**6. Conclusions**

The previous nutritional recommendations are aimed to achieve a good GC and nutritional management in the long-term; nonetheless, it is necessary to address the acute dietary complications, meaning the management of hypoglycaemia, because it is the most common acute complication of the treatment of T1DM. In case of hypoglycaemia (<60–70 mg/dl) it is necessary an immediate oral, rapidly absorbed, simple carbohydrate to raise blood glucose up to

**Table 2.** Main effects of low and high glycaemic index diets on the nutritional management of diabetes in children and

Area under the blood glucose response curve, AUC; body mass index, BMI; cardiovascular, CV; glycated haemoglobin A1c, HbA1c; high density lipoprotein cholesterol, HDL-c; low density lipoprotein cholesterol, LDL-c; postprandial

**High GI diet** Marsh et al. [14] • Rapid rise in blood glucose and insulin levels

> • Increased postprandial glycaemia • Higher need to medication • Fasting hypertriglyceridaemia

Increased risk of T2DM up to 40%

International Diabetes

• Lower HDL-c levels • Reduced fibrinolysis

**References Low GI diet**

Marsh et al. [14]; Rahelić et al. [17] Increased insulin resistance

glucose excursion, PPGE; type 1 diabetes mellitus, T1DM; type 2 diabetes mellitus, T2DM\*

Marsh et al. [14]; Rahelić et al. [17];

Blaak et al. [18]

Finally, the exercise is indispensable in the management of diabetes, especially in T2DM children and adolescents, due to this pathology is commonly associated with obesity. The American Academy of Paediatrics recommends that health care professionals encourage children and adolescents with T2DM to practice moderate to vigorous exercise for at least 60 minutes daily and to limit non-academic '*screen time*', such as watching television or playing computer games, to less than 2 hours per day for the reduction of BMI and the improvement of GC. Physical activity is an integral part of weight management for the prevention and treatment of T2DM. Although there is scarce available data from children and adolescents with T2DM, several well-controlled studies performed in obese children and adolescents at risk of

Although, the optimal diet and macronutrient composition in diabetes remain controversial and the evidence is not sufficiently robust to recommend a low GI diet as the primary dietary

metabolic syndrome and T2DM provide guidelines for physical activity [43].

100 mg/dl [39].

Federation.

136 Diabetes Food Plan

adolescents.

**5. Future prospects**

Further research is needed in diabetic children and adolescents, especially well-designed long-term randomised controlled trials with larger sample size to determine the true value of low GI diets on overall quality of life, long-term GC and the prevention or management of diabetes-related complications. The results obtained up to the present moment are inconclusive due to discrepancies between the methods of analysis and the diversity in the methodology employed. Therefore, it is difficult to generalise results. It is necessary the use of validated questionnaires for the dietary assessment and standardised the GI databases in order to make the data comparable between different studies. One limitation of all observational studies published to date is that none of the food frequency questionnaires have been specifically designed to assess the GI and until recently, few were validated against another method of dietary assessment, such as 24 h recalls or diet records. Therefore, these questionnaires have poor ability to estimate carbohydrate intake, calling into question the accuracy of any GI or glycaemic load estimation [14]. On the other hand, the studies use different cognitive tests to assess cognitive domains. Therefore, it is difficult to compare results between studies. Brain imaging is becoming essential to clarify the effects of diabetes on brain development, and it will offer us new perspectives for the prevention of neurological disorders and mental health.

Covariates that could affect neurocognitive testing and should be taken into account are, age, education, sex, history of other chronic illnesses, psychiatric and neurological disorders, absence from school, socioeconomic status, and hypo/hyperglycaemia during testing. Most of the studies control for at least some of these covariates, but most fail to control all of them [34].

**Acknowledgements**

**Abbreviations**

BMI body mass index

DM diabetes mellitus

GI glycaemic index

EEG electroencephalography EOD early onset of diabetes GC glycaemic control

GDM gestational diabetes mellitus

HDL-c high density lipoprotein cholesterol HPA hypothalamic-pituitary-adrenal

LDL-c low density lipoprotein cholesterol

MUFAs monounsaturated fatty acids NKS Nutrition Knowledge Survey PPGE postprandial glucose excursion PUFAs polyunsaturated fatty acids T1DM type 1 diabetes mellitus T2DM type 2 diabetes mellitus

WHO World Health Organisation

GPA gluco-psychosocial axis HbA1c glycated haemoglobin A1c

IQ intelligence quotient

LOD late onset of diabetes

CDC Centres for Disease Control CNS central nervous system DHEA dehydroepiandrosterone

ADHD attention deficit hyperactivity disease AGEs advanced glycation end products

AUC area under the blood glucose response curve

The authors of this chapter are participating in the DynaHEALTH project *'Understanding the dynamic determinants of glucose homeostasis and social capability to promote healthy and active aging'. European Union's Horizon 2020 Research and Innovation Programme under Grant Agreement No 633595*.

Influence of Glycaemic Control on Cognitive Function in Diabetic Children and Adolescents

http://dx.doi.org/10.5772/intechopen.75562

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There is wide criticism and controversies about low GI diet. Some authors state that is easy to follow and effective, whereas other authors think GI is highly variable, not physiological and difficult to learn and follow. Despite this, GI concept is accepted by many diabetes associations around the world as an integral part of the dietary treatment of diabetes. Despite the controversy, there is substantial evidence that a low GI diet can improve the GC in subjects with diabetes. It is vital to carry out further research of the role of GI in the prevention and treatment of diabetes and its complications together with beneficial effects of a low GI diet [17]. One of the major controversies about GI is that different studies state that the GI of food change in the presence of other macronutrients, but the reality is that GI is an intrinsic characteristic of food. Therefore, the GI of food does not change in the presence of other macronutrients, such as lipids, proteins and fibre, is just the glycaemic response. It has been shown that proteins induce greater insulin secretion, while fats reduce gastric emptying and slow down the absorption of carbohydrate. It is essential to study the effects of protein, fat and fibre on the glycaemic response to a carbohydrate meal [15], especially in children and adolescents.

On the other hand, nutritional education and physical activity are essential in order to achieve a good GC of the disease. The main goal of diabetes management is to prevent long-term complications, not only cognitive dysfunction, also micro and macrovascular complications. More studies in cognitive function in diabetic children and adolescents with severe hypoglycaemia are needed, because preventing hypoglycaemia could reduce cognitive dysfunction [36], and improve healthy ageing in the diabetic patients. Long-term interventions will help also to know the impact of disease duration on cognition. More intensive diabetes medical regimes will be associated with less neurocognitive deficits, especially in patients with an EOD because they are more expose through time to glycaemic extremes (hypo and hyperglycaemias). It is vital to identify the factors that are involved in the aetiology and progression of the neurological complications, because currently the pathophysiology of cognitive dysfunction in diabetes is not well understood [1]. Therefore, it is important to understand the pathogenesis of cognitive dysfunction secondary to diabetes in order to establish more efficient treatments and prevent or reverse these cognitive alterations [34]. Thus, further well designed human studies are needed to elucidate the pathophysiology and the mechanisms of action of cognitive dysfunction through neuroimaging [3].

In conclusion, it is necessary to carry out well designed long-term intervention randomised control trials with larger sample size, detailed cognitive assessment combined with neuroimaging [7] and adequate dietetic management. Furthermore, it is essential an early dietetic intervention in order to prevent or reduce diabetes-related complications, especially in children and adolescents with an EOD, because they are exposed through time to glycaemic extremes and are more vulnerable than adults, because their CNS is developing and any damage could be irreversible. Finally, it is important to identify population at risk during early life and childhood in order to develop clear recommendations, prevent the development of diabetes and promote healthy ageing.
