SBSB Research: Eating Behavior in Youth with Type 1 Diabetes

Dietary guidelines for youth with type 1 diabetes are similar to those for the general population, and nutrition education for families of youth 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. Youth with type 1 diabetes consume diets low in fruits, vegetables, and whole grains, and high in saturated fat. Poor diet quality in these patients is particularly concerning due to the increased risk of dyslipidemia and cardiovascular disease and the high prevalence of cardiovascular risk factors. Thus, improving diet quality in this population has the potential to improve short- and long-term health outcomes. This program of research 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 tested 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 parallel-group study with equal randomization was conducted at an outpatient diabetes center. Eligible youth were 8 to 16 years old with a type 1 diabetes diagnosis at least1 year and glycated hemoglobin (HbA1c) levels between 6.5 and 10.0 percent. Participants were 136 parent-youth pairs. The intervention consisted of 9 clinic sessions delivered to the child and parent, whereas the control condition comprised equivalent assessments and number of contacts without dietary advice. The intervention approach was grounded in social cognitive theory, self-regulation, and self-determination theory, and integrated motivational interviewing, active learning, and applied problem-solving. Data collected included 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 were dietary intake and glycemic control. Findings demonstrated that the intervention improved youth adherence to dietary guidelines and intake of whole plant foods, with no adverse effect on glycemic control.

To request a copy of the intervention materials, email Tonja.Nansel@nih.gov.

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 interviews, youth self-report surveys, parent self-report surveys, youth 3-day diet records, and parent food frequency questionnaires. 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.

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 youth with type 1 diabetes. Findings indicate that these families experience developmental and environmental challenges surrounding healthful eating similar to those reported among families in the general population, along with additional obstacles 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 that flexible basal-bolus regimens may increase opportunities for unhealthful eating.

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.

Acceptability of Lower Glycemic Index Meals in the Diabetes Camp Setting

Youth ages 7 to 15 years 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. Findings indicated high acceptability of the lower glycemic meals.

Principal Investigator

Tonja Nansel, Ph.D.

DIPHR Collaborators

Investigators

Publications

  • Nansel TR, Lipsky LM, Haynie DL, Eisenberg MH, Dempster K, Liu A. Picky eaters improved diet quality in a randomized behavioral intervention trial in youth with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics. 2018; 118(2):308-316.  PMID: 29389510. PMCID: PMC5908245
  • Eisenberg Colman MH, Quick VM, Lipsky LM, Dempster KW, Liu A, Laffel LMB, Mehta SN, Nansel TR. Disordered eating behaviors are not increased by an intervention to improve diet quality but are associated with poorer glycemic control among youth with type 1 diabetes. Diabetes Care. 2018; 41(4):869-875. PMID: 29371234. PMCID: PMC5860841
  • Quick V, Lipsky LM, Nansel TR. Psychometric properties and factor structure of the adapted Self-Regulation Questionnaire assessing autonomous and controlled motivation for healthful eating among youth with type 1 diabetes and their parents. Child: Care, Health and Development. 2018; 44(4):651-658. PMID: 29770461. PMCID: PMC6005751
  • Eisenberg MH, Lipsky LM, Gee B, Liu A, Nansel TR. Parent healthful eating attitudes and motivation are prospectively associated with dietary quality among youth with type 1 diabetes. Vulnerable Children and Youth Studies. 2017; 12(3):226-240. PMID: 29861779. PMCID: PMC5978430
  • Lipsky LM, Gee B, Liu A, Nansel TR. Body mass index and adiposity indicators associated with cardiovascular biomarkers in youth with type 1 diabetes followed prospectively. Pediatric Obesity. 2016; 12(6):468-476. PMID: 27417272
  • Nansel TR, Lipsky LM, Eisenberg MH, Liu A, Mehta SN, Laffel LM. Can families eat better without spending more? Improving diet quality does not increase diet cost in a randomized clinical trial among youth with type 1 diabetes and their parents. Journal of the Academy of Nutrition and Dietetics. 2016; 116(11):1751-1759.e1. PMID: 27597745. PMCID: PMC5085870
  • Eisenberg MH, Lipsky LM, Dempster KW, Liu A, Nansel TR. I should but I can't: controlled motivation and self-efficacy are related to disordered eating behaviors in adolescents with type 1 diabetes. The Journal of Adolescent Health. 2016; 59(5):537-542. PMID: 27567063. PMCID: PMC5077655
  • Lipsky LM, Gee B, Liu A, Nansel TR. Glycemic control and variability in association with body mass index and body composition over 18 months in youth with type 1 diabetes. Diabetes Research and Clinical Practice. 2016; 120:97-103. PMID: 27525365
  • Nansel TR, Lipsky LM, Liu A. Greater diet quality is associated with more optimal glycemic control in a longitudinal study of youth with type 1 diabetes. The American Journal of Clinical Nutrition. 2016; 104(1):81-87. PMID: 27194309. PMCID: PMC4919526
  • Nansel TR, Laffel LM, Haynie DL, Mehta SN, Lipsky LM, Volkening LK, Butler DA, Higgins LA, Liu A. Improving dietary quality in youth with type 1 diabetes: randomized clinical trial of a family-based behavioral intervention. The International Journal of Behavioral Nutrition and Physical Activity. 2015; 12:58. PMID: 25952160. PMCID: PMC4436744
  • Nansel T, Haynie D, Lipsky L, Mehta S, Laffel L. Little variation in diet cost across wide ranges of overall dietary quality among youth with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics. 2015; 115(3):433-439.e1. PMID: 25266245. PMCID: PMC4344866
  • Caccavale LJ, Nansel TR, Quick V, Lipsky LM, Laffel LM, Mehta SN. Associations of disordered eating behaviors with the family diabetes environment in adolescents with type 1 diabetes. Journal of Developmental and Behavioral Pediatrics. 2015; 36(1):8-13. PMID: 25493461. PMCID: PMC4276537
  • Mehta SN, Nansel TR, Volkening LK, Butler DA, Haynie DL, Laffel LM. Validation of a contemporary adherence measure for youth with type 1 diabetes: The Diabetes Management Questionnaire. Diabetic Medicine. 2015; 32(9):1232-1238. PMID: 26280463. PMCID: PMC4802856
  • Nansel TR, Lipsky LM, Liu A, Laffel LM, Mehta SN. Contextual factors are associated with diet quality in youth with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics. 2014; 114(8):1223-1229. PMID: 24651028. PMCID: PMC4111984
  • Quick V, Lipsky LM, Laffel LM, Mehta SN, Quinn H, Nansel TR. Relationships of neophobia, pickiness with dietary variety, dietary quality and diabetes management adherence in youth with type 1 diabetes. European Journal of Clinical Nutrition. 2014; 68(1):131-136. PMID: 24253761. PMCID: PMC4165343
  • Katz ML, Mehta S, Nansel T, Quinn H, Lipsky LM, Laffel LM. Associations of nutrient intake with glycemic control in youth with type 1 diabetes: differences by insulin regimen. Diabetes Technology & Therapeutics. 2014; 16(8):512-518. PMID: 24766666. PMCID: PMC4115802
  • Kornides ML, Nansel TR, Quick V, Haynie DL, Lipsky LM, Laffel LM, Mehta SN. Associations of family meal frequency with family meal habits and meal preparation characteristics among families of youth with type 1 diabetes. Child: Care, Health and Development 2014; 40(3): 405-411. PMID: 23731337. PMCID: PMC4086450
  • Nansel TR, Haynie DL, Lipsky LM, Wang J, Mehta SN, Laffel LM. Relationships among parent and youth healthful eating attitudes and youth dietary intake in a cross-sectional study of youth with type 1 diabetes. The International Journal of Behavioral Nutrition and Physical Activity. 2013; 10:125. PMID: 24195642. PMCID: PMC3827889
  • Sands AL, Higgins LA, Mehta SN, Nansel TR, Lipsky LM, Laffel LM. Associations of youth and parent weight status with reported versus predicted daily energy intake and hemoglobin A1c in youth with type 1 diabetes mellitus. Journal of Diabetes Science and Technology. 2013; 7(1):263-270. PMID: 23439184. PMCID: PMC3692240
  • Nansel TR, Haynie DL, Lipsky LM, Laffel LM, Mehta SN. 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. 2012; 112(11):1728-1735. PMID: 23102173. PMCID: PMC3985553
  • Tse J, Nansel TR, Haynie DL, Mehta SN, Laffel LM. Disordered eating behaviors are associated with poorer diet quality in adolescents with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics. 2012; 112(11):1810-1814. PMID: 23102180. PMCID: PMC3483560
  • Rovner AJ, Nansel TR, Mehta SN, Higgins LA, Haynie DL, Laffel LM. Development and validation of the type 1 diabetes nutrition knowledge survey. Diabetes Care. 2012; 35(8):1643-1647. PMID: 22665217. PMCID: PMC3402267
  • Lipsky LM, Nansel TR, Haynie DL, Mehta SN, Laffel LM. 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. PMCID: PMC3428468
  • Rovner AJ, Mehta SN, Haynie DL, Robinson EM, Pound HJ, Butler DA, Laffel LM, Nansel TR. 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. 2010; 110(9):1302-1306. PMID: 20800121. PMCID: PMC2930892
  • Gellar L, Nansel TR. High and low glycemic index mixed meals and blood glucose in youth with type 2 diabetes or impaired glucose tolerance. The Journal of Pediatrics. 2009; 154(3):455-458. PMID: 19874764. PMCID: PMC2771116
  • Rovner AJ, 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. PMID: 19244565. PMCID: PMC2772111
  • Rovner AJ, Nansel TR, Gellar L. 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. 2009; 109(2):303-307. PMID: 19167958. PMCID: PMC2713749
  • Gellar L, Rovner AJ, Nansel TR. Whole grain and legume acceptability among youths with type 1 diabetes. The Diabetes Educator. 2009; 35(3):422-427. NIHMSID #106766. PMID: 19289543. PMCID: PMC2843422
  • Nansel TR, Gellar L, McGill A. Effect of varying glycemic index meals on blood glucose control assessed with continuous glucose monitoring in youth with type 1 diabetes on basal-bolus insulin regimens. Diabetes Care. 2008; 31(4):695-697. PMID: 18202243.  PMCID: PMC2367100
  • Nansel TR, Gellar L, Zeitzoff L. Acceptability of lower glycemic index foods in the diabetes camp setting. Journal of Nutrition Education and Behavior. 2006; 38(3):143-150. PMID: 16731448. PMCID: PMC2367101
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