Chapter 10: Nutritional management
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1/24/2018 at 4:07:21 PM GMT
Posts: 19
Chapter 10: Nutritional management

Dear ISPAD member/friend,

Thank you for your continued interest in the 2018 ISPAD Clinical Practice Consensus Guidelines and in the previous drafts chapters we shared with you.

We are happy to announce that chapter 10 on Nutrional Management is now ready for you to read and comment on. We are looking forward to hearing your thoughts and input on this chapter. 

Kind regards,

David Maahs

ISPAD Secretary-General


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Last edited Wednesday, January 24, 2018
1/27/2018 at 5:09:01 PM GMT
Posts: 7
Nutrition Management
I enjoyed reading the informative chapter on Nutritional Management.
I offer the following comments for your consideration.

Executive summary

Suggest changing the sentence: "Nutrition therapy is recommended … as well as the cognitive abilities and psychosocial circumstances of the child and family (E)" 

5th bullet Perhaps it is implied, but I suggest explicitly stating that both growth (height) and weight should be monitored. 
In the US and Europe, excessive weight gain is common. This is mentioned later in the chapter.

I do not disagree with the last bullet, but I am not sure it is appropriate to include in an Executive Summary of Nutritional Management

P.8 Vitamins, minerals and antioxidants 
"… following a country's national dietary guidelines …"

P.12 Insulin regimens (not regimes)
Important to point out that there is a possibility of some meal time flexibility if rapid- or short-acting insulin is not a component of a premixed insulin formulation; i.e., is injected separately from NPH or long-acting analog

P.13 last paragraph
Here, it is important clarify that this is instead of a rapid-acting analog

P.18 The worldwide prevalence ranges from 1.6% to 16.4% according to Pham-Short et al. (review in Pediatrics 2015)

P.19 In these guidelines, I suggest providing more specific information concerning a widely used validated screening questionnaire for Eating Disorders so that the interested reader does not have to go searching. Perhaps provide this as a supplement at the end of the article? 
 


1/28/2018 at 8:59:14 PM GMT
Posts: 3
Dear Joe,

Thank you and all great points.

We will provide more detail on the current validated screening questionnaires for Eating Disorders in children and adolescents with diabetes. How they are used does vary with most clinics then referring to a psychologist or an Eating Disorder team for more detailed screening.

Best Wishes,
Carmel


1/29/2018 at 3:23:22 PM GMT
Posts: 1
Comments on Chap. 10, Nutritional management

I enjoyed reading the draft Nutritional Management Guidelines for youth with diabetes - they look excellent. I especially love the inclusion of the Joslin Diabetes Center plate. I might include a note here that the plate can be thought of as a guide to both the individual meal and the day as a whole, as some people will choose to break it up and have dairy and fruit as a snack in between meals, rather than alongside of a meal.

Just a couple of other comments:

  • On page 7 "No more than 10% energy from saturated and trans fatty acids is recommended" - since evidence supports that there is no safe level of trans fats and that they are not necessary in the diet (1,2), and industrially produced trans fats are avoidable by examining ingredient lists for partially hydrogenated oils (3), it could be beneficial to make this distinction in the guidelines by saying "No more than 10% energy from saturated fats and no consumption of industrially manufactured trans fats is recommended."

1. German, J. B., & Dillard, C. J. (2004). Saturated fats: what dietary intake?. The American journal of clinical nutrition, 80(3), 550-559.

2. Trumbo, P., Schlicker, S., Yates, A. A., & Poos, M. (2002). Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. Journal of the American Dietetic Association, 102(11), 1621-1630.

3. Trans fat: Avoid this cholesterol double whammy - Mayo Clinic [Internet]. [cited 2018 Jan 29]. Available from: https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/trans-fat/art-20046114

  • On pg 17 and anywhere else where blood glucose is given in mmol/L, it would be nice to have mg/dl in parenthesis for easy conversion, i.e. "below 5mmol/L (90 mg/dl)..."

Thank you again,

Katie



Last edited Monday, January 29, 2018
1/30/2018 at 3:48:04 AM GMT
Posts: 3
Dear Katie,
Thank you so much for your feedback.
We will add the point that the plate is a guide to both daily and individual meal content.
I agree it is good to spell out that Trans fats need to be further limited.
Thanks again!
Carmel


1/30/2018 at 8:11:05 PM GMT
Posts: -3
Thank you team for this comprehensive chapter on Nutrition Management.
It will form a very integral part of the 2018 guidelines.
I have a few inputs.

pg 6 under low carbohydrate diets, last sentence " caregivers need reassurance that optimal glycemic.........quality carbohydrate. I think the phrase quality carbohydrate is vague and I suggests a more specific recommendation such as "complex".

Pg 6. Sucrose - bullet 2, second and final sentence. " Diet or light drinks can be ......
have you had any consideration of the research and evidence on diet sodas and the following:
- T2 DM
- Gut microbiome
-Weight gain
-Cardiovascular diseases?

pg 9 Specially labeled Foods, bullet 4-6
saccharin .... If they are all speaking to the same thing they need to be linked, maybe a shorter sentence.

Great work, I await the final guidelines.

Best Regards

Rosalee


1/31/2018 at 5:47:48 AM GMT
Posts: 3
Thank you very much Rosalee for these comments.

We are only suggesting the inclusion of diet drinks at events such as birthday parties, so very infrequent consumption (and also space limited!). However, to address your point a sentence has been added to encourage water consumption.

Thanks again for your feedback!
Carmel


2/20/2018 at 9:10:29 AM GMT
Posts: 1
This is an excellent and very practical review.  I note that the overall message regarding low carb diets is quite negative and may not adequately address interests of the parents/patients who are using some degree of low carbohydrate intake with good results. The guidelines are not actually inconsistent with recognizing that in the process of individualizing care, some patients may wish to consume fairly low amounts of carbohydrate.  The guidelines  provide all the very appropriate caveats (particularly for young children) but I think could be more effectively presented by recognizing and providing additional specific guidance to ensure appropriate use of such diets in a safe manner, including ranges of carbohydrate intake (e.g., < 20%, 20-30%, 30-40%).


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