Waldron Sheridan, Hanas Ragnar, Palmvig Birthe
Leicestershire Nutrition and Dietetic Service, Leicestershire and Rutland Healthcare NHS Trust, Leicester, UK.
Horm Res. 2002;57 Suppl 1:62-5. doi: 10.1159/000053315.
The dietary management of childhood diabetes is complex. Is it possible to educate young people to balance carbohydrate with their insulin? Can dietary knowledge be translated into lasting behaviour change? Do present teaching methods provide the skills necessary for children and parents to adjust their insulin therapy adequately? Evidence shows great variation in glycaemic control between centres and countries but the impact of dietary education methods is poorly evaluated and its links with clinical and psychosocial outcomes is virtually unknown. There is also little evidence to suggest cohesive teamworking with clear dietary targets for glycaemic control, lipids, incidence of hypoglycaemia, compliance, effect on peer and sibling relationships, and evaluation of individual dietary components, e.g. fibre, fat, antioxidants. There is wide variation in methods of dietary education, which are often based on historic practice. They include rigid counting of grams of carbohydrate, carbohydrate portion assessments, qualitative diets, low glycaemic index diets and the more recent 'intensified' carbohydrate measures with daily adjustments of insulin (the basis also of pump management). This last method has many benefits although it requires extensive nutrition education, it allows greater flexibility and variety of food intake, is sensitive to the varying daily energy expenditure of childhood and it addresses postprandial glycaemic excursions, all of which are inadequately managed by conventional therapy. However, one of the problems of overemphasizing carbohydrate measurement is that total carbohydrate intake may be suppressed, with a resulting increase in fat, this may contribute to an increase in cardiovascular risk. The ISPAD Consensus Guidelines 2000 contain dietary recommendations but scientific evidence is often lacking. Limited dietary studies show that some countries can meet guidelines more successfully than others. There are many reasons for this, such as food availability, types of food eaten, food preferences and family/cultural/religious influences. Educational methods must be adapted to local customs. Is there enough evidence to recommend a particular dietary education method? What outcomes do we hope to achieve? The workshop explored these issues in order to develop a deeper understanding of the complexity of dietary modification in childhood diabetes.
儿童糖尿病的饮食管理很复杂。能否教育年轻人使碳水化合物摄入与胰岛素剂量相平衡？饮食知识能否转化为持久的行为改变？目前的教学方法能否提供儿童及其家长充分调整胰岛素治疗所需的技能？有证据表明，不同中心和国家之间血糖控制情况差异很大，但饮食教育方法的效果评估不足，其与临床及社会心理结果之间的联系几乎无人知晓。也几乎没有证据表明，在血糖控制、血脂、低血糖发生率、依从性、对同伴及兄弟姐妹关系的影响以及对膳食纤维、脂肪、抗氧化剂等个体饮食成分的评估方面，存在明确饮食目标的紧密团队协作。饮食教育方法差异很大，且往往基于传统做法。这些方法包括严格计算碳水化合物克数、评估碳水化合物份数、定性饮食、低血糖指数饮食以及最近的“强化”碳水化合物措施（即每日调整胰岛素，这也是胰岛素泵管理的基础）。最后这种方法有很多优点，尽管它需要广泛的营养教育，但它能使食物摄入更具灵活性和多样性，能适应儿童每日不同的能量消耗情况，还能解决餐后血糖波动问题，而这些都是传统疗法难以充分应对的。然而，过度强调碳水化合物测量的一个问题是，总碳水化合物摄入量可能会受到抑制，脂肪摄入量随之增加，这可能会导致心血管疾病风险上升。《2000年国际儿童和青少年糖尿病学会（ISPAD）共识指南》包含了饮食建议，但往往缺乏科学依据。有限的饮食研究表明，一些国家比其他国家更能成功遵循指南。原因有很多，比如食物供应情况、所吃食物种类、食物偏好以及家庭/文化/宗教影响等。教育方法必须因地制宜。是否有足够的证据推荐某种特定的饮食教育方法？我们希望达成什么样的结果？本次研讨会探讨了这些问题，以便更深入地了解儿童糖尿病饮食调整的复杂性。
