearing a continuous glucose monitor for a few days may also be very helpful for keeping track of highs and lows.

So many people with type 1 diabetes have learned to compete successfully at a very high level in sports, including pro-football player Jay Cutler, quarterback for the Chicago Bears! No matter what your son’s future athletic dreams may be, with a little extra monitoring and adjustments, he should be able to stay on the right track.

Source - Paula Jameson, MSN, ARNP, Certified Diabetes Educator and Program Coordinator with Florida Hospital for Children, Orlando, Florida

Q: A family we met at our clinic invited us to their daughter's "diaversary" celebration. Our son was just diagnosed and I can't imagine celebrating the day he received his diagnosis. What is this all about?

A: In addition to the usual list of birthdays, holidays, and other special occasion days that take place throughout the year, some families decide to mark the anniversary of their child’s diagnosis with type 1 diabetes -- the child’s “diaversary” -- in a special way.

The reason for doing so is quite simple: looking for the positives in such a life-altering diagnosis can be very therapeutic -- for your child, for you, and for the rest of the family, too. A diaversary celebration, however basic or elaborate, is a chance to acknowledge your child’s strength and determination, a way to recognize how far your family has come in the past year, and a great opportunity to make having diabetes a little more fun.   

Planning a diaversary doesn’t require any special party-throwing skills. If your child is old enough to weigh in on the decision of how to celebrate his diaversary, ask him what he would like to do and let these wishes guide you. Most young children really enjoy a true birthday party-style celebration and look forward to it every year. Ideas include enjoying a special "anything goes meal" at a favorite restaurant followed by a fun activity of the child's choosing. Some families include a gift for the child and invite friends and relatives to join in the festivities. If the child is too young, or not interested in a special celebration, some parents make a donation on their child's behalf to a hospital or charity as a way to still mark the occasion.

The best way to find out what a diaversary celebration is all about may be to attend the one you’ve just been invited to! Helping another child celebrate this special day will probably be a very positive experience for your child. However, before you RSVP, make sure you talk to your son about what the party will be about and allow him to be the one to ultimately decide whether or not to attend.

When your child’s “day” rolls around, no matter what the plan, set time aside to reflect on his bravery, discipline, strength, knowledge, sacrifices, and courage...and your own. It’s a day worth celebrating! Just one note about food-centered celebrations: don’t forget to ask your diabetes team for help to accommodate any major deviation from normal eating and activity. They want this to be a happy occasion, too!

Source- Paula Jameson, MSN, ARNP, Certified Diabetes Educator and Program Coordinator with Florida Hospital for Children, Orlando, Florida