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HBB Research - Health Behavior Change in Medical Settings

Dietary Intake in Youth with Type 1 Diabetes

Nutrition guidelines for children with type 1 diabetes are similar to those for the general population, and nutrition education for families of children with type 1 diabetes includes recommendations for general healthful eating and efforts to achieve and maintain optimal weight for height. Current treatment standards emphasize physiologic insulin replacement; therefore, a primary component of medical nutrition therapy in type 1 diabetes is carbohydrate estimation, as carbohydrates are the principal macronutrient affecting glycemic excursions. A major focus is on integrating the insulin regimen and carbohydrate estimation into the family’s lifestyle, conforming to preferred meal routines, food choices, and physical activity patterns. Concurrently, children with type 1 diabetes are consuming diets low in fruits, vegetables, and whole grains, and high in saturated fat. Poor diet quality is particularly concerning due to the increased risk of dyslipidemia and cardiovascular disease and the high prevalence of cardiovascular risk factors recently observed in youth with diabetes. Limited research has examined relations between usual dietary intake and diabetes management in type 1 diabetes. However, there is a growing body of evidence indicating that dietary intake, particularly carbohydrate quality, may affect blood sugar control, insulin demand, and weight management. This series of studies examines determinants of dietary intake among youth with type 1 diabetes and tests the efficacy of strategies to improve diet quality in this population.

Cultivating Healthful Eating in Families of Children with Type 1 Diabetes (CHEF)

This study tests the efficacy a family-based behavioral intervention designed to improve diet quality by promoting intake of fruit, vegetables, whole grains, legumes, nuts, and seeds. A sample of 139 families was randomized to the behavioral nutrition intervention including continuous glucose monitoring feedback or to continuous glucose monitoring feedback only. The intervention approach, which is grounded in social cognitive theory, self-regulation, and self-determination theory, integrates motivational interviewing, active learning, and applied problem-solving to target increased dietary intake of fruits, vegetables, whole grains, legumes, nuts, and seeds. Data collected include medical record abstraction, parent-youth interview, youth self-report surveys, parent self-report surveys, youth 3-day diet records, parent 3-day diet records, youth continuous glucose monitoring, youth body composition (DXA), and youth biomarkers including lipids, carotenoids, and markers of inflammation and oxidative stress. Primary outcomes include glycemic control and dietary intake.

Acceptability of Lower Glycemic Index Meals in the Diabetes Camp Setting

Youth ages 7 to 15 who attended a diabetes summer camp received standard diabetes camp menus and lower glycemic index diabetes camp menus in a daily, alternating cross-over design. Measures of satisfaction with the camp meals and snacks were obtained from youth and staff, and observations of meal consumption were conducted. Additional data were collected via focus groups and self-report of food patterns and preferences. Meal plans and blood-glucose monitoring data were obtained from camp records. Findings indicated high acceptability of the lower glycemic meals.

Blood Glucose Response to Meals of Varying Glycemic Index

In this study, youth with diabetes participated in 5 days of continuous blood-glucose monitoring during which they received both low and high glycemic index meals in a structured clinic setting and in the home environment. Food intake, insulin, and blood glucose self-monitoring were recorded. Participants demonstrated lower mean blood glucose and variability when consuming low glycemic index meals in both the in-clinic and the at-home conditions. During ad libidum intake at home, children also consumed more fiber and less fat when consuming low glycemic index meals.

Perceptions of Healthful Eating among Families of Youth with Type 1 Diabetes

A series of focus groups, conducted separately with children, adolescents, and parents, examined perceptions of healthful eating among families of children with type 1 diabetes. Findings indicate that families of youth with type 1 diabetes experience developmental and environmental issues surrounding healthful eating similar to those reported among families in the general population; but that additional challenges specific to diabetes management are faced. For example, findings suggest that the emphasis placed on carbohydrate intake for disease management may adversely impact overall diet quality due to reliance on packaged foods and avoidance of fruit intake, and flexible basal-bolus regimens may increase opportunities for unhealthful eating.

Eating Behaviors among Youth with Type 1 Diabetes

This study enrolled 291 families (parent-youth dyads) in a cross-sectional study of psychosocial factors related to eating behaviors in families with youth with type 1 diabetes. Data were obtained using medical record abstraction, parent-youth interview, youth self-report surveys, parent self-report surveys, youth 3-day diet records, parent food frequency questionnaire. Findings document low intake of fruit vegetables, and whole grains, and poor overall diet quality among youth with type 1 diabetes, and indicate potentially modifiable child and family determinants of dietary intake.

Diet, Weight Change, and Obesity in Pregnancy

The rising prevalence of obesity in the U.S. over the past several decades and the accompanying spread of adverse long-ranging health effects pose serious public health and economic consequences. At least half of women of reproductive age now enter pregnancy at a high body mass index (BMI, kg/m2), and the majority experience pregnancy-associated weight gains in excess of Institute of Medicine (IOM) guidelines, leading to increased perinatal and chronic health risks for both mother and child. Limited intervention research has indicated moderate improvement in short-term maternal diet and gestational weight gain, with little evidence of long-term adherence. The well-documented inadequacies of these and traditional weight-loss interventions relying on existing paradigms suggest the need for innovations that allow for a shift in the theoretical framework underlying the determinants of eating behavior. Recent findings from basic research in neuroscience suggest that the brain reward response to food is a critical element that is currently absent in this theoretical framework. However, this quickly-expanding body of work has not been incorporated into population-based research to date. This observational study, currently in development, will address this knowledge gap by examining the implications of findings on the importance of the food reward response for understanding and influencing maternal diet and weight change. The overarching goal of this research is to advance understanding of the determinants of eating behavior in order to develop and test novel interventions for improving maternal diet and weight change, leading to improved maternal and child health trajectories.

Principal Investigator

Tonja Nansel, Ph.D.

DIPHR Collaborators

Selected Publications

  • Kornides M, Nansel TR, Haynie D, Lipsky L., Laffel L, Mehta S. Family sociodemographics, eating environment, and meal characteristics: Associations with frequency of family meals. Child: Care Health and Development (In Press). Epub Jun 4, 2013. doi: 10.1111/cch.12078. PMID: 23731337.
  • Nansel TR, Haynie DL, Lipsky LM, Laffel L, Mehta SN. (2012). Multiple indicators of poor diet quality in children and adolescents with type 1 diabetes are associated with higher body mass index percentile but not glycemic control. Journal of the Academy of Nutrition and Dietetics, 112(11):1728-1735. PMID: 23102173
  • Tse J, Nansel T, Haynie D, Laffel L, Mehta S. (2012). Disordered eating behaviors are associated with poorer diet quality in adolescents with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics, 112(11):1810-1814. PMID: 23102180
  • Rovner AJ, Nansel TR, Mehta SN, Higgins LA, Haynie DL, Laffel LMB. (2012). Development and validation of the type 1 diabetes nutrition knowledge survey. Diabetes Care, 35(8):1643-7. PMID: 22665217
  • Lipsky L, Nansel T, Haynie D, Mehta S, Laffel L. Associations of food preferences and household food availability with dietary intake and quality in youth with type 1 diabetes. Appetite 2012; 59(2):218-223. PMID: 22595289
  • Rovner AJ, Haynie D, Mehta S, Robinson E, Duffy C, Bucey N, Ryan B, Teodore M, Pound H, Higgins L, Laffel L, & Nansel T. (2010). Perceived benefits, barriers, and strategies of family meals among children with type 1 diabetes mellitus and their parents: focus-group findings. Journal of the American Dietetic Association, 110(9), 1302-1306. PMID: 20800121
  • Gellar L & Nansel TR. (2009). High and low glycemic index mixed meals and blood glucose in youth with type 2 diabetes or impaired glucose tolerance. Journal of Pediatrics, 154(3), 455-458. PMCID: PMC2771116 PMID: 19874764
  • Rovner A, Nansel TR. Are children with type 1 diabetes consuming a healthful diet?: a review of the current evidence and strategies for dietary change. The Diabetes Educator 2009; 35(1): 97-107. PMCID: PMC2713749 PMID: 19244565
  • Rovner AJ, Nansel TR, & Gellar L. (2009). The effect of a low glycemic diet versus a standard diet on blood glucose levels and macronutrient intake in youths with type 1 diabetes. Journal of the American Dietetic Association, 109, 303-307. PMCID: PMC2713749 PMID: 19167958
  • Nansel TR, Gellar L, & McGill A. (2008). Effect of varying glycemic index meals on blood sugar control assessed with continuous glucose monitoring in youth with type 1 diabetes. Diabetees Care, 31(4), 695-697. PMCID: PMC2367100 PMID: 18202243
  • Gellar L, Rovner A, Nansel TR. Whole grain and legume acceptability among youths with type 1 diabetes. The Diabetes Educator 2009; 35: 422 - 427. NIHMSID #106766 PMID: 19289543
  • Nansel TR, Gellar L, & Zeitzoff L. (2006). Acceptability of lower glycemic index foods in the diabetes camp setting. Journal of Nutrition Education and Behavior, 38(3), 143-150. PMCID: PMC2367101 PMID: 16731448
Last Reviewed: 09/09/2014

Contact Information

Name: Dr Stephen Gilman
Acting Branch Chief
Health Behavior Branch
Phone: 301-435-8395

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