SBSB Research: Eating Behavior in Youth with Type 1 Diabetes

Dietary guidelines for youth with type 1 diabetes are similar to those for the general population, and nutrition education for families of youth with type 1 diabetes includes recommendations for general healthy eating and efforts to achieve and maintain optimal weight for height. Current treatment standards emphasize physiologic insulin replacement; therefore, a primary component of medical nutrition therapy in type 1 diabetes is carbohydrate estimation, as carbohydrates are the principal macronutrient affecting glycemic excursions. A major focus is on integrating the insulin regimen and carbohydrate estimation into the family's lifestyle, conforming to preferred meal routines, food choices, and physical activity patterns. Youth with type 1 diabetes consume diets low in fruits, vegetables, and whole grains, and high in saturated fat. Poor diet quality in these patients is particularly concerning due to the increased risk of dyslipidemia and cardiovascular disease and the high prevalence of cardiovascular risk factors. Thus, improving diet quality in this population has the potential to improve short- and long-term health outcomes. This program of research examines determinants of dietary intake among youth with type 1 diabetes and tests the efficacy of strategies to improve diet quality in this population.

Cultivating Healthy Environments in Families of Children with Type 1 Diabetes (CHEF)

This study tested the efficacy of a family-based behavioral intervention designed to improve diet quality by promoting intake of fruit, vegetables, whole grains, legumes, nuts, and seeds. A parallel group study with equal randomization was conducted at an outpatient diabetes center. Eligible youth were 8 to 16 years old with a type 1 diabetes diagnosis at least 1 year prior to joining the study and glycated hemoglobin levels between 6.5 and 10.0%. Participants were 136 parent-youth pairs. The intervention consisted of nine clinic sessions delivered to the child and parent, whereas the control condition comprised equivalent assessments and number of contacts without dietary advice. The intervention approach was grounded in social cognitive theory, self-regulation, and self-determination theory, and integrated motivational interviewing, active learning, and applied problem-solving. Data collected included medical record abstraction, parent-youth interview, youth self-report surveys, parent self-report surveys, youth 3-day diet records, parent 3-day diet records, youth continuous glucose monitoring, youth body composition, and youth biomarkers including lipids, carotenoids, and markers of inflammation and oxidative stress. Primary outcomes were dietary intake and glycemic control. Findings demonstrated that the intervention improved youth adherence to dietary guidelines and intake of whole plant foods, with no adverse effect on glycemic control, disordered eating, or diet cost. Unexpectedly, greater improvement in diet quality was observed in intervention youth with higher pickiness. There was no evidence of differential reporting bias by treatment assignment, supporting the conclusion that the observed treatment effect on diet quality was due to real change in dietary intake rather than differential reporting error between treatment groups.

To request a copy of the intervention materials, email tonja.nansel@nih.gov.

Eating Behaviors among Youth with Type 1 Diabetes

This cross-sectional study of 291 parent-youth dyads examined psychosocial factors related to eating behaviors in families with youth with type 1 diabetes. Data were obtained using medical record abstraction, parent-youth interviews, youth self-report surveys, parent self-report surveys, youth 3-day diet records, and parent food frequency questionnaires. Findings document low intake of fruit, vegetables, and whole grains, and poor overall diet quality among youth with type 1 diabetes and indicate potentially modifiable child and family determinants of dietary intake.

Perceptions of Healthy Eating among Families of Youth with Type 1 Diabetes

A series of focus groups, conducted separately with children, adolescents, and parents, examined perceptions of healthy eating among families of youth with type 1 diabetes. Findings indicate that these families experience developmental and environmental challenges surrounding healthy eating similar to those reported among families in the general population, along with additional obstacles specific to diabetes management . For example, findings suggest that the emphasis placed on carbohydrate intake for disease management may adversely affect overall diet quality due to reliance on packaged foods and avoidance of fruit intake, and that flexible basal-bolus regimens may increase opportunities for unhealthy eating.

Blood Glucose Response to Meals of Varying Glycemic Index

In this study, youth with type 1 diabetes participated in 5 days of continuous blood-glucose monitoring during which they received both low and high glycemic index meals in a structured clinic setting and in the home environment. Food intake, insulin, and blood glucose self-monitoring were recorded. Participants demonstrated lower mean blood glucose and variability when consuming low glycemic index meals in both the in-clinic and the at-home conditions. During ad libitum intake at home, children also consumed more fiber and less fat when consuming low glycemic index meals.

Acceptability of Low Glycemic Index Meals at Diabetes Camp

Youth ages 7 to 15 years who attended a diabetes summer camp received standard diabetes camp menus and low glycemic index diabetes camp menus in a daily, alternating cross over design. Measures of satisfaction with the camp meals and snacks were obtained from youth and staff, and observations of meal consumption were conducted. Additional data were collected via focus groups and self-report of food patterns and preferences. Findings indicated high acceptability of the low glycemic meals.

Principal Investigator

Tonja Nansel, Ph.D.

Division Collaborators

Publications

Zhang, W., Liu, A., Zhang, Z., Nansel, T., & Halabi, S. (2020). Best (but oft-forgotten) practices: Sample size and power calculation for a dietary intervention trial with episodically consumed foods. The American Journal of Clinical Nutrition, 112(4), 920–925. PMID: 32644103
Sanjeevi, N., Lipsky, L. M., & Nansel, T. R. (2019). Hyperglycemia and carotenoid intake are associated with serum carotenoids in youth with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics, 119(8), 1340–1348. PMID: 31101482
Sanjeevi, N., Lipsky, L., Liu, A., & Nansel, T. (2019). Differential reporting of fruit and vegetable intake among youth in a randomized controlled trial of a behavioral nutrition intervention. The International Journal of Behavioral Nutrition and Physical Activity, 16(1), 15. PMID: 30709403
Lipsky, L. M., Haynie, D. L., Liu, A., & Nansel, T. R. (2019). 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. Journal of the Academy of Nutrition and Dietetics, 119(1), 98–105. PMID: 30389377
Kassahun-Yimer, W., Albert, P. S., Lipsky, L. M., Nansel, T. R., & Liu, A. (2019). A joint model for multivariate hierarchical semicontinuous data with replications. Statistical Methods in Medical Research, 28(3), 858–870. PMID: 29117781
Sanjeevi, N., Lipsky, L. M., & Nansel, T. R. (2018). Cardiovascular biomarkers in association with dietary intake in a longitudinal study of youth with type 1 diabetes. Nutrients, 10(10), 1552. PMID: 30347780
Sanjeevi, N., Lipsky, L. M., & Nansel, T. R. (2018). Greater inflammation and adiposity are associated with lower bone mineral density in youth with type 1 diabetes. Diabetes Research and Clinical Practice, 144, 10–16. PMID: 30114458
Nansel, T. R., Lipsky, L. M., Haynie, D. L., Eisenberg, M. H., Dempster, K., & Liu, A. (2018). Picky eaters improved diet quality in a randomized behavioral intervention trial in youth with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics, 118(2):308-316. PMID: 29389510
Eisenberg Colman, M. H., Quick, V. M., Lipsky, L. M., Dempster, K. W., Liu, A., Laffel, L. M. B., Mehta, S. N., & Nansel, T. R. (2018). 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, 41(4):869-875. PMID: 29371234
Quick, V., Lipsky, L. M., & Nansel, T. R. (2018). Psychometric properties and factor structure of the adapted Self-Regulation Questionnaire assessing autonomous and controlled motivation for healthful eating among youth with type 1 diabetes and their parents. Child: Care, Health, and Development, 44(4):651-658. PMID: 29770461
Eisenberg, M. H., Lipsky, L. M., Gee, B., Liu, A., & Nansel, T. R. (2017). Parent healthful eating attitudes and motivation are prospectively associated with dietary quality among youth with type 1 diabetes. Vulnerable Children and Youth Studies, 12(3):226-240. PMID: 29861779
Lipsky, L. M., Gee, B., Liu, A., & Nansel, T. R. (2017). Body mass index and adiposity indicators associated with cardiovascular biomarkers in youth with type 1 diabetes followed prospectively. Pediatric Obesity, 12(6):468-476. PMID: 27417272
Nansel, T. R., Lipsky, L. M., Eisenberg, M. H., Liu, A., Mehta, S. N., & Laffel, L. M. (2016). 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. Journal of the Academy of Nutrition and Dietetics, 116(11):1751-1759.e1. PMID: 27597745
Eisenberg, M. H., Lipsky, L. M., Dempster, K. W., Liu, A., & Nansel, T. R. (2016). I should but I can't: Controlled motivation and self-efficacy are related to disordered eating behaviors in adolescents with type 1 diabetes. The Journal of Adolescent Health,59(5):537-542. PMID: 27567063
Lipsky, L. M., Gee, B., Liu, A., & Nansel, T. R. (2016). Glycemic control and variability in association with body mass index and body composition over 18 months in youth with type 1 diabetes. Diabetes Research and Clinical Practice, 120:97-103. PMID: 27525365
Nansel, T. R., Lipsky, L. M., & Liu, A. (2016). Greater diet quality is associated with more optimal glycemic control in a longitudinal study of youth with type 1 diabetes. The American Journal of Clinical Nutrition, 104(1):81-87. PMID: 27194309
Nansel, T. R., Laffel, L. M., Haynie, D. L., Mehta, S. N., Lipsky, L. M., Volkening, L. K., Butler, D. A., Higgins, L. A., & Liu, A. (2015). Improving dietary quality in youth with type 1 diabetes: Randomized clinical trial of a family-based behavioral intervention. The International Journal of Behavioral Nutrition and Physical Activity, 12:58. PMID: 25952160
Nansel, T., Haynie, D., Lipsky, L., Mehta, S., & Laffel, L. (2015). Little variation in diet cost across wide ranges of overall dietary quality among youth with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics, 115(3):433-439.e1. PMID: 25266245
Caccavale, L. J., Nansel, T. R., Quick, V., Lipsky, L. M., Laffel, L. M., & Mehta, S. N. (2015). Associations of disordered eating behaviors with the family diabetes environment in adolescents with type 1 diabetes. Journal of Developmental and Behavioral Pediatrics, 36(1):8-13. PMID: 25493461
Mehta, S. N., Nansel, T. R., Volkening, L. K., Butler, D. A., Haynie, D. L., & Laffel, L. M. (2015). Validation of a contemporary adherence measure for youth with type 1 diabetes: The Diabetes Management Questionnaire. Diabetic Medicine, 32(9):1232-1238. PMID: 26280463
Nansel, T. R., Lipsky, L. M., Liu, A., Laffel, L. M., & Mehta, S. N. (2014). Contextual factors are associated with diet quality in youth with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics, 114(8):1223-1229. PMID: 24651028
Quick, V., Lipsky, L. M., Laffel, L. M., Mehta, S. N., Quinn, H., Nansel, T. R. (2014). Relationships of neophobia, pickiness with dietary variety, dietary quality, and diabetes management adherence in youth with type 1 diabetes. European Journal of Clinical Nutrition, 68(1):131-136. PMID: 24253761
Katz, M. L., Mehta, S., Nansel, T., Quinn, H., Lipsky, L. M., & Laffel, L. M. (2014). Associations of nutrient intake with glycemic control in youth with type 1 diabetes: Differences by insulin regimen. Diabetes Technology & Therapeutics, 16(8):512-518. PMID: 24766666
Kornides, M. L., Nansel, T. R., Quick, V., Haynie, D. L., Lipsky, L. M., Laffel, L. M., & Mehta, S. N. (2014). Associations of family meal frequency with family meal habits and meal preparation characteristics among families of youth with type 1 diabetes. Child: Care, Health, and Development, 40(3): 405-411. PMID: 23731337
Nansel, T. R., Haynie, D. L., Lipsky, L. M., Wang, J., Mehta, S. N., & Laffel, L. M. (2013). Relationships among parent and youth healthful eating attitudes and youth dietary intake in a cross-sectional study of youth with type 1 diabetes. The International Journal of Behavioral Nutrition and Physical Activity, 10:125. PMID: 24195642
Sands, A. L., Higgins, L. A., Mehta, S. N., Nansel, T. R., Lipsky, L. M., & Laffel, L. M. (2013). Associations of youth and parent weight status with reported versus predicted daily energy intake and hemoglobin A1c in youth with type 1 diabetes mellitus. Journal of Diabetes Science and Technology, 7(1):263-270. PMID: 23439184
Nansel, T. R., Haynie, D. L., Lipsky, L. M., Laffel, L. M., & Mehta, S. N. (2012). 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. Journal of the Academy of Nutrition and Dietetics, 112(11):1728-1735. PMID: 23102173
Tse, J., Nansel, T. R., Haynie, D. L., Mehta, S. N., & Laffel, L. M. (2021). Disordered eating behaviors are associated with poorer diet quality in adolescents with type 1 diabetes. Journal of the Academy of Nutrition and Dietetics, 112(11):1810-1814. PMID: 23102180
Rovner, A. J., Nansel, T. R., Mehta, S. N., Higgins, L. A., Haynie, D. L., & Laffel, L. M. (2012). Development and validation of the type 1 diabetes nutrition knowledge survey. Diabetes Care, 35(8):1643-1647. PMID: 22665217
Lipsky, L. M., Nansel, T. R., Haynie, D. L., Mehta, S. N., & Laffel, L. M. (2012). Associations of food preferences and household food availability with dietary intake and quality in youth with type 1 diabetes. Appetite, 59(2):218-223. PMID: 22595289
Rovner, A. J., Mehta, S. N., Haynie, D. L., Robinson, E. M., Pound, H. J., Butler, D. A., Laffel, L. M., & Nansel, T. R. (2010). Perceived benefits, barriers, and strategies of family meals among children with type 1 diabetes mellitus and their parents: Focus-group findings. Journal of the American Dietetic Association, 110(9):1302-1306. PMID: 20800121
Gellar, L., & Nansel, T. R. (2009). High and low glycemic index mixed meals and blood glucose in youth with type 2 diabetes or impaired glucose tolerance. The Journal of Pediatrics, 154(3):455-458. PMID: 19874764
Rovner, A. J., & Nansel, T. R. (209). Are children with type 1 diabetes consuming a healthful diet?: A review of the current evidence and strategies for dietary change. The Diabetes Educator, 35(1):97-107. PMID: 19244565
Rovner, A. J., Nansel, T. R., & Gellar, L. (2009). The effect of a low-glycemic diet versus a standard diet on blood glucose levels and macronutrient intake in youths with type 1 diabetes. Journal of the American Dietetic Association, 109(2):303-307. PMID: 19167958
Gellar, L., Rovner, A. J., & Nansel, T. R. (2009). Whole grain and legume acceptability among youths with type 1 diabetes. The Diabetes Educator, 35(3):422-427. PMID: 19289543
Nansel, T. R., Gellar, L., & McGill, A. (2008). Effect of varying glycemic index meals on blood glucose control assessed with continuous glucose monitoring in youth with type 1 diabetes on basal-bolus insulin regimens. Diabetes Care, 31(4):695-697. PMID: 18202243
Nansel, T. R., Gellar, L., & Zeitzoff, L. (2006). Acceptability of lower glycemic index foods in the diabetes camp setting. Journal of Nutrition Education and Behavior, 38(3):143-150. PMID: 16731448