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T1DM: Guideline Overview (2024)

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T1DM: Guideline Overview (2024)

Guideline Title
Type 1 Diabetes Mellitus (Pediatrics) Evidence-Based Nutrition Practice Guideline (2024)

Guideline Narrative Overview

Introduction

Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases among children and adolescents in the United States, with a notable rise in prevalence occurring over the past two decades.1 Among children and adolescents 19 years or younger, the estimated T1DM prevalence per 1000 youths significantly increased from 1.48 (95% CI, 1.44-1.52) in 2001 to 2.15 (95% CI, 2.10-2.20) in 2017,1 demonstrating the prominent rise of this lifelong autoimmune disease among children and adolescents in the U.S. 

Nutrition plays a critical role in the health of all children and adolescents as it fosters optimal physical, mental, and emotional growth and development.2 However, for children and adolescents with T1DM, nutrition is of heightened importance due to the direct association between macronutrient intake and blood glucose levels.3 Furthermore, research has shown an association between dietary quality/pattern and T1DM management.4 In looking at T1DM disease management across the lifespan, adolescents consistently demonstrate the poorest glycemic outcomes, followed by children.5 Intervening during adolescence is important for establishing lifelong healthy habits and behaviors with an overarching objective of enhancing overall quality of life and longevity, reducing incidence of disordered eating and long-term complications such as cardiovascular disease.6-8 Therefore, nutrition interventions aiming to improve glycemic management among children and adolescents with T1DM are a priority to improve short- and long-term health outcomes among this vulnerable population.9 Given the intricate role dietary intake plays in T1DM management and evidence demonstrating poorer diet quality among children and adolescents with T1DM compared with their healthy counterparts, interventions targeting dietary behaviors have great potential.8      

Guideline Development

Guideline development is a detailed and comprehensive process. This evidence-based nutrition practice guideline (EBNPG) followed Academy of Nutrition and Dietetics guideline development process10,11 and GRADE (Grading of Recommendations Assessment, Development and Evaluation) method’s Evidence to Decision Framework.12,13 The steps followed to develop this guideline were:

  • Select the expert panel that works with the guideline development team.
  • Orient the expert panel to the process of guideline development and systematic review process.
  • Develop research questions, inclusion exclusion criteria, and a detailed search plan, as well as identify interventions and outcomes of interest.
  • Search multiple databases based on the approved search plan.
  • Screen abstracts and full-text articles based on a priori eligibility criteria.
  • Extract data and critically assess the quality of included studies (risk of bias of studies).
  • Synthesize evidence in narrative (evidence summary and conclusion statements) and in table format. Grade the quality of evidence for each outcome and provide Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tables.
  • Review the findings and evidence quality of the systematic review and related evidence that will inform the guideline recommendations with the expert panel.
  • Orient and train the expert panel in use of GRADE’s Evidence to Decision Framework (EtD).
  • Develop recommendation statements based on the findings of the systematic review using the EtD framework and assign a “strength of recommendation”.
  • Assemble the draft guideline.
  • Conduct an external and public review of the guideline.
  • Respond to reviewer comments and update the guideline before publication.

Topics addressed in this EBNPG include:

  • Nutrition Screening
  • Nutrition Assessment
  • Medical Nutrition Therapy Intervention
  • Diet Quality
  • Carbohydrate Management Strategies
  • Macronutrient Composition
  • Dietary Patterns
  • Vitamin D
  • Culturally Relevant/Responsive Nutrition
  • Food Insecurity

The number of supporting documents for this topic is:

  • Recommendations: 14
  • Conclusion Statements: 8
  • Evidence Summaries: 8
  • Article Worksheets: 29

Monitoring, Evaluating and Auditing Guideline Implementation

The process of the evidence-based cycle extends beyond creating practice recommendations. Ideally, recommendations are implemented into practice, evaluated for efficacy, and updated accordingly. At the Academy, implementation research may be conducted by the Nutrition Research Network.14 RDNs can contribute to research examining implementation and evaluation of recommendations by participating in Nutrition Research Network studies, including by providing client data in the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) program. When determining which recommendation to prioritize for implementation, RDNs are encouraged to prioritize recommendations that will have the greatest impact on their specific circumstances and clients. 

Contributors

Expand the section titled “Project Team and Disclosures” on the project landing page to see the list of individuals including the expert workgroup members, methodologists and analysts who contributed to the development of the systematic review and EBNPG.

Revision

Academy guidelines are revisited every five years. A scoping review will be conducted to examine the need for new and revised recommendations based on the available science. The process includes:

  • Literature searches and evidence scoping to identify new research published since the previous searches were completed. Updated inclusion/exclusion criteria and search terms may be warranted.
  • Council on Research review to determine if the update will inlcude modification to all, some or no recommendations compared to the earlier version(s) of the guideline, or development of new recommendations.
  • Creation of a table comparing the new guideline and the older version of the guideline. The document will indicate which recommendations remain unchanged; updated, new; or not reviewed.

Using the Academy's process, an unbiased and transparent systematic review will be completed, and the updated guideline will be published on the EAL. To learn more about the Academy's development process, download Papoutsakis C, Moloney L, Sinley R, et al. Academy of Nutrition and Dietetics Methodology for Developing Evidence-Based Nutrition Practice Guidelines. J Acad Nutr Diet 2017 May 117; (5):794-804 PMID: 27614690 doi: 10.1016/j.jand.2016.07.011 or visit the Policy and Process section of the EAL. 

References

  1. Lawrence JM, Divers J, Isom S, et al. Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001-2017. JAMA 2021;326(8):717-27. doi: 10.1001/jama.2021.11165.
  2. Leidy HJ, Gwin JA. Growing up strong: The importance of physical, mental, and emotional strength during childhood and adolescence with focus on dietary factors. Appl Physiol Nutr Metab. 2020;45(10):1071-1080. doi: 10.1139/apnm-2020-0058. Epub 2020 Jul 10.
  3. Holesh JE AS, Martin A. Physiology, Carbohydrates. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. 2023 May 12. PMID: 29083823 Bookshelf ID: NBK459280
  4. Garonzi C, Forsander G, Maffeis C. Impact of Fat Intake on Blood Glucose Control and Cardiovascular Risk Factors in Children and Adolescents with Type 1 Diabetes. Nutrients. 2021;13(8):2625. doi: 10.3390/nu13082625
  5. Franz MJ. Protein: metabolism and effect on blood glucose levels. Diabetes Educ. 1997;23(6):643-646, 648, 650-641. doi: 10.1177/014572179702300603
  6. American Diabetes Association. 13. Children and Adolescents: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S163-s182. doi: 10.2337/dc20-S013.
  7. Araia E, King RM, Pouwer F, Speight J, Hendrieckx C. Psychological correlates of disordered eating in youth with type 1 diabetes: Results from diabetes MILES Youth-Australia. Pediatr Diabetes. 2020;21(4):664-672. doi: 10.1111/pedi.13001. Epub 2020 Mar 11
  8. 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. J Acad Nutr Diet. 2012;112(11):1728-1735. doi: 10.1016/j.jand.2012.08.029
  9. Joanne Spinks SG. Dietary Management of Children with type 1 diabetes. Pediatrics and Child Health. 2017;27(4):176-180.
  10. Handu D, Moloney L, Wolfram T, Ziegler P, Acosta A, Steiber A. Academy of Nutrition and Dietetics Methodology for Conducting Systematic Reviews for the Evidence Analysis Library. J Acad Nutr Diet. 2016;116(2):311-318. doi: 10.1016/j.jand.2015.11.008
  11. Papoutsakis C, Moloney L, Sinley RC, Acosta A, Handu D, Steiber AL. Academy of Nutrition and Dietetics Methodology for Developing Evidence-Based Nutrition Practice Guidelines. J Acad Nutr Diet. 2017;117(5):794-804. doi: 10.1016/j.jand.2016.07.011. Epub 2016 Sep 7.
  12. Alonso-Coello P, Schünemann HJ, Moberg J, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ. 2016;353:i2016. doi: 10.1136/bmj.i2016.
  13. Moberg J, Oxman AD, Rosenbaum S, et al. The GRADE Evidence to Decision (EtD) framework for health system and public health decisions. Health Res Policy Syst. 2018;16(1):45. doi: 10.1186/s12961-018-0320-2
  14. Academy of Nutrition and Dietetics. Nutrition Research Network. https://www.eatrightpro.org/research/projects-tools-and-initiatives/nutrition-research-network. Published 2022. Accessed April 7, 2022.

 

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