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Food for thought: What is a Paediatric Diabetes Dietician with Kirsty MacLean

Hi! My name is Kirsty MacLean and I am a Children’s Diabetes Dietitian. I have worked as a diabetes dietitian for 12 years; working with children and young people for 11 of them! For the last 6 years I have been working in Glasgow. For anyone who has met me it will make sense that I do my job because I love talking and I love food! My interest in diabetes started when I began volunteering with Diabetes UK in 2009 at their Type 1 Events where I have met some amazing children and volunteers with diabetes over the years, including Alyssa. I have been fortunate enough to be able to put the things I am interested in and love together as a job, and I work with an amazing team of doctors, nurses, other dietitians and diabetes support workers to help children and families living with diabetes.

Kirsty and Alyssa

Firstly, what are the main duties that a diabetes dietician does day-to-day?


Diabetes dietitians work as part of a multidisciplinary team which means we work with lots of other job roles who specialise in diabetes to make sure we can give the best advice to our children and families. Our main job is to teach about how food can affect blood glucose levels, how to count the carbohydrate in food and match this to insulin doses. We can advise on snacks for exercise, hypo treatments and some of the more complex effects of food and how to manage this to get the best blood glucose levels possible. We do this at the hospital when someone is newly diagnosed, at clinic appointments, over video and telephone calls as well as email so our days can differ a lot. We also check that children and young people are growing and can speak about other diet related issues such as allergies or coeliac disease if this affects any of the young people we are working with.

 


What role does a registered dietitian play in educating families about carbohydrate counting and meal planning for children with Type 1 diabetes?


At diagnosis, a dietitian will meet with a young person and their family to find out what their daily routine of meals, snacks and activities were like before diagnosis to be able to advise on how diabetes can fit into this and any healthy changes that might be needed. Dietitians have excellent knowledge of food and how it relates to blood glucose levels as well as having the knowledge of how to make sure a young person is getting all of the vital nutrition they need from all of the food groups, taking into account any likes and dislikes, allergies or religious food restrictions to make sure that the advice given is tailored to meet the needs of that young person diagnosed with diabetes.


Dietitians will discuss healthy eating including the roles of the food groups in the body, identifying carbohydrates from all the food groups including starch, lactose, fructose and refined sugar found in confectionary and processed foods, how to count the carbohydrate including a variety of methods such as picture books, apps, labels and weighing portions.


Generally humans are creatures of habit, meaning we eat similar things and often repeat meals week on week. Families will often feedback that when they are able to plan ahead, this saves time as they are able to work out the carbohydrate in advance and adjust the insulin dose based on the blood glucose level using the correction factor/insulin sensitivity factor. For times that planning is not easy or a challenge like birthday parties or eating out, dietitians can help to educate families on how to manage these trickier times whilst keeping diabetes safe and in check!



What are some practical methods for teaching parents and children how to effectively count carbohydrates in meals and snacks?


During my time working in diabetes the technology has come a long way! There is now so much information online and many apps that can be used to help children and families to count carbohydrates, including Nurtacheck and Carbs and Cals. As dietitians we will always teach the “old fashioned” way of reading labels, weighing out portions and how to work out the carbohydrates. This is important to make sure that if technology fails there is a back up plan!! I would always teach families to be cautious if using labels for “dry” foods like pasta and rice to ensure they are using the correct nutritional information for the way a food has been cooked when they are weighing it out.


Other practical methods to help make carb counting a bit easier include using handy measures such as the same cup or bowl to have standard portion size or the same serving spoon which can be adjusted as a young person grows and their portion size increases. Apps and websites can be very useful but people with diabetes should try to use trusted resources to make sure they get the most accurate information available to them!


Apps now often include barcode scanners but may contain nutritional information that is not verified so children and families should check with their teams what apps they are recommending. There are newer apps that use artificial intelligence to take a photo of the food but these apps do not seem to be the most accurate and are not supported with clinical data for use at the moment so we would not recommend them!



Why is carbohydrate counting essential for children with Type 1 diabetes, and how does it help in managing blood sugar levels?


Carbohydrate counting with flexible insulin dose adjustment is the best way to achieve time in range for blood glucose level. It is a simple principle (not always simple in reality!) which means the more carbohydrate someone is going to eat, the more glucose that enters the blood stream therefore the more insulin that is required to allow this glucose to get into the cells to use as energy or get stored away. Achieving this optimal time in range (~70% glucose levels between 3.9-10mmol/l) for blood glucose is essential to make sure that children and young people with diabetes can grow and develop at the same rate as their peers and ensure that the extremes of blood glucose e.g. hypoglycaemia and hyperglycaemia are minimised, reducing the impact on day to day activities and therefore quality of life. By achieving a time in range more than 70% of the time, this is associated with an Hba1c ~48-53mmol/ mol which is associated with a reduced risk of diabetes related complications. If we can get this right as soon after diagnosis as possible then it is thought that the body “remembers” periods of good diabetes control which can benefit young people as they grow into young adults.



How can parents ensure that their child maintains a balanced diet while also managing carbohydrate intake for diabetes control?


A healthy balanced diet is essential for all children and young people whether they have diabetes or not! Carbohydrates are required for energy and should be included at every meal. By aiming for a balanced plate of food including starchy carbohydrates (pasta, bread, potatoes, rice, wholegrain cereals), lean protein (chicken, eggs, fish, pulses, lean meat) and a large portion of fruit and vegetables, the impact on blood glucose will be minimal and will “match” the insulin given.


Families should choose high fibre, starchy carbohydrates for the majority of the carbohydrate that they eat which is more slowly released into the bloodstream as glucose. This helps to match the carbohydrate with the action of the fast acting insulin. This can improve the time in range for blood glucose and reduce the risk of hypo and hyperglycaemia. Of course, in reality, it can be much more complicated than that!!


Often there are particular meals that might be higher in fat or protein that can cause issues with the blood glucose. Meals like pizza are a good example. Often the fat and the protein in the pizza means the glucose releases very slowly into the bloodstream and often the insulin works quicker than the release of glucose resulting in a  hypo within 30 minutes of eating and injection/blousing for a meal. Dietitians can help to advise on strategies for managing tricky meals.



When it comes to managing exercise and physical activity in type 1 diabetes, what role does a dietician play?


Children aged one to five years should be physically active for 3 hours per day, at least an hour of this should be moderate to vigorous for 3 to 4 year olds!! That means being out of breath with a raised heart rate. For children aged 5-18 years this should be 60 minutes every day of moderate activity with heart rate raised and feeling a bit warm and sweaty!


Adding exercise and physical activity into the balance of carbohydrate and insulin can often cause issues for many people with diabetes. Dietitians have the understanding of the effect exercise has on the body, its requirement for fuel and the need for recovery nutrition so are able to look at the complex relationship between carbohydrate, insulin and exercise to provide individualised advice on how best to manage sports and physical activity to optimise the blood glucose levels whilst ensuring that performance and recovery are also prioritised. Often for everyday activity such as PE or going to a dancing/kickboxing class a minor adjustment to carb intake or insulin might be required. When the intensity, duration or frequency of the activity is increased more planning around carbs, insulin and post activity nutrition is required and that is where a dietitian can help with this.



What are some strategies for adjusting insulin doses and carbohydrate intake before, during, and after exercise to maintain stable blood sugar levels?


This very much depends on the duration, intensity and frequency of the exercise as well as when the last bolus (food dose) of fast acting insulin is given. As a starting point if the exercise is within 2 hours of a meal with fast acting insulin then less insulin will be needed for the meal. This is because the fast acting insulin will be still working hard when the exercise starts. The amount to reduce by will be very much dependent on the individual and will depend if they are using injections of insulin, an insulin pump or a hybrid closed loop pump. Usually a 20-50% reduction to the insulin with the meal before is required sometimes with the need for additional carbohydrate drinks or snacks during the activity too! If you or your child do a lot of physical activity and are finding it is impacting on diabetes or diabetes is impacting on the activity then get in touch with your local team for advice on how to manage this.



What resources are available to help parents and children learn about the relationship between exercise, diet, and Type 1 diabetes management?


Diabetes UK and JDRF are charity websites with lots of information on them. The Digibete website is also full of useful information. Some health boards in Scotland and NHS Trusts in England may also be using the Digibete app which can then be accessed on a mobile device.



What are some common misconceptions that people have about diabetes dietitians, and how can we debunk these myths?


That we are the food police!! Most dietitians have chosen this career due to wanting to help people and an interest in food and science. ~No question is silly and if something is complicated, dietitians are specialists in being able to turn tricky information into easy to understand advice so please ask.



Are dieticians included in clinic appointments as routine? 

This varies depending on where you live but there will always be a dietitian who works with the team that you can get in touch with. Check with your diabetes teams to know how best to contact the dietitian.



What message do you want to let people know about dietetics in paediatric diabetes?

Dietetics goes hand in hand with all other aspects of diabetes self-management including blood glucose testing, insulin dose adjustment, management of hypos and hyperglycaemia and there is no “one size fits all”. Everything needs to be considered on an individualised basis and that is where you dietitian and your diabetes team can help.



Diabetes camps and the improvement in practice after the camps: Can you share your experience volunteering at the diabetes camps and how your practice evolved after these experiences?


Living as a minority (I do not have diabetes) with a group of children and adult volunteers who do have diabetes for a week was a hugely valuable and humbling experience. I was given the privilege of sharing their experiences and thought processes based on the activities we were undertaking including snack adjustment, insulin adjustments, overnight testing etc. The children and volunteers were all able to learn from each other and the practical application of physical activity principles was the best learning experience I could have asked for. It is certainly what got me to where I am today and I now know a fabulous community of people with diabetes with “real life” experience who I admire and can learn from every day!



Any other opinions you would like to share?


Diabetes is always there and can seem overwhelming but your dietitian and diabetes team can help to plan and try to make sure that diabetes does not stop you from doing the things you want to!


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