**3. Carbohydrate**

the prevention of type 2 diabetes in youth, interventions similar to those shown to be effec‐ tive for prevention of type 2 diabetes in adults (lifestyle changes including reduced energy intake and regular physical activity) are likely to be beneficial. Clinical trials of such inter‐

Individuals who have pre-diabetes or diabetes should receive individualized medical nutri‐ tion therapy (MNT); such therapy is best provided by a registered dietitian familiar with the components of diabetes MNT. Meta-analysis of studies in non-diabetic, free-living subjects and expert committees report that MNT reduces LDL cholesterol by 15–25 mg/dl. (Yu-Poth

The prevalence of overweight children and adolescents with type I Diabetes mellitus has tri‐ pled over the past 20 years, which appears to correspond to the increasing prevalence of obesity in the general population. The authors (Kliegman M Robert et al., 2007), have ob‐ served patients with type I diabetes, normal-weight preschool children have better glycemic control than age-matched overweight children. This may mean that excess body weight sta‐

The basis for energy requirements calculations is the determination of ideal body-weight. It is assessed corresponding to the respective tables comprising child's age, gender and body

**Age kcal/kg/d Protein (in grams) kg/d**

6 months 115 2.2 12 months 105 2.0 3 years 100 1.8 6 years 85 1.5 10 years 86 1.2

11-14 years 60 1.0 15-18 years 42 0.85 19-22 years 41 0.80

11-14 years 48 1.0 15-18 years 38 0.84 19-22 years 38 0.80 Adapted from National Academy of Sciences Food and Nutrition Board

tus may impede achievement of therapeutic goals in this group of patients.

ventions are ongoing in children.

S. et al., 1999. Grundy SM., et al. 1997 )

Guidelines for daily caloric requirements in children

**•** *1500-2000 kcal + 100 Kcal/year of age > 12 ( for females 12-15)* **•** *2000-2500 Kcal+ 200 Kcal/year of age > 12 ( for males 12-15)*

**•** *1000 Kcal + 100 Kcal/year age ( for 0-12 year old)*

**Male**

**Females**

**Table 1.**

size data.

470 Type 1 Diabetes

Dietary carbohydrate has both chemical structural features and form which have gained in importance in recent years. The process of digestion of carbohydrate has been known for many years and instinctively it is held that a monosaccharide must be absorbed more readi‐ ly than an oligosaccharide, which requires hydrolysis before absorption.

The recommended dietary allowance (RDA) for digestible carbohydrate is 130 g/day and is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested proteins and fats. Although brain fuel needs can be met on lower-carbohydrate diets, long-term metabolic effects of very-low-car‐ bohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability (Institute of Medicine:2002). There are no trials specifically in patients with diabetes restricting total car‐ bohydrate to <130 g/day. However, 1-year follow-up data from a weight-loss trialamong the subset with diabetes indicated that the reduction in fasting glucose was 21 mg/dl (1.17 mmol/l) and 28 mg/dl (1.55 mmol/l) for the low-carbohydrate and low-fat diets, respectively, with no significant difference in A1C levels (Stern L., et al. 2004).

Department for Agriculture ( USDA) reveal that – 43%-47% of calories are contributed by dietary carbohydrate, whereas 36-37% of calories are contributed by dietary fat, with 13% from saturated fatty acids, 14% from monosaturated, and 7% from polyunsaturated. A re‐ duction in high dietary takes of saturated fats, trans-fatty acids and cholesterol (all of which contains cholesterol-raising fatty acids) is an important goal to reduce the risk of cardiovas‐ cular disease. Although diabetes mellitus is usually categorized as a disease of carbohydrate metabolism, abnormalities of lipoprotein metabolism and adipose tissue distribution are al‐ so common. Cardiovascular disease accounts for the majority of deaths in people with dia‐ betes. Analysis of the Multiple Risk Factor Intervention Trial data for men with diabetes matched with non-diabetic men reported relative risk of death for men with diabetes was increased at a range from 2.83 to 4.46 depending on their level of serum cholesterol. (Stamler J. et al. 1993)

The use of the glycemic index has been shown to provide additional benefit to glycemic con‐ trol over that observed when total carbohydrate is considered alone (Brand-Miller. et al. 2003*).* This index compares glycaemic excursions after ingestion of a carbohydrate and com‐ pares it with the glycemic excursions after an equivalent amount of the monosaccharide glu‐ cose. Thus numerical values can be ascribed to potatoes, rice, bread, etc., which give a

Nutritional Management in Type 1 Diabetes Mellitus

http://dx.doi.org/10.5772/52465

473

Factors that affect the glycemic response of foods are feeding rate, the rate of food ingestion, food ingredients (fat, protein, fiber, starch) and methods of cooking and food processing. In‐ fluence on glycemic response and physiological mechanisms of degradation of consumed food (pre-gastric and gastric hydrolysis, gastric emptying rate, intestinal hydrolysis and re‐ action to pancreatic and intestinal hormones). Bread, crackers, grain, potatoes, millet, corn, and chips have a high GI (> 90). Bran, oatmeal, rice, buckwheat have medium glycemic in‐ dex (e.g. 70-90). Black bread, pasta, barley and cooked rice have the lowest glycemic in‐

A controlled study in children using the GI of foods found flexible dietary instruction based on the food pyramid and low-GI choices achieved significantly better glycemic control after 12 months than more traditional dietary advice. (Gilbertson H. et al. 2001). In their study, Miller JB et al confirmed the significant influence of the lower GI nutrition on postprandial glucose levels. However, the impact on long-term glycemic control and co-morbidity was

Choosing low-GI foods in place of conventional or high-GI foods has a small but clinically useful effect on medium-term glycemic control in patients with diabetes. The incremental benefit is similar to that offered by pharmacological agents that also target postprandial hy‐

In addition, several prospective observational studies have found that the overall GI and gly‐ cemic load (GI × g carbohydrate) of the diet, but not total carbohydrate content, are independ‐ ently related to the risk of developing type 2 diabetes (Salmeron J et al, 1997), cardiovascular

Low GI carbohydrate foods (GI < 55) may lower post-prandial hyperglycemia when they are chosen to replace higher GI foods (GI > 70) (Brand-Miller J. et al. 2003) Examples of low GI food sources include wholegrain breads, pasta, temperate fruits and dairy products. (Foster-Powell K. et al. 2002) Glycemic load (GL) is another method of predicting the postprandial blood glucose response, which takes into account both the GI of the food and the portion

Artificial sweeteners are widely used among diabetic patients. Two kinds of sweeteners may be distinguished:nutritive sweeteners which contain calories (fructose, sorbitol, mannitol) and non-nutritive which are calories-free (saccharin, cyclamate, aspartame). Fructose has the ad‐ vantage over sucrose; for its better taste, slow absorption from the digestive system; no insulin is required for itsutilization and it causes hyperglycemia less often The fructose intake should be limited to 25g/d. Saccharin is about 500 times the sweeter than sucrose; its use may be con‐

disease (Liu S et al, 2000), and some cancers (Augustin L, 2001, Franceschi S et al, 2001)

size. (Colombani PC, 2004). There has been no assessment of its efficacy in children.

nected to the increased risk of bladder carcinoma (Dimitrijevic-Srećković V., 2002).

comparative indication of glycemic consequence.

dex(<70) (Dimitrijević- Srećković V. 2002).

less efficient than pharmacological treatment.

perglycemia. (Jennie Brand-Miller et al. 2003)

Approximately 70% of the carbohydrate content should be derived from complex such as starch; intake of sucrose and highly refined sugars should be limited.

An intake of simple carbohydrates with high fiber foods - such as complex grains (bran), vegetables (beans and peas containing galactomannan) and fruit (pectin) is recommended; this combination of food slows intestinal food absorption, reduce postprandial hyperglyce‐ mia and lowers serum cholesterol levels (Stepanović R., et al. 1991).
