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FOOD FOR THOUGHT

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MAT T E R S O F L IF E S T Y L E

Nutrition Strategies for Prevention and Management of

Type 2 Diabetes in Children CARRIE S. SWIFT, MS, RD, BC-ADM, CDE

As children in the United States have become less active and increasingly overweight and obese, the incidence of type 2 diabetes in youth has risen. This is particularly true for children ages 10 years old and up. According to the National Diabetes Education Program (NDEP), most children and teens diagnosed with type 2 diabetes have a family history of diabetes and are insulin resistant. Similar to adults, type 2 diabetes is more common in certain racial and ethnic groups, including African Americans, American Indians, Hispanic/Latino, and Asian and Pacific Islander. The largest risk factor however is being overweight. Children who are too heavy have more fatty tissue, making insulin resistance more likely. Since physical activity helps improve insulin resistance, being inactive compounds the problem. It’s important for parents to understand these risks.

Most children and teens diagnosed with type 2 diabetes have a family history of diabetes and are insulin resistant.

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Table 1. Weight Status Categories for Children BMI-for-Age Percentilesa Weight Status Category

Percentile Range

Underweight

Less than fifth percentile

Healthy weight

Fifth to less than eighty-fifth percentile

Overweight

Eighty-fifth percentile to less than ninety-fifth percentile

Obese

Equal or greater than the ninety-fifth percentile

a BMI-for-age percentile charts can be found online at: BMI percentile chart for girls ages 2 to 20: cdc.gov/growthcharts/data/set2clinical/cj41l074.pdf; BMI percentile chart for boys ages 2 to 20: cdc.gov/growthcharts/data/set2clinical/cj41l073.pdf.

Body Mass Index for Age

Screening for Type 2 Diabetes

It is recommended that health care professionals

The ADA recommends screening for type 2

start screening for overweight and obesity in children

diabetes should begin at 10 years old or at the

at 2 years old. Potential weight issues in children can

onset of puberty, whichever is sooner. However,

be determined by using body mass index (BMI). BMI

if children have symptoms of diabetes, they

is calculated from the height and weight and then

should be tested right away. Diabetes symptoms

in children are similar

plotted on the appropriate gender chart.

in children are similar to adults: feeling tired,

to adults: feeling tired,

Use this equation to calculate a child’s BMI:

increased thirst, having to urinate more often,

Weight in pounds ÷ height in inches ÷ height in inches again × 703 = BMI

Diabetes symptoms

weight loss, blurry vision, slow healing of cuts

increased thirst, having

or wounds, and urinary tract infections. Without

to urinate more often,

symptoms, the primary screening criteria in children is a BMI greater than the eighty-fifth

weight loss, blurry vi-

For example, the BMI for an 80-pound child who is

percentile for age and gender along with any two

sion, slow healing of

52 inches tall is calculated like this:

of the following risk factors:

cuts or wounds, and

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80 pounds ÷ 52 inches ÷ 52 inches

first-degree relative (a parent, brother, or sister)

× 703 = 21 (20.8)

aunt, or uncle); ■

race/ethnicity (American Indian, African

for adults, children and teenagers’ BMIs are both

American, Hispanic/Latino, Asian American, or

age and gender specific and are referred to as

Pacific Islander);

BMI-for-age. Adult BMI tables don’t take into

■

insulin resistance or conditions associated

account the changes in healthy weight as children

with insulin resistance (acanthosis nigricans,

grow and gradually gain more lean muscle mass.

hypertension, elevated lipid levels, polycystic

There are also expected differences in body fat

ovary syndrome, or low birth weight);

between boys and girls. The BMI-for-age charts are used to assess children’s size and growth pattern, along with comparison among children of the same gender and age. Weight status categories and BMI-for-age percentiles are shown in Table 1.

urinary tract infections.

or a second-degree relative (a grandparent,

While BMI is calculated the same for children as it is for adults, the interpretation is different. Unlike

a family history of type 2 diabetes in either a

■

if the mother had type 2 diabetes or gestational diabetes during the pregnancy with this child. An A1C test, fasting blood glucose test, or both

may be used to screen for type 2 diabetes. Children not meeting the criteria who have health conditions related to type 2 diabetes may also be screened.

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Whatever healthy eating and activity changes the children are expected to make,

What Parents Should Know

restricted foods more—for instance, candy rather

Children learn habits, both good and bad, from

than fruit. However, if fruit is regularly offered

their parents. This is true for eating and physical

in place of dessert, and then at some meals

activity as well as social and other behaviors. So it’s

everyone in the family is offered a small portion of

important for parents to understand they are role

a dessert, it can take away the feeling that sweets

models and that “do as I say but not as I do” is not

are totally off limits. By offering a small amount

effective for children’s behavior change. Whatever

of sweets occasionally, it won’t seem like such a

healthy eating and activity changes the children

big deal when they are available away from home.

are expected to make, parents need to commit to

As a result, children may be less likely to overeat

making the same changes.

these foods. Snacks play an important role in meeting

Registered dietitian nutritionist (RDN) and child

parents need to

feeding specialist Ellyn Satter provides guidance

children’s nutrition needs and should be included

commit to making the

for parents on child and family eating behaviors.

even if a child is overweight. Eating an after-school

A key principle of her guidelines is the division

snack may help prevent overeating at dinner.

of responsibility for feeding between parents and

Encourage parents to have nutritious snacks

children. For parents of toddlers up to teenagers,

available and then allow the children to choose

she shares the following:

between them. For instance, instead of asking

same changes.

■

■

The parent is responsible for what, when, and

“Would you like an orange?,” ask “Would you rather

where the children eat.

have an orange or a [light] yogurt for a snack?” Snack ideas for school-age children with

The child is responsible for how much and whether to eat. Satter is also a proponent that given the right

opportunities and without too much interference, a child will eat the amount they need. Furthermore, it’s the child’s responsibility to learn to eat the same foods eaten by the rest of the family and behave appropriately during meals. In other words, the

type 2 diabetes are shown below. Each contains approximately 15 g of carbohydrate (1 carbohydrate choice). ■

small apple and 1 tablespoon peanut butter

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4 oz sugar-free pudding cup

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2 small plums and 1 oz string cheese

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turkey roll-up: 1 to 2 slices of turkey on a 6-inch tortilla with lettuce and a dab of light

parents prepare and offer healthy food choices,

mayonnaise or mustard

but the child has the final say in whether they eat those foods. Consistently offering healthful foods,

■

low-fat cottage cheese

even if a child isn’t currently choosing them, is the key for parents. A child may choose not to eat broccoli the first 4 times it’s offered, but if parents continue to offer, eat, and enjoy broccoli,

■

3 cups air-popped or light microwave popcorn

■

6 oz light yogurt

■

hardboiled egg with 8 whole-grain crackers (check the label for carbohydrate content)

eventually the child will follow their lead. Strategies that attempt to force a child to eat, such as making a child sit at the table until all of the vegetables are eaten, don’t work. Some may feel that children diagnosed with type 2 diabetes shouldn’t choose how much and what foods they eat. However, if “bad foods” are overly restricted, it can also cause the opposite of the desired effect. Children may tend to want the

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single-serving fruit cup with one-quarter cup

■

1 cup vegetable soup

■

sugar snap peas and baby carrots (or any nonstarchy vegetables) with 2 tablespoons hummus and 6 whole-grain crackers (check the label for carbohydrate content).

In addition to deciding what foods to offer and

Parents should be encouraged to offer scheduled meal times and snack times. Not having

when to offer them, where snacks can be eaten is

a schedule can lead to over- or undereating at

also be a factor. Snacking in front of the television,

meals. For instance, having a snack right after

in the child’s bedroom, or while playing games

school is an ideal time; however, having a snack 15

on the computer may lead to overeating. To help

minutes before dinner is not.

the child avoid distractions and focus on the

It’s important for both the parents and children

enjoyment of food, eating in the kitchen or dining

to know and understand when snack times and

room is recommended. Meals should be eaten

mealtimes are. If children choose not to eat what’s

while sitting at the table. The television, mobile

offered at snack time or mealtime, that’s okay.

devices, and cell phones should be turned off. The 5-4-3-2-1 Go! guidelines can help parents

However, it’s important to not offer other foods or beverages, other than water, in place of what

create a healthy home environment. Here are

they chose not to eat. If a child takes insulin, the

some teaching tips to help parents meet the

mealtime insulin can be given immediately after

guidelines:

the meal based on actual carbohydrate intake. If

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Discuss the importance of having plenty of

the child doesn’t eat, the mealtime insulin would

nonstarchy vegetables available and ready to

not be given (to help prevent hypoglycemia). A

eat. Let parents know it’s okay for children to

carbohydrate source, such as juice or glucose

add nonstarchy vegetables to any snack or meal

tablets, should always be available should the child experience low blood glucose. Regular blood glucose monitoring is important.

when children are still hungry after eating. ■

Promote keeping fruit on hand for snacks in place of sweets or chips. This ensures children are getting fiber, vitamins, and other nutrients instead of “empty calories.”

5-4-3-2-1 GO!

The Consortium to Lower Obesity in Chicago Children came up with this memorable lifestyle message for children and families. ➜ 5 servings of fruits and vegetables a day ➜ 4 servings of water a day ➜ 3 servings of low-fat dairy a day ➜ 2 or less hours of screen time a day (includes computer, television, and video games) ➜ 1 or more hours of physical activity a day

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■

Explain that sugar-sweetened beverages (soda,

■

lemonade, sports drinks, fruit punch, etc) add

on reading, drawing, or using the computer for

extra calories—up to 400 calories a day for children—and carbohydrates. It’s best to skip

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■

Encourage setting limits on screen time but not homework.

■

Explore opportunities for parents to be active

them altogether. Juice should be limited to 6

with their children. Examples are walking the

oz per day, and low-fat or nonfat milk or water

dog, having a family “dance off” to see who has

should be offered with meals.

the best dance moves, and going to the park.

Remind parents that they can choose to leave the empty-calorie snack foods out of the pantry.

Key Teaching Point

If they choose to include them, do so less often

Encourage parents to be patient. Children actually

and in smaller portions. If cost is not an issue,

thrive on structure, but if parents haven’t previously

consider portion-controlled packaging.

established routines, change doesn’t happen

Recommend that televisions stay out of

immediately. Have the discussion with parents that

children’s bedrooms. This is also a good idea for

it will take time, but with consistency, the whole

tablets, laptops, and handheld games.

family can be active and eat more healthfully together. Q Carrie S. Swift, MS, RD, BC-ADM, CDE, is a certified diabetes educator at Kadlec Medical Center in Richland, WA. She is the author of Idiot’s Guides: Overcoming Type 2 Diabetes.

REFERENCES

Overview of diabetes in children and adolescents. http:// ndep.nih.gov/media/Overview-of-Diabetes-Children-508_ 2014.pdf. Accessed October 20, 2015. About child and teen BMI. http://www.cdc.gov/healthyweight/ assessing/bmi/childrens_bmi/about_childrens_bmi.html. Accessed October 19, 2015. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2015;38(suppl 1):S1-S2. Ellyn Satter’s division of responsibility in feeding. http:// ellynsatterinstitute.org/cms-assets/documents/203702180136.dor-2015-2.pdf. Accessed October 20, 2015. Consortium to Lower Obesity in Chicago Children. 54321Go! http://www.clocc.net/our-focus-areas/ health-promotion-and-public-education/. Accessed October 20, 2015.

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