Current Paediatrics (I 999) 9, 164-l 68 8 1999 Harcourt Publishers Ltd Symposium: Diabetes Diabetic diets: which one? N. Harding Dietary advice given to families of children with dia- betes has changed conside rably over the last 70 years from st rict c arbohyd rate prescriptions to a more lib- eral 10 g exchange system and now to the unrestr icted healthy-eating advice that has become m ore com mon today. Although there is consensus throughout most dia- betes centres on the fundamental nutritional require- ments for children with diabetes the re stil l remain considerable areas of controversy on the advice sur- rounding carbohydrate intake. This mainly surrounds quantificati on of carbohydrate versus a more liberal approach based on healthy-eating princ iple s, the emphasis on other nutrients such as fat and fibre plus psychosocial implications of dietary control.’ This has resulted in a lack of consistency between teaching methods within the UK. AIMS OF DIETARY INTERVENTION The primary goal of dietary modification is to mini- mize blood glucose variation through providing daily insulin dose. In a ttempting to achieve t he primary goal the followi ng additional factors have to be considered: l Avoidan ce of extremes of hyper/hypoglycaemia in the child l Maintenance of ideal body weight and normal growth and development l Minimization of the risk s of long-ter m micro/macrovascular disease l Maintenance of normal so cial functioning. Nicky Harding BSc, SRD , Paediatric Dietitian, Department of Nutrition and Dietetics, Southampton General Hospital, Southampton SO16 6YD, UK. Correspondence and requests for offprints to NH. In practice, achievi ng all of the above c an pose chal- lenges to t he health professional due to complex external factors which can include: 0 Varying so cial circumstances l Family eating patterns and practices l Education abilities l Parental attitude and peer pressure. EVOLUTION OF DIABETIC DIETS Historically evidence shows that dietary modification has played a key role in the control of diabetes for over 2 00 years. Before the widespread use of in suli n therapy in the 1920s a starvation diet was typically prescribed to relieve the symptoms of diabetes. If the primary effect of this treatment was to delay death from ketoacidosis, death would nevertheless result from malnutrition. By the 1920s the use of in sulin therapy was widespread within the UK and accepted as the pri- mary treatment for diabetes. This led to th e further development of diabetic diets to ensure sufficient car- bohydrate intake to balance the insu lin d ose. This was achieved throug h rules such as the ‘red/black line sys- tem’ establishe d in the mid 1920s. These rules were designed specifically to restrict energy intake from car- bohydrate to excepti onall y low leve ls of around 20%. This inevitably resulted in fat energy intake levels of up to 70%, which c onfl icts with the 30-35X now rec- ommen ded with the well-understood ris ks of high-fat intake and cardiovascular complications of diabetes . ‘Counted’ diets evolved over the next 50 years becoming more flexible and thereby allowing patients to eat more normal diets, but stil l restricting the quantity of carbohydrate consumed. An indi vidual’s carbohydrate requirement would be calculate d based on their averag e calorie intake. It is then divided into portions, usually 10 g, and distribute d into meals and 16 4
