Abstract
BACKGROUND
Medical nutrition therapy (MNT) has an integral role in overall diabetes management. During adolescence, consideration of physiological and psychosocial changes is essential for implementing an optimal diabetes treatment.
OBJECTIVES
Our aim was to identify, summarize, and interpret the published literature about MNT in adolescents with type 1 diabetes.
METHODS
The Medline (PubMed) and EMBASE databases were searched from January 1959 to December 2021. The inclusion criteria were interventional studies with MNT in adolescents with type 1 diabetes with a disease duration over 1 year, including the following outcomes: dietary intake and daily eating patterns (assessed with validated tools, two or more 24 h dietary recall or 3-day dietary records), the diabetes self-management education and support (DSMES), glycemic control, lipid profile and body mass index (BMI). The exclusion criteria were studies without a control group (except for pre-post studies), the lack of randomization and those studies that assessed only a single nutrient, food or meal consumption, as well as reviews, and in-vitro/in-vivo studies. The risk of bias assessment was performed using the Cochrane risk-of-bias tool for randomized trials. A narrative synthesis was performed to present the results. The quality of evidence was assessed with the GRADE guidance.
RESULTS
From a total of 5377 records, 12 intervention studies (9 RCT and 3 pre-post intervention studies) were included. The data were assessed in order to perform a meta-analysis; however, the studies were too heterogeneous. The studies showed conflicting results about the effectiveness of MNT on dietary pattern, DSMES, glycemic control, lipid profile and BMI.
CONCLUSIONS
Clinical research studies on the effectiveness of MNT in adolescents with type 1 diabetes are scarce. The limited number of studies with a high risk of bias precludes establishing robust conclusions on this issue. Further research is warranted.
Similar content being viewed by others
Introduction
The American Diabetes Association (ADA) defines that lifestyle management is a cornerstone of diabetes care and includes diabetes self-management education and support (DSMES), medical nutrition therapy (MNT), physical activity, smoking cessation counseling, and psychosocial care [1]. For people with type 1 diabetes, MNT is a key point in the management of the disease and is also a component of DSMES. Carbohydrate counting and insulin management are mainly targeted to enable people with type 1 diabetes to self-manage the disease [2, 3]; furthermore, education about how to use fat and protein content to determine insulin dosing is recommended to improve glycemic control [2]. In addition, nutritional recommendations based on healthy dietary habits are included in the MNT of people with diabetes [4]. Nutrition therapy has an integral role in overall diabetes management, and people with diabetes should be actively engaged in education, self-management, and treatment planning with the healthcare team [1].
During adolescence, attention to family dynamics, developmental stages, and physiological changes related with sexual maturity are essential for implementing an optimal diabetes treatment [2]. Moreover, diabetes distress has been shown to be positively associated with disordered eating in adolescents with type 1 diabetes [5]. In addition, a poor adherence to nutritional recommendations has been observed in children and adolescents with type 1 diabetes [6]. Having a robust evidence-base regarding the effectiveness of MNT is important to inform healthcare professionals. The Academy of Nutrition and Dietetics published a systematic review to assess the effectiveness of MNT in adults with type 1 and type 2 diabetes so that healthcare professionals are knowledgeable about MNT for people with both types of diabetes [7, 8]. However, to our knowledge, a systematic review to assess the effectiveness of MNT in adolescents with type 1 diabetes has so far not been performed. Adolescents with type 1 diabetes have particular challenges: attention to family dynamics, developmental stages, and physiological changes related with sexual maturity are essential for implementing an optimal diabetes treatment [2]. Moreover, diabetes distress has been shown to be positively associated with disordered eating in adolescents with type 1 diabetes [5]. Furthermore, poor adherence to the nutritional recommendations has been observed in children and adolescents with type 1 diabetes. For this reason, in this systematic review, we aimed to identify, summarize, and interpret the published literature about MNT of adolescents with type 1 diabetes.
Materials and methods
This systematic review followed the Preferred Reported Items for Systematic Review and Meta-analysis (PRISMA) checklist [9]. The protocol was registered with PROSPERO in April 2020 (ID: CRD42020162314).
Search strategy
A systematic review was performed using the MEDLINE (PubMed) and EMBASE databases searched with a date range from January 1959 to December 2021. We included all published studies in peer-reviewed journals in the English language. The search strategy is available in Table S1. Mesh terms were included.
Eligibility criteria
Studies were included in the systematic review if the study participants fulfilled the predefined inclusion criteria: studies that performed an intervention with MNT in adolescents diagnosed with type 1 diabetes with a disease duration of more than 1 year; adolescence was defined by the researchers of the included studies. Moreover, studies were included if the main outcomes were as follows: the dietary intake, which referred to the daily eating patterns of an individual (including specific foods, nutrients and calories consumed and relative quantities), estimated using validated food frequency questionnaires, two or more 24 h (h) dietary recall and a 3-day dietary record, at a minimum; the dietary pattern, which referred to the distribution and selection of daily food intake, estimated with validated quality dietary indexes; the DSMES including knowledge, skills, and abilities necessary for optimal diabetes self-care, incorporating the needs, goals, and life experiences of the person with diabetes; glycemic control including hypoglycemia and hyperglycemia defined according to the international consensus report; lipid profile and body mass index (BMI) [10].
Study selection
Eligible study designs were randomized controlled trials (RCT), post-hoc analysis of interventional studies and pre-post interventional studies. Exclusion criteria were as follows: interventional studies without a control group, except for pre-post interventional studies; lack of randomization in controlled trials; studies that only assessed a single nutrient or consumption of a specific food or meal; the use of non-validated instruments, or the use of only one 24 h dietary recall to estimate dietary intake. Furthermore, the following types of articles were also excluded: reviews; studies performed with animals and in-vitro/in-vivo studies; studies without a defined outcome and papers with insufficient data to establish conclusions.
Data extraction and risk of bias assessment
The selection of the studies was performed by three individual researchers. Studies were found to be eligible when two of the independent researchers agreed with the inclusion decision according to the inclusion and exclusion criteria. Nevertheless, in case of a discordant decision, this was discussed with a third researcher including a common thorough revision of inclusion/exclusion criteria of the systematic review. Data extraction was performed by a single researcher and checked by a second researcher; this included the following set of variables: first author’s surname, year of publication, journal, study design, country, sample size, study sample characteristics, age of participants, dietary assessment including instruments used, statistical methods and adjustment for potential confounders. Effect estimates from included studies was extracted to obtain data in terms of risk ratios (with 95% confidence intervals [CIs]) for dichotomous outcomes, and mean differences (with 95% CIs) for continuous outcomes. Disagreements were resolved by discussion with the corresponding author (DM).
The risk of bias assessment of the RCT was performed using the Cochrane risk-of-bias tool for randomized trials [11]. This tool classifies RCT according to the following domains: the randomization process, intended interventions, missing outcome data, measurement of the outcome and the selection of the reported results. RCT were considered to have a low risk of bias, uncertain and high risk [12]. In addition, non-randomized studies were assessed using the Risk of Bias in Non-Randomized Studies - of Interventions tool (ROBINS-I tool) [13]. This tool classifies the studies according to seven domains as follows: confounding, selection of participants into the study, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes and selection of the reported results. The studies were classified according to the risk of bias as follows: low risk (the study was comparable with a well-performed randomized trial), moderate (the study provided sound evidence for a non-randomized study but could not be considered comparable with a well-performed randomized trial), serious risk (the study had some important problems), critical risk (the study was too problematic to provide any useful evidence and should not be included in the systematic review), and no information [14].
Data synthesis
A summary table with the data extraction was performed including the risk of bias. Data analysis was performed with a sensibility analysis of the results taking into account the study design, and the risk of bias. A narrative synthesis of the findings of the review was performed according to the outcomes of interest. According to the GRADE guidance [15], the quality of evidence for primary outcomes was assessed as an expression of the confidence in the effect estimates obtained in the review through the assessment of risk of bias, directness of evidence, heterogeneity and precision of effect estimates.
Results
A total of 5377 records were identified from the two databases search. Following the eligibility criteria, a total of 23 references reporting on 12 different studies were included in the systematic review. From these, 9 were RCT [16,17,18,19,20,21,22,23,24], 11 were post-hoc studies from these RCT [25,26,27,28,29,30,31,32,33,34,35], and 3 were pre-post intervention studies [36,37,38]. The PRISMA flow chart is provided in Fig. 1.
Risk of bias of the included studies
A summary of the studies included in the systematic review is detailed in Table 1. A total of six randomized trials and the pre-post intervention studies showed a high risk of bias, while the other three RCT had uncertain risk. The details of the risk of bias assessment are described in Tables S2 and S3. Furthermore, a summary of included studies and their published reports is described in Table S4. The data were assessed in order to perform a meta-analysis; however, the studies were too heterogenous in terms of study duration, intervention type and the reported outcomes.
Effect of medical nutrition therapy on the dietary intake and diabetes self-management education
Studies that assessed the effectiveness of MNT for improving dietary pattern and DSMES are detailed in Table 2. A total of five RCT, six post-hoc from RCT and three pre-post intervention studies assessed these interventions. A RCT performed in Poland with a sample of 151 adolescents with type 1 diabetes found that an educative intervention with multimedia methods based on the ADA recommendations improved the nutrition knowledge and the dietary quality index of the participants [16]. Nansel et al. [17] demonstrated that a family-based behavioral intervention to increase whole plant food intake during an 18-month period increased the adherence to a healthy eating pattern in adolescents with type 1 diabetes compared to usual care (i.e., no dietary advice). Dietary resemblance (i.e., the diet of the child resembles the diet of the parent) was stronger in the intervention group for the outcome of whole plant food density (WPFD) [26], while an intervention effect on diet quality was only positive for a subgroup of picky eaters [28].
A pilot-study performed with a small sample of adolescents (N = 17) showed that an intervention with an optimized-mixed diet for 3 months (based on five meals per day with more than 50% of whole grain and low consumption of sweetened beverages) reduced protein intake [20]. Moreover, an intervention with a flexible low-glycemic diet (based on a list of avoid food consumption with low-glycemic index, free meals, whole grains and a poor consumption of beverages) reduced the carbohydrate intake [20]; however, the researchers did not find differences between both groups of intervention in terms of nutrient intake and Nutritional Quality Index. On the other hand, Hackett et al. [24] did not find changes in the dietary intake of adolescents and children that received a MNT based on the ADA nutritional recommendations. Moreover, Gilbertson et al. [35] did not find differences in reported nutrient intake between an intervention based on a low-glycemic index (low-GI) diet and a traditional carbohydrate-exchange diet.
In a pre-post intervention study, an intervention based on carbohydrate counting with nutritional recommendations by ADA was associated with an increase in carbohydrate intake and a reduced total fat and protein intake from baseline to 18-months of follow-up [36]. Moreover, MNT also based on the ADA nutritional recommendations, reduced the total fat and cholesterol intake, and increased the fiber consumption of adolescents in a 6-month pre-post intervention study [37]. In addition, Lorini et al. [38] observed a reduction of energy intake, total fat, polyunsaturated and saturated fatty acids, and an increased intake of carbohydrate and fiber after an intensive MNT based on nutritional guidelines for the general population.
In terms of DSMES, a post-hoc analyses of a RCT performed to assess the relationship between parent attitudes and youth diet quality, described no effect of the intervention on parent attitudes or beliefs [30]; however, a higher parent self-efficacy and autonomous motivation were positively associated with those youth with a higher adherence to a WPFD diet. Furthermore, a secondary data analysis from this RCT found that a behavioral intervention to improve dietary quality did not increase disordered eating behaviors in adolescents [29]; nevertheless, a greater adherence to diabetes self-management was associated with lower diabetes eating problems in adolescents with type 1 diabetes [29].
Effect of medical nutrition therapy on glycemic control
The characteristics of the studies that reported the effect of a dietary intervention on glycemic control in adolescents with type 1 diabetes are shown in Table 3. Dłużniak-Gołaska et al. [16] found a significant reduction in glycated hemoglobin (HbA1c) concentrations after 3 months of treatment with educational materials plus interactive methods compared to a control group with educational methods alone. However, HbA1c was not reduced after 6 months from treatment initiation even though the dose of insulin was increased in the intervention group [16]. Hackett et al. [24] found an improved glycemic control in adolescents over age 11 years after MNT based on nutritional recommendations established in 1989. A RCT performed to assess the effect of an intervention with a WPFD did not find differences in HbA1c between the intervention and control groups [17]; however, a post-hoc analysis of this RCT described that an optimal glycemic control was associated with a healthier eating pattern (measured with the Healthy Eating Index-2005) and a higher adherence to a WPFD diet [34]. In addition, a RCT and a pre-post interventional study with MNT based on carbohydrate counting found a positive effect on the glycemic control of adolescents with type 1 diabetes [18, 36]; however, the dose of insulin was not modified with the intervention. A RCT performed to compare a traditional carbohydrate-exchange diet with a low-GI diet found a slight improvement of HbA1c with the carbohydrate-exchange diet [21]. On the other hand, Cadario et al. [37] did not find changes in glycemic control of the study participants even though an increased dose of insulin was observed with a nutritional intervention based on the ADA recommendations. Furthermore, the other studies did not observe any effect of dietary intervention on glycemic control in adolescents with type 1 diabetes [19, 20, 22, 38].
Effect of medical nutrition therapy on lipid profile and body mass index
The effectiveness of MNT on cardiovascular risk factors, i.e., BMI and lipid profile, in adolescents with type 1 diabetes is shown in Table 4. Only two RCT with their post-hoc studies and one pre-post intervention study assessed this issue [16, 18, 27, 32, 38]. Dłużniak-Gołaska et al. [16] found that trial participants had an increased BMI in both the control group (education alone) and intervention groups (education with an interactive intervention with multimedia applications) after 6 months from treatment initiation; no between-group differences were observed. On the other hand, a post-hoc analyses from a randomized controlled behavioral nutrition intervention trial to assess the associations of BMI and body composition with cardiovascular risk factors did not find an intervention effect on cardiovascular risk factors after 18 months from treatment initiation [32].
In terms of lipid profile, a post-hoc analyses from an RCT designed to examine the association of cardiovascular biomarkers with dietary quality diet observed that a healthy eating pattern was not associated with lipid profile [27]. However, the intake of whole grain was inversely related with total cholesterol and high-density lipoprotein (HDL) cholesterol; moreover, added sugars and saturated fat were positively associated with triglycerides and HDL cholesterol, respectively [27]. On the other hand, a RCT to assess the effect of carbohydrate counting on serum lipid levels did not find differences between the intervention and control group during 2 years of follow-up [18]; nevertheless, HDL cholesterol was higher in the carbohydrate counting group during the study follow-up. Finally, Lorini et al. [38] found a reduction of HDL and LDL cholesterol levels after 3 months of intensive MNT in a pre-post intervention study.
Discussion
Only 12 interventional studies were identified in this systematic review, demonstrating the paucity of evidence about the effectiveness of MNT in adolescents with type 1 diabetes. In addition, the included studies had a small sample size and a high risk of bias, further contributing to a lack of a robust evidence base. Furthermore, results could not be meta-analyzed because the study methods, i.e., duration of the study, intervention type and data, were not comparable. In addition, this review included a number of post-hoc analysis and publications derived of a single trial [17].
According to this review, an intervention with MNT based on carbohydrate counting as well as with multimedia methods, whole plant food intake or nutritional recommendations, has a positive impact on the dietary pattern of the adolescents with type 1 diabetes. These benefits on dietary intake were shown as a reduction of total fat and protein intake, an increased adherence to a healthy eating pattern, a higher parent-child WPFD diet, and a high intake of fiber. However, inconsistent results in carbohydrate intake were reported, with some studies observing an increased carbohydrate intake with standard nutritional recommendations, whereas others found a reduced carbohydrate intake with an intervention based on a low-GI diet [20, 36, 38]. These contradictory results could be due to different study methods, type of interventions and duration of the study. Moreover, there may have been differences in the study participants, while even the fact of participating in an RCT can impact on the lifestyle of the study participants, changing their dietary habits and daily routines to different extents. Overall, there was a lack of robust evidence about the effects of MNT on dietary patterns. This is in line with a recent systematic review that reported a lack of evidence to assess the effectiveness of technology-based interventions on dietary habits in children and young people with type 1 diabetes [39].
In terms of DSMES, only two post-hoc analyses from a RCT addressed this issue [29, 30]. The authors found that a higher adherence to a WPFD diet was associated with a higher parent self-efficacy and motivation [30]. Furthermore, adolescents with a healthy eating diet showed a lower presence of disordered eating behaviors. A cross-sectional study found that disordered eating behaviors were associated with a poorer diet quality in adolescents with type 1 diabetes [40]. Of note, another cross-sectional study observed that adolescents with a diabetes duration of 5 years or more had less diabetes care activities compared with individuals with shorter diabetes duration [41]. A review performed to assess the effects of carbohydrate-restricted diets in youth with type 1 diabetes described that the relationship between carbohydrate counting therapies and quality of life had still not been adequately assessed among youth with type 1 diabetes [42]. However, this review suggested that restrictive dietary practices may be related with the presence of disordered eating behaviors in adolescents with type 1 diabetes [42]. A systematic review performed to assess the relationship between psychological factors and diabetes self-management observed that a greater adherence to the diet had stronger effects on cognitive and emotional variables [43]; these included greater motivation, dietary self-efficacy, perceived support for autonomy and from family, and stronger beliefs with the effectiveness of behavior for diabetes and complications. In addition, diabetes-specific disordered eating behaviors are more frequent in girls in comparison with boys [44, 45]. Insulin under-dosing, intentional vomiting, feeling of losing control over food, a short-term weight loss (over 6 kg), and body dissatisfaction are disordered eating behaviors that have been reported to be associated with type 1 diabetes in adolescents and youth [46,47,48].
This systematic review shows different results regarding MNT and glycemic control. Few RCT demonstrated that a dietary intervention based on standard nutritional recommendations or healthy dietary pattern improved glycemic control in adolescents with type 1 diabetes without changes in insulin dose. However, other clinical trials did not find any effect of the dietary intervention on glycemic control. According to the published evidence, adolescents with type 1 diabetes who did not meet nutritional guidelines showed a poorer glycemic control due to a lower adherence to nutritional recommendations [49]. The Diabetes Control and Complications Trial observed that low adherence to a healthy eating regimen was associated with a poorer glycemic control and higher insulin dose in adults and youths with type 1 diabetes [50]. Furthermore, a cross-sectional study performed with adults and adolescents with type 1 diabetes observed that those participants with a higher adherence to the prescribed diet had an optimal glycemic control in comparison with a low-adherence group [51]. Maffeis et al. [52] observed a positive relationship between a saturated fatty acid-rich intake and a poorer glycemic control in adolescents with type 1 diabetes. Moreover, a retrospective longitudinal study performed to compare glycemic control and lipid profile of children and adolescents undergoing a carbohydrate-counting treatment with a dietary counseling based on caloric distribution of food, found an improvement of HbA1c with carbohydrate-counting diet [53]. According to the ADA recommendations, adolescents with type 1 diabetes should have a DSMES including MNT as part of diabetes care, with a physical activity program in addition of insulin therapy [2]. For this reason, the effectiveness of MNT on glycemic control and insulin dose of individuals with type 1 diabetes should be focused on overall lifestyle interventions, including physical activity.
Finally, only a few results have been published about MNT and cardiovascular risk factors such as BMI and lipid profile in adolescents with type 1 diabetes. In this review, results of the interventional studies are contradictory. A RCT demonstrated that a WPFD diet was not associated with BMI [32]; however, Dłużniak-Gołaska et al. [16] found that an interactive intervention was associated with an increased BMI. Furthermore, a WPFD diet was related to a lower total and HDL cholesterol [27]. Nevertheless, other clinical trials did not find any association between a dietary intervention and BMI or lipid profile [18, 38]. Dalsgaard et al. [53] did not observe significant changes in the lipid profile of the adolescents with type 1 diabetes with a carbohydrate-counting diet. However, in a cross-sectional study performed with adolescent-onset individuals with type 1 diabetes in Japan, a poorer lipid profile was associated with western dietary habits [54].
This systematic review provides an overview of the effectiveness of MNT in adolescents with type 1 diabetes. However, the search strategy did not include other databases apart from PubMed. This is the first review performed to assess whether MNT influences in the dietary pattern, diabetes self-management, glycemic control and cardiovascular risk factors. The methodology of this review following the Cochrane guidelines allows a critical assessment of the current scientific evidence. Moreover, the included studies with different target groups and interventions, with high and uncertain risk of bias should be considered as a weakness. For this reason, these findings could not be meta-analyzed. Finally, studies included in this review were only focused on dietary interventions without taking into account physical activity; thus, final conclusions could not be made about the potential effect of MNT as part of an integrated DSMES strategy.
In conclusion, few studies have demonstrated the potential effectiveness of MNT in adolescents with type 1 diabetes. Furthermore, these limited number of studies had a high risk of bias, precluding conclusions on this issue. Further research is needed to determine the effectiveness of MNT. In addition to MNT, physical activity should be included in future study interventions, which are two key components of the DSMES.
References
American Diabetes Association. 5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43:S48–S65.
American Diabetes Association. 13. Children and Adolescents: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43:S163–S182.
Tascini G, Berioli MG, Cerquiglini L, Santi E, Mancini G, Rogari F, et al. Carbohydrate counting in children and adolescents with type 1 diabetes. Nutrients. 2018;10:1–11.
American Diabetes Association. 5. Lifestyle Management: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42:S46–S60.
Araia E, King RM, Pouwer F, Speight J, Hendrieckx C. Psychological correlates of disordered eating in youth with type 1 diabetes: Results from diabetes MILES Youth—Australia. Pediatr Diabetes. 2020;21:664–72.
Nansel TR, Haynie DL, Lipsky LM, Laffel LMB, Mehta SN. Multiple indicators of poor diet quality in children and adolescents with type 1 diabetes are associated with higher body mass index percentile but not glycemic control. J Acad Nutr Diet. 2012;112:1728–35.
Franz MJ, MacLeod J, Evert A, Brown C, Gradwell E, Handu D, et al. Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet. 2017;117:1659–79.
MacLeod J, Franz MJ, Handu D, Gradwell E, Brown C, Evert A, et al. Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: nutrition intervention evidence reviews and recommendations. J Acad Nutr Diet. 2017;117:1637–58.
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372. https://doi.org/10.1136/BMJ.N71.
Agiostratidou G, Anhalt H, Ball D, Blonde L, Gourgari E, Harriman KN, et al. Standardizing clinically meaningful outcome measures beyond HbA1c for type 1 diabetes: a consensus report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endo. Diabetes Care. 2017;40:1622–30.
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. (eds.). Cochrane Handbook for Systematic Reviews of Interventions. 2nd ed. Chichester (UK): John Wiley & Sons; 2019 https://doi.org/10.1002/9781119536604.
Higgins P, Savovic H, Page M, Sterne J. Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) short version (CRIBSHEET). RoB 2.o Dev Gr. 2019. www.riskofbias.info (accessed 23 Jan 2020).
Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.
Sterne J, Hernán M, Reeves B, Savović J, Berkman N, Viswanathan M, et al. Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I): detailed guidance. 2016. http://www.riskofbias.info (accessed 23 Jan 2020).
Schünemann H, BroZek J, Guyatt G, Oxman A. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. 2013. https://gdt.gradepro.org/app/handbook/handbook.html.
Dłużniak-Gołaska K, Panczyk M, Szypowska A, Sińska B, Szostak-Węgierek D. Interactive nutrition education is more effective in terms of improved levels of glycated hemoglobin in adolescent patients with poorly controlled type 1 diabetes – A randomized study. Diabetes Metab Syndr Obes Targets Ther. 2019;12:2619–31.
Nansel TR, Laffel LMB, Haynie DL, Mehta SN, Lipsky LM, Volkening LK, et al. Improving dietary quality in youth with type 1 diabetes: Randomized clinical trial of a family-based behavioral intervention. Int J Behav Nutr Phys Act. 2015;12:1–11.
Gökşen D, Altinok YA, Özen S, Demir G, Darcan Ş. Effects of carbohydrate counting method on metabolic control in children with type 1 diabetes mellitus. J Clin Res Pediatr Endocrinol. 2014;6:74–8.
Spiegel G, Bortsov A, Bishop FK, Owen D, Klingensmith GJ, Mayer-Davis EJ, et al. Randomized Nutrition Education Intervention to Improve Carbohydrate Counting in Adolescents with Type 1 Diabetes Study: Is More Intensive Education Needed? J Acad Nutr Diet. 2012;112:1736–46.
Marquard J, Stahl A, Lerch C, Wolters M, Grotzke-Leweling M, Mayatepek E, et al. A prospective clinical pilot-trial comparing the effect of an optimized mixed diet versus a flexible low-glycemic index diet on nutrient intake and HbA1c levels in children with type 1 diabetes. J Pediatr Endocrinol Metab. 2011;24:441–7.
Gilbertson HR, Evans S, Brand-Miller JC, Chondros P, Thorburn AW, Werther GA. The Effect of Flexible Low Glycemic Diets on Glycemic Control in Children With Type 1 Diabetes. Diabetes Care. 2001;24:1137–43.
Donaghue KC, Pena MM, Chan AKF, Blades BL, King J, Storlien LH, et al. Beneficial effects of increasing monounsaturated fat intake in adolescents with type 1 diabetes. Diabetes Res Clin Pr. 2000;48:193–9.
Pichert JW, Smeltzer C, Snyder GM, Gregory RP, Smeltzer R, Kinzer CK. Traditional vs Anchored Instruction for Diabetes-Related Nutritional Knowledge, Skills, and Behavior. Diabetes Educ. 1994;20:45–8.
Hackett AF, Court S, Matthews JNS, McCowen C, Parkin JM. Do education groups help diabetics and their parents? Arch Dis Child. 1989;64:977–1003.
Sanjeevi N, Lipsky L, Liu A, Nansel T. Differential reporting of fruit and vegetable intake among youth in a randomized controlled trial of a behavioral nutrition intervention. Int J Behav Nutr Phys Act. 2019;16:1–8.
Lipsky LM, Haynie DL, Liu A, Nansel TR. Resemblance of Diet Quality in Families of Youth with Type 1 Diabetes Participating in a Randomized Controlled Behavioral Nutrition Intervention Trial in Boston, MA (2010–2013): a secondary data analysis. J Acad Nutr Diet. 2019;119:98–105.
Sanjeevi N, Lipsky LM, Nansel TR. Cardiovascular biomarkers in association with dietary intake in a longitudinal study of youth with type 1 diabetes. Nutrients. 2018;10:1–12.
Nansel TR, Lipsky LM, Haynie DL, Eisenberg MH, Dempster K, Liu A. Picky Eaters Improved Diet Quality in a Randomized Behavioral Intervention Trial in Youth with Type 1 Diabetes. J Acad Nutr Diet. 2018;118:308–16.
Eisenberg-Colman MH, Quick VM, Lipsky LM, Dempster KW, Liu A, Laffel LMB, et al. Disordered eating behaviors are not increased by an intervention to improve diet quality but are associated with poorer glycemic control among youth with type 1 diabetes. Diabetes Care. 2018;41:869–75.
Eisenberg MH, Lipsky LM, Gee B, Liu A, Nansel TR. Parent healthful eating attitudes and motivation are prospectively associated with dietary quality among youth with type 1 diabetes. Vulnerable Child Youth Stud. 2017;12:226–40.
Nansel TR, Lipsky LM, Eisenberg MH, Liu A, Mehta SN, Laffel LMB. Can Families Eat Better Without Spending More? Improving Diet Quality Does Not Increase Diet Cost in a Randomized Clinical Trial among Youth with Type 1 Diabetes and Their Parents. J Acad Nutr Diet. 2016;116:1751–9.e1.
Lipsky LM, Gee B, Liu A, Nansel TR. Body mass index and adiposity indicators associated with cardiovascular biomarkers in youth with type 1 diabetes followed prospectively. Pediatr Obes. 2017;12:468–76.
Lipsky LM, Gee B, Liu A, Nansel TR. Glycemic control and variability in association with body mass index and body composition over 18 months in youth with type 1 diabetes. Diabetes Res Clin Pr. 2016;120:97–103.
Nansel TR, Lipsky LM, Liu A. Greater diet quality is associated with more optimal glycemic control in a longitudinal study of youth with type 1 diabetes. Am J Clin Nutr. 2016;104:81–7.
Gilbertson HR, Thorburn AW, Brand-Miller JC, Chondros P, Werther GA. Effect of low-glycemic-index dietary advice on dietary quality and food choice in children with type 1 diabetes. Am J Clin Nutr. 2003;77:83–90.
Marigliano M, Morandi A, Maschio M, Sabbion A, Contreas G, Tomasselli F, et al. Nutritional education and carbohydrate counting in children with type 1 diabetes treated with continuous subcutaneous insulin infusion: The effects on dietary habits, body composition and glycometabolic control. Acta Diabetol. 2013;50:959–64.
Cadario F, Prodam F, Pasqualicchio S, Bellone S, Bonsignori I, Demarchi I, et al. Lipid profile and nutritional intake in children and adolescents with Type 1 diabetes improve after a structured dietician training to a Mediterranean-style diet. J Endocrinol Investig. 2012;35:160–8.
Lorini R, Ciriaco O, Salvatoni A, Livieri C, Larizza D, D’Annunzio G. The influence of dietary education in diabetic children. Diabetes Res Clin Pr. 1990;9:279–85.
Knox ECL, Quirk H, Glazebrook C, Randell T, Blake H. Impact of technology-based interventions for children and young people with type 1 diabetes on key diabetes self-management behaviours and prerequisites: a systematic review. BMC Endocr Disord. 2019;19:1–14.
Nansel TR, Tse J, Haynie DL, Mehta SN, Laffel LMB. Disordered Eating Behaviors Are Associated with Poorer Diet Quality in Adolescents with Type 1 Diabetes. J Acad Nutr Diet. 2012;112:1810–4.
Chao A, Whittemore R, Minges KE, Murphy KM, Grey M. Self-Management in Early Adolescence and Differences by Age at Diagnosis and Duration of Type 1 Diabetes. Diabetes Educ. 2014;40:167–77.
Gallagher KAS, DeSalvo D, Gregory J, Hilliard ME. Medical and Psychological Considerations for Carbohydrate-Restricted Diets in Youth With Type 1 Diabetes. Curr Diab Rep. 2019;19:1–8.
Martinez K, Frazer SF, Dempster M, Hamill A, Fleming H, McCorry NK. Psychological factors associated with diabetes self-management among adolescents with Type 1 diabetes: A systematic review. J Health Psychol 2018;23:1749–65.
Baechle C, Hoyer A, Stahl-Pehe A, Castillo K, Toennies T, Lindner LME, et al. Course of Disordered Eating Behavior in Young People With Early-Onset Type I Diabetes: Prevalence, Symptoms, and Transition Probabilities. J Adolesc Heal. 2019;65:681–9.
Baechle C, Castillo K, Straßburger K, Stahl-Pehe A, Meissner T, Holl RW, et al. Is disordered eating behavior more prevalent in adolescents with early-onset type 1 diabetes than in their representative peers? Int J Eat Disord. 2014;47:342–52.
Cecilia-Costa R, Volkening LK, Laffel LM. Factors associated with disordered eating behaviours in adolescents with Type 1 diabetes. Diabet Med. 2019;36:1020–7.
Troncone A, Cascella C, Chianese A, Zanfardino A, Piscopo A, Borriello A, et al. Body Image Problems and Disordered Eating Behaviors in Italian Adolescents With and Without Type 1 Diabetes: An Examination With a Gender-Specific Body Image Measure. Front Psychol. 2020;11. https://doi.org/10.3389/FPSYG.2020.556520.
Young V, Eiser C, Johnson B, Brierley S, Epton T, Elliott J, et al. Eating problems in adolescents with Type1 diabetes: a systematic review with meta-analysis. Diabet Med. 2013;30:189–98.
Mackey ER, O’Brecht L, Holmes CS, Jacobs M, Streisand R. Teens with Type 1 diabetes: how does their nutrition measure up? J Diabetes Res. 2018;2018:5094569.
Delahanty LM, Nathan DM, Lachin JM, Hu FB, Cleary PA, Ziegler GK, et al. Association of diet with glycated hemoglobin during intensive treatment of type 1 diabetes in the Diabetes Control and Complications Trial. Am J Clin Nutr. 2009;89:518–24.
Davison KAK, Negrato CA, Cobas R, Matheus A, Tannus L, Palma CS, et al. Relationship between adherence to diet, glycemic control and cardiovascular risk factors in patients with type 1 diabetes: a nationwide survey in Brazil. Nutr J. 2014;13:19.
Maffeis C, Morandi A, Ventura E, Sabbion A, Contreas G, Tomasselli F, et al. Diet, physical, and biochemical characteristics of children and adolescents with type 1 diabetes: Relationship between dietary fat and glucose control. Pediatr Diabetes. 2012;13:137–46.
Dalsgaard H, Saunders C, Padilha PdeC, Luescher JL, Berardo RS, Accioly E. Glycemic control and lipid profi le of children and adolescents undergoing two different dietetic treatments for type 1 diabetes mellitus. Nutr Hosp. 2014;29:547–52.
Saito M, Kuratsune H, Nitta H, Kawahara K, Hamano M, Matsuda M, et al. Plasma lipid levels and nutritional intake in childhood- and adolescence-onset young type 1 diabetic patients in Japan. Diabetes Res Clin Pr. 2006;73:29–34.
Acknowledgements
CIBERDEM is an initiative from Instituto de Salud Carlos III (Plan Nacional de I+D+I and Fondo Europeo de Desarrollo Regional).
Author information
Authors and Affiliations
Contributions
MG-C, IS, and DM contributed to the conception and design of the study. MG-C, IS, MH, JJ, M-IR, and DM performed the systematic search and study selection. MG-C realized the data extraction. MG-C, IS, and DM performed the quality assessment of studies. MG-C drafted the paper. MG-C, IS, and DM contributed to the discussion of the results, review and revision. All authors approved the final paper.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Granado-Casas, M., Solà, I., Hernández, M. et al. Effectiveness of medical nutrition therapy in adolescents with type 1 diabetes: a systematic review. Nutr. Diabetes 12, 24 (2022). https://doi.org/10.1038/s41387-022-00201-7
Received:
Revised:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41387-022-00201-7
- Springer Nature Limited
This article is cited by
-
The emergence of obesity in type 1 diabetes
International Journal of Obesity (2024)