Medical management of children with type 1 diabetes on low-carbohydrate or ketogenic diets.

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.

Improving the Insulin Pump Initiation Process for Pediatric Patients with Type 1 Diabetes through Application of Lean Quality Improvement Methods.

CONTEXT: Our pediatric diabetes center initiated insulin pump therapy for more than 250 patients with type 1 diabetes in 2014, but onboarding was inefficient. OBJECTIVE: To decrease time from the decision to initiate pump therapy to the ambulatory encounter after pump start (lead time) for new pump users from 132.5 days to less than 110 days within 5 months. DESIGN: Define, Measure, Analyze, Improve, Control method. We identified key problems: Long wait for training classes, unclear metrics, complicated scheduling, and nonstandardized processes. We then implemented 17 changes, including shortened classes, increased class offerings and space, clarified metrics, built a reporting dashboard, designated and cross-trained staff, created appeals letter templates, and educated clinicians. At project conclusion, we established a reaction plan if the processes were not performing as designed. MAIN OUTCOME MEASURES: Outcomes of pump orders placed before and after improvements were implemented. RESULTS: During this project, 229 patients initiated the pump start process. Median lead time decreased from 132.5 to 98.5 days (p = 0.007). Patients with lead time under 110 days increased from 37% to 60% (p = 0.001). There were 31 pump nonstarters, with no significant association between group and whether the patient was a starter or nonstarter (p = 0.58). Nonstarters had a longer diabetes duration (median = 3.43 vs 2.05 years, p = 0.001). CONCLUSION: Project goals were met. A high proportion of patients not starting pump therapy was discovered, but this was not affected by the project. We implemented further changes and a process-monitoring system.

Randomized nutrition education intervention to improve carbohydrate counting in adolescents with type 1 diabetes study: is more intensive education needed?

BACKGROUND: Youth with type 1 diabetes do not count carbohydrates accurately, yet it is an important strategy in blood glucose control. OBJECTIVE: The study objective was to determine whether a nutrition education intervention would improve carbohydrate counting accuracy and glycemic control. DESIGN: We conducted a randomized, controlled nutrition intervention trial that was recruited from February 2009 to February 2010. SUBJECTS: Youth (12 to 18 years of age, n = 101) with type 1 diabetes were screened to identify those with poor carbohydrate counting accuracy, using a previously developed carbohydrate 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 years, 41 male, diabetes duration = 6 ± 4 years, hemoglobin A1c [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 registered dietitian/certified diabetes educator and twice kept 3-day food records, which were used to review carbohydrate counting progress. MAIN OUTCOME MEASURES: Carbohydrate counting accuracy (measured as described) and HbA1c were evaluated at baseline and 3 months to determine the effectiveness of the intervention. STATISTICAL ANALYSES PERFORMED: t Tests, Spearman correlations, and repeated measures models were used. RESULTS: At baseline, carbohydrate content was over- and underestimated in 16 and 5 of 29 food items, respectively. When foods were presented as mixed meals, participants either significantly over- or underestimated 10 of the 9 meals and 4 snacks. After 3 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 carbohydrate counting accuracy. CONCLUSIONS: More intensive intervention might be required to improve adolescents' carbohydrate counting accuracy and nutrition management of type 1 diabetes. Additional research is needed to translate nutrition education into improved health outcomes.

Carbohydrate counting for children with diabetes: why, what and how?

Carbohydrates are an important part of a healthful diet. With type 1 or 2 diabetes, balancing insulin or medication with carbs and emphasizing carbs from fruits, vegetables, whole grains and low-fat milk and yogurt is key. Families should learn how to follow a consistent carb meal plan or adjust insulin for carbs to help keep their child's blood glucose close to target levels. The family's RD or healthcare team can help them decide which meal planning method is best for their child.