Type 1 diabetes

TYPE 1 DIABETES AND INTUITIVE EATING

Few studies are available that look at the effects of intuitive eating (IE) on Type 1 diabetes (T1D) management. This article considers the research available on both, demonstrating how traditional T1D management can lead to disordered eating behaviours, and examines how IE could provide a complimentary management option for T1D.

T1D is an autoimmune disorder characterised by insulin dependence. Its onset most often occurs in youth and represents about 8% of diabetics in the UK.1 It is typically caused by an unknown trigger, which activates the immune system and leads to the destruction of the insulin-producing beta cells in the pancreas.

Insulin is an essential hormone that allows glucose to enter the cells, therefore reducing blood glucose. Insulin can also store excess glucose as glycogen and fat in the liver and adipose tissue, respectively. Without insulin, glucose cannot be taken up by the tissues and remains in the blood, causing high blood glucose (hyperglycaemia), which can lead to a series of health conditions, such as retinopathy, neuropathy and nephropathy.

The opposite trend – hypoglycaemia – occurs when there is too much insulin, causing more glucose to enter the cells than needed, severely lowering blood glucose. Hypoglycaemia (hypo, or ‘a low’) is dangerous; it starts with dizziness and fatigue, and if untreated, can lead to convulsions and potentially death. However, this is extremely rare.2 Maintaining blood glucose in the target range is, therefore, essential. Glycaemic status is measured using HbA1c, a marker that determines the amount of glycated red blood cells over three months. Excess glucose attaches to red blood cells during hyperglycaemia, thereby glycating them. The ideal HbA1c range for an individual with T1D is between 6.5% and 7.5%2 (4858mmol/mol).3

INSULIN ADMINISTRATION Insulin administration is essential for anyone with T1D. The two main ways of delivering this medication are multiple daily injections (MDI) and the insulin pump. MDI consists of using two different kinds of insulin: 1 a background or long-acting insulin, which releases insulin continually in tiny doses for 8-24 hours depending on the brand; and 2 fast-acting insulin, which acts within 15 minutes to one hour of injecting.

Patients with T1D on MDI focus on matching the number of carbohydrates eaten to the correct insulin dose, thanks to ratios previously established by the patient’s endocrinologist.4 This is required as carbohydrate-rich foods get digested into glucose, thereby raising blood glucose.

The insulin pump is a small device, which can be tubular or not. Tubular pumps are connected to the body via a tube linked to a catheter and a small infusion kit with a cannula that sits under the skin. Non-tubular pumps often communicate with the catheter via Bluetooth or through a smartphone, or another specialised device, creating a closed-loop system. Fast-acting insulin

Eloize Kazmiersky ANut

Eloize graduated from the University of Nottingham in June 2020 with a BSc in Nutrition. She is further undertaking an MSc in Dietetics at Ulster University, in order to specialise in eating disorders and the psychology behind eating behaviours.

eloize_nutritional_ baker

EKazmiersky

REFERENCES Please visit: nhdmag.com/ references.html

Using diet, exercise and lifestyle to reduce the number of insulin injections needed is one strategy for T1D management.

is injected permanently and continuously with both methods. Some pumps automatically calculate the amount of insulin per amount of carbohydrates ingested, based on the preprogrammed ratios. Some individuals prefer this option to MDI, as it allows more freedom from calculations, injections and overall better control, with HbA1c reduced by 0.9% after six years follow-up.5 However, pumps require significantly more equipment, can break down, can be expensive and cannulas can get infected.5,6

TRADITIONAL DIETARY MANAGEMENT Using diet, exercise and lifestyle to reduce the number of insulin injections needed is one strategy for T1D management. The most popular diets adopted by some to help manage T1D are the low-carb and ketogenic diets. These were initially the only way to treat T1D before insulin was discovered, and little to no carbs consumed significantly reduces insulin injections. Although research in this area is limited, several studies have concluded that low-carb and ketogenic diets improve overall glycaemic control in T1D treatment short-term. A ketogenic diet was also associated with more hypoglycaemic events and dyslipidaemia.7

The very nature of T1D treatment can potentially trigger eating disorders (EDs) or disordered eating behaviours. Up to 60% of one sample8 qualified for the diagnosis of a diabetes-specific ED, diabulimia. Young girls with T1D are 2.6 times more likely to suffer from an ED than the general population.9 Some reasons offered for these alarming statistics include: • fear of hypoglycaemic events10 – low blood glucose symptoms are unpleasant and potentially debilitating, getting in the way of everyday life; • overtreating low blood glucose – eating or drinking too much to treat hypoglycaemia can spike blood glucose, requiring

‘unnecessary’ insulin to return to the target range, which can lead to weight gain;11 • increased anxiety and depression symptoms caused by T1D;12 • significant focus on eating and weight, as well as potential dietary restriction, leading to binge eating and insulin restriction;12

• body image and self-esteem issues – women with T1D are on average 6.8kg heavier than non-diabetic women, potentially leading to these issues.13

WHAT IS INTUITIVE EATING (IE)? There is no one set definition for IE. Generally, it can be considered a group of principles that encourage reconnecting with hunger and fullness bodily cues and letting go of any diet culture, weight shaming/stigma and food rules.14 IE is often used as a tool for people who suffer from disordered eating to prevent them from spiralling further and developing an ED, one of the most fatal psychiatric diseases.15 Treating an ED requires special attention from a team of specific healthcare professionals. IE is not sufficient as a treatment alone for an ED, but can serve as a toolbox for people with disordered eating behaviours.16

The research

The peer-reviewed and only study currently available exploring the impact of IE on T1D management suggests that IE could be beneficial to adolescents with T1D to reduce emotional eating and improve overall glycaemic control by preventing an increase in HbA1c. It showed that adolescents with T1D have slightly lower IE scores (according to the IE scale) than controls. A higher frequency of blood glucose selfmonitoring was significantly associated with lower reliance on internal hunger and satiety cues. The study also focused on emotional eating: glycaemic control was worse in those engaged in these behaviours. However, IE was associated with lower HbA1c: for each unit increase of the IE score, HbA1c was significantly lower by 22%.16 HbA1c was also lower in those who selfmonitored blood glucose levels more frequently.

These findings echo the results of similar studies done on people with Type 2 diabetes. In conclusion, the study16 demonstrated that T1D and its management are associated with less reliance on internal cues of hunger and satiety and that emotional eating can harm T1D control. However, IE has a significantly beneficial impact on emotional eating and HbA1c levels.16

MY PERSONAL EXPERIENCE I have found that IE has helped me progress tremendously in my T1D management. The principles behind IE not only improved my relationship with food but with my chronic illness as well. It removed the guilt I felt for wanting to eat more and hence needing to inject more. When I was doing the Dose Adjustment for Normal Eating (DAFNE) course, I was constantly comparing myself to my peers, and it made me realise that I am a lot more insulin resistant than most people with T1D. Initially, I felt self-conscious about it, but IE principles helped me accept myself and listen to my body’s needs and cues, albeit from a nutritional or diabetes standpoint. Sometimes I can feel that I am going low, so I will have a small snack to start feeling better again (despite my doctors not liking that). Alternatively, I can feel when my blood sugar is spiking, which pushes me to check my levels and treat accordingly. IE has helped me ‘dedramatise’ T1D and has taken away a lot of the guilt I felt in the past for the way I ate and its impact on my levels.

CONCLUSION Research into the area of IE as a dietary management option for T1D is nascent. It requires far more investigation to establish a causal link of the potential benefits of IE on T1D management. More observational and intervention studies on a larger population scale and environment are needed, the results of which could provide people with T1D to simultaneously improve their glycaemic control and relationship with food using IE methods.

WANT TO STAY INFORMED?

Don’t miss out on our FREE weekly NH-eNews Bulletins and Alerts, emailed directly into your inbox. Receive updates on industry news, Jobs, webinars, events and new products relevant to dietetics and nutrition. PLUS extra essential NHD features to keep you up-to-date with CPD. Sign up on our homepage www.NHDmag.com

PAEDIATRIC ALLERGIES AND WEANING

Introducing solid foods can be a worrying time for parents, especially if a baby suffers from an allergy. Some parents with perfectly healthy infants may simply be concerned about high profile allergens such as peanuts and eggs. This article looks at the main food allergens and discusses the recommendations and advice for safe and successful weaning.

In the UK, 7.1% of breastfed children have increased prevalence for food allergy: 1 in 40 develop a peanut allergy and 1 in 20 develop an egg allergy.1 Children who have early onset eczema are at an even higher risk of developing a food allergy, particularly peanut allergy.2 Increasing numbers of children admitted to hospital for anaphylaxis reflects the increase in prevalence of food allergy in children in the UK.3

In the past decade the guidance and advice around when to introduce allergens into an infant’s diet has changed and is varied, causing healthcare professionals and parents confusion. Fortunately, over the past five years there has been increasing research into food allergies and weaning, which focus on the prevention of food allergies, such as the LEAP and EAT studies, with data from both showing that introducing allergenic foods at the same time as other solid foods may in fact protect infants from developing a food allergy.4

Table 1: Main food allergens (UK)

Cow’s milk

Egg (egg without the red lion stamp should not be eaten raw or be lightly cooked for infants) Cereals containing gluten, including wheat, rye, barley and oats Tree nuts (crushed, ground or in a butter for children under five years) Peanut (crushed, ground or in a butter for children under five years) Sesame WHAT ARE THE MAIN ALLERGENS? There are 14 main allergens that are the most likely to trigger an allergic reaction in the UK population (see Table 1). By law, these allergens have to be highlighted on an ingredients list on any prepackaged foods you buy.5

Shellfish (not to be served raw or lightly cooked for infants)

Fish

Mustard

Celery

Sulphur dioxide

Lupin Molluscs (not to be served raw or lightly cooked for infants)

Roslyn Gray RD

Roslyn is a Registered Freelance Dietitian specialising in paediatrics and eating disorders.

www.graynutritionrd.co.uk

graynutritionrd

REFERENCES Please visit: nhdmag.com/ references.html

NEW FORCOW ’S MILKALLERGY

For healthcare professionals only

Help them face life’s adventures

EleCare® is designed to help support the immune needs immune needs of formula-fed infants with severe cow’s milk allergy and/or multiple food allergies.

EleCare is the fi rst amino acid-based formula to contain 2’-FL*†, a major component of most mothers’ breast milk:1

Helps support the immune system in the gut and beyond 1–3

Contains 2’-FL* which has proven benefi ts on the gut and systemic immune responses‡

Supports healthy growth and symptom growth and symptom

resolution§4–7

with

Trusted by mums and healthcare and healthcare professionals8,9

2’-FL*

Contact your local Abbott Account Manager to learn more or call Freephone Nutrition Helpline on 0800 252 882

IMPORTANT NOTICE: Breastfeeding is best for infants and is recommended for as long as possible during infancy. EleCare is a food for special medical purposes and should only be used under the recommendation or guidance of a healthcare professional. *The 2’-FL (2’-fucosyllactose) used in this formula is biosynthesised and structurally identical to the human milk oligosaccharide (HMO) 2’-FL, found in most mothers’ breast milk.1 †MIMS. September 2020. ‡Studies conducted in healthy-term infants consuming standard Similac formula with 2’-FL (not EleCare), compared to control formula without 2’-FL. §Studies conducted in infants fed standard EleCare formula without 2’-FL. References.1. Reverri EJ, et al. Nutrients. 2018;10(10). pii: E1346. 2. Goehring KC, et al. J Nutr. 2016;146(12):2559–2566. 3. Marriage BJ, et al. J Pediatr Gastroenterol Nutr. 2015;61(6):649–658. 4. Borschel MW, et al. Clin Pediatr(Phila). 2013;52(10):910–917. 5. Borschel MW, et al. BMC Pediatr. 2014;14:136. 6. Sicherer SH, et al. J Pediatr. 2001;138:688–693. 7. Borschel MW, et al. SAGE Open Med. 2014;2:2050312114551857. 8. RTI research. Abbott EleCare No.1 Dr Recommended. Final Results. 2019. 9. Abbott. EleCare Promotional Claims Parent Survey. 2019. UK--2000065 September 2020

Table 2: Recommendations for introducing food allergens9

Allergen Recommendations

Choose British Lion stamped eggs.

Egg Egg in raw form is more likely to cause an allergic reaction than in a baked food. Boiled egg could firstly be offered mashed into other cooked foods, eg, vegetables or rice. Aim for one egg over the course of the week.

Peanut Never give whole peanuts or chopped nuts. Use finely grounded nuts or a smooth peanut butter, or ‘puffed peanut’ snacks. Never give whole nuts or chopped nuts.

Tree nuts Use finely grounded nuts or smooth nut butters, eg, cashew butter, almond butter mixed with yoghurt, porridge or fruit.

Cow’s milk Sugar-free yoghurts or fromage frais, fresh whole milk added to meals, eg, porridge, sauces, mashed potatoes.

Wheat Weetabix or other cereals containing wheat, well-cooked pasta, toast fingers.

Seeds Hummus mixed with tahini (sesame seeds), crushed seeds added to yoghurt, porridge or fruit.

Fish, Pureed, flaked or mashed cooked fish (cooked haddock, salmon or trout), or seafood (prawns, seafood crab, mussels).

Soya Soya is found in many bread products and so does not need to be offered separately as a soya product.

DIETETIC ADVICE AND RECOMMENDATIONS For the general population, the UK Department of Health recommends exclusive breastfeeding for around the first six months of life and the introduction of solids from around six months of age alongside breastfeeding.6 Recommendations include the following: • Babies with a known risk factor for food allergy should be introduced to cooked egg and then peanut alongside other solids early in the weaning process, when they are developmentally ready.7 • Babies with no risk factors for food allergy should be introduced to solids at around six months of age. Cooked egg and peanut should be included with other foods that are eaten as part of their family’s normal diet.8 • The deliberate exclusion or delayed introduction of specific allergenic foods may increase the risk of developing a food allergy to the same foods.9

FIRST STEPS INTO SOLID FOODS There are three main considerations: 1 Can baby hold their head up and sit unsupported? 2 Does the baby have hand-eye coordination?

Do they bring food to their mouth? 3 Can they move food from the front of their mouth to the back of their mouth and swallow?

Once the infant is ready to wean, at around six months of age, parents/carers can introduce complementary foods. They should start by offering small amounts of vegetables, fruit, starchy foods and protein. Once they feel confident that baby is managing purees, they should start to consider introducing allergens with the following considerations: • Ensure baby is well and not recovering from any sickness. • Include foods associated with food allergies that are part of the family’s diet. These can include egg, foods containing peanut and tree nuts, pasteurised dairy foods, fish/ seafood and wheat. • Introduce one allergen at a time. • Consider offering food earlier in the day, for example at breakfast or lunch, to allow for time to monitor any signs or reaction. • Start with a small amount, eg, quarter teaspoons and slowly increase the amount over the next two to three days. • Once foods containing allergens have been introduced, it is important for parents to continue introducing those foods, particularly egg and peanut, aiming for two to three times a week. • If the infant does have eczema, it is best to make sure their skin is in a good condition prior to introducing a new allergen.

Table 3: Symptoms of immediate- and delayed-type food allergies9

Immediate-type food allergy Delayed-type food allergy

Symptoms are caused by IgE antibodies and usually occur within 30 minutes of eating the triggering food.

Mild-moderate allergic symptoms include: • swollen lips, face or eyes • itchy skin rash, eg, hives • abdominal pain, vomiting

Severe symptoms (anaphylaxis) include: AIRWAY: BREATHING: CONSCIOUSNESS: • persistent cough, swollen tongue, hoarse cry • difficult/noisy breathing, wheezing • pale or floppy • unresponsive/unconscious Symptoms usually happen hours to days later, and: • recur when the food is eaten again • resolve when that food is avoided

Gut symptoms include: • recurrent abdominal pain • worsening vomiting/reflux • feeding difficulties • loose/frequent stools (>6-8 times per day) or constipation/infrequent stools (2 or fewer per week) Skin symptoms include: • skin reddening • itching • worsening of eczema Delayed-type food allergy is of particular concern when the baby’s growth is also affected. Delayed-

type allergy is not caused by IgE antibodies, and cannot cause anaphylaxis.

• If the infant dislikes the food, reassure parents to be patient and try again another day. • Keep a food diary of what foods have been introduced and any reactions that occur.

DIETETIC MANAGEMENT OF A SUSPECTED FOOD ALLERGY Firstly, it is important to distinguish between a food intolerance and an allergy and to define what an immediate-type food allergy reaction is compared with a delayed-type food allergy.

Part of the dietetic assessment is taking a detailed allergy-focused history concentrating on: • parents’ diet recall and suspected allergens; • family history of atopic disease and allergies; • symptom history: age at onset of symptoms, rate of onset, spread and severity of symptoms, as well as the frequency of symptoms; • any current food exclusions or past food exclusions that have been tried previously.

WHAT ABOUT INFANTS AT HIGHER RISK OF FOOD ALLERGY? Some infants are at a higher risk of developing a food allergy, including those: • with eczema; • who already have a food allergy; research has shown that these infants may benefit from the introduction of foods containing egg and peanut from four months alongside other complementary foods;10 • who have known allergies – parents should not continue to feed their baby something they are reacting to.

Referral to a specialist allergy clinic is recommended for all infants with immediate-type food allergy.

WHAT ABOUT OTHER SIBLINGS? Often if an older sibling has a food allergy, parents are concerned that their younger children may also have it. Recent studies have found that this factor alone does not significantly increase the risk of food allergy in an infant sibling.11

However, parents may delay that particular allergen from being introduced, which, thereby, increases the risk. Of course, if members of the household do have food allergies, parents need to carefully plan introductions of that allergen without putting their other children at risk of an allergic reaction.