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Alternative snack system for children and teenagers with diabetes mellitus
PERSPECTIVES INPRACTICE
Alternative snack system for children and teenagers with diabetes mellitus EMILYLOGHMANI, MS, RD; KARYL A. RICKARD, PhD, RD
utritionmanagementis awidely recognized cornerstone of ABSTRACT An alternative snack system facilitates diabetes management and provides a teaching tool for age-appropriate nutrition education of children and teenagers with diabetes mellitus. The system consists of four snack sizes: Mini - 7 to 10 g available glucose, Little - 15 to 20 g, Big - 30 to 35 g, and Super-Big 50 to 55 g. Within each category, several snack patterns are equivalent to each other in terms of available glucose and energy. By using this system, a child or teenager can eat snacks that contain different food groups and still adhere to the overall meal plan. When additional carbohydrate is needed for exercise or the prevention of nighttime hypoglycemia, a snack from the next largest category will increase available glucose by approximately 15 g and energy intake by approximately 100 kcal. Generally, for every hour of extra physical activity, a Little snack is added. When blood glucose concentrations before a nighttime snack are 4.4 to 6.7 mmol/L, a Little Snack is added to the usual bedtime snack, and when levels are less than 4.4 mmol/L, a Big snack is added. Further adjustments are made for children younger than 5 years old. The alternative snack system is a valuable nutrition education tool for the management of diabetes in children and teenagers. JAm Diet Assoc. 1994; 94:1145-1148.
the medical management of diabetes mellitus. Snacks are of particular importance for children and teenagers with insulin-dependent diabetes mellitus (IDDM) because these patients usually receive a combination of short-acting and intermediate-acting insulin twice daily and eat three meals and one to three snacks to enhance metabolic control. An alternative snack system, developed at J. W. Riley Hospital for Children, is an effective teaching tool for children and adolescents. The system is simple to learn, allows young people of all ages to be independent in creating their own snacks, and is easy to use. The system also offers flexibility and variety for usual snacks and additional food eaten to prevent hypoglycemia related to increased exercise or low concentrations of blood glucose at bedtime. Furthermore, daily adjustments in types of food eaten as snacks can be made depending on food availability. Use of the alternative snack system may promote decision-making skills related to diabetes management, enhance growth and development, and nurture self-esteem. Most importantly, children and teenagers are intrigued by the snack names - Mini, Little, Big, and Super-Big and quickly become active participants in figuring out how their favorite snacks can be eaten. A discussion of alternative snacks can lead to a desire to learn more about exchanges, food groups, and portion sizes. The alternative snack system contributes to meeting the educational objectives for children and families in our diabetes education program. At diagnosis, a detailed nutrition history is obtained to learn about the child's school and activity schedule, food likes and dislikes, and family eating patterns. An individualized meal plan is developed with this information, and the family learns about meal planning with the use of the food exchange lists (1). A dietitian helps the family write sample menus to be used at home. Often children are passive listeners to the meal-planning discussion, but their ears perk up when the alternative snack system is introduced. When the child is shown how favorite snack foods can be incorporated into the snack patterns, the concepts of food groups and portion sizes become more meaningful. ChilE. Loghmani (correspondingauthor) is a pediatric dietitianand certified diabetes educatorand K A. Rickard is professor of nutrition and dietetics in the Department of Nutrition and Dietetics, Indiana University School of Medicine, James Whitcomb Riley HospitalforChildren, 702 BarnhillDr, Room 1010, Indianapolis,IN46202-5200. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 1145
PISPCIVWEs H PRCTICE
Table 1 Available glucose and approximate energy provided in each category of the alternative snack system Snack category
Available glucose (g)
Approximate energy (kcal)
Mini
7-10
50-75
Little
15-20
100-135
Big
30-35
200-250
Super-Big
50-55
300-350
dren who are referred to our program because of poor glycemic control often have difficulty following the prescribed meal plan; this may be related, in part, to lack of variety in food choices. Once taught how to use the alternative snack system, families report increased satisfaction with the recornuended meal pattern. The purpose of this article is to describe the alternative snack system and ways to adjust snacks to account for children's increased exercise and lower blood glucose concentrations at night. We also discuss how the alternative snack system contributes to age-appropriate nutrition education of children and teenagers with IDDM. DESCRIPTION OF THE ALTERNATIVE SNACK SYSTEM The alternative snack system consists of four sizes of snacks: Mini, Little, Big, and Super-Big (Table 1). Within each snack category, three to five food combinations (Table 2) have an equivalent amount of available glucose and energy. For example, a Little snack of one bread exchange and one fat exchange has 17 g available glucose and 125 kcal, whereas a Little snack of one fruit exchange and one meat exchange has 20 g available glucose and 135 kcal. The available glucose was calculated based on the premise that 100% of the grams of carbohydrate, 58% of the grams of protein, and 10% of the grams of fat in each food combination are converted to glucose after digestion (2,3). Energy content was calculated with 2% milk and medium-fat meat exchanges. Children and family members are taught that the food combinations in each list provide similar available glucose and total energy. The specifics of the total available glucose (TAG) system for meal planning is not part of the educational process because of its inherent complexity. Generally, meal patterns for children and teenagers with IDDM contain 50% to 55% carbohydrate, 12% to 20% protein and 25% to 30% fat. The protein in the alternative snack system is calculated into the meal plan to avoid excessively high protein intakes, which may be associated with deterioration in kidney function (4,5). Usually, the morning snack is calculated with no meat or milk exchange; the afternoon and evening snacks are calculated with one meat or one milk exchange for the Little and Big snacks and two meat or one meat and one milk exchange for the SuperBig snack. If a child or teenager routinely eats more protein in snacks than what is calculated, the meal plant is adjusted to keep protein intake at a reasonable level. With the alternative snack system, a child or teenager can eat snacks from different food groups while following his or her meal pattern. For example, a child who has a Little snack in the moring may choose to eat six vanilla wafers for one starch/bread and one fat exchange on Monday, /4-c cottage cheese with two diet peach halves for one fruit and one meat exchange on Tuesday, and '/z meat sandwich for one starch/bread and 'h meat exchange on Wednesday. Given a variety of possible food combinations for snacks, children learn how to flexibly manage and control available glucose at home, at school, at sports events, or with friends. 1146 / OCTOBER 1994 VOLUME 94 NUMBER 10
Adjustments in Snacks for Increased Exercise The alternative snack system is a useful tool for deterrninirg how to increase food intake in those situations that may lead to hypoglyceitia, such as increased activity or lower blood glucose concentrations at night. Generally, the child and amily members are taught to increase the usual snack by adding a Little snack (15 to 20 g available glucose) for each hour of activity or exercise that is not in the normal routine. For activities of short duration (less than an hour) or activities such as baseball during which physical exertion starts and stops, a Mini snack (7 to 10 g available glucose) in addition to the usual snack is sufficient in most instances to prevent exercise-induced hypoglycenmia. For longer, more strenuous sports, such as swimming, cross-country r running, or basketball, a Big snack (30 to 35 g available glucose) may be added to the usual snack eaten before the activity, andl additional carbohydrate-containing foods should be available to add as needed. For activities of short duration, a snack that is mainly car)ollydrat, (eg, granola bar, crackers, or fruit) is recorrmended; for sports of' longer duration, that is those lasting 2 hIours or mliore, anlalterriative snack with protein and carbohydrate is re( omlnmended (eg, meat sandwich, peanut butter and crackers). The alternative snack system is used to prevent rather than treat hypoglycemia, because even asymptonmatic hypoglycemia may be related to neuropsychological changes (6,7), and recovery of mental efficiency may take longer than the physiologic increase in blood glucose concentrations to normal (7). If hypoglycermiia occurs during exercise (or otherwise), families have specific and different guidelines for treating the condition with quick-acting carbohydrate (eg, glucose tablets) rather thal more complex combinations of food. Exercise-induced hypoglycemia related to sporadic activity canl often be preventedi by adding a Little snack (15 to 20 g available glucose) to the usual snack for every hour of activity. Some situations, however, require a reduction i insulin dose or additional blood glucose monitoring before, during, and after exercise to determine the glycendc pattern (4,8). A child who plays soccer 2 days a week front 6 to 7 f, can add a Little snack to the evening meal before the game. A teenager who trains for competitive volleyball 5 days a week from 3 to 6 I'M will need to begin with an additional Super-Big snack (50 to 55 g available glucose) that contains protein and may need( to decrease the morning dose ofintermediat c-actinginsulin. Sonme athletes prfelr to decrease the insulin dose instead of eating extra food. This is especially true for athletes who prefer not to exercise after eating or for those who are weight conscious and want to avoid the additional energy in extra snacks. (Children and teenagers can explerielnce nexpe tedl hypoglycermia 12 to 24 hours after exercise as the body repletes glycogen stores in the liver (4,9). Extra monitoring f blood glucose concentration is the best. way to ascertain and avoid the risk of delayed hypoglycemnia. Postexercise hypoglycemia or an increased frequency of hypoglycemia nmay occur at t:he beginning of an active vacation or the start of the school year. Blood glucose monitoring also provides information about times when blood glucose is high (>13.9 nrmol/L) 1 and the addition of extra carbohydrate may be counterproductive. Adjustments in Snacks at Night Adjustments in the alternative snack system have been extremely valuable in managing blood glucose (concentrations during the night and in relieving parents' anxiety about nighttime 'To convert minot/L glucose Io to n/dL, lltiplt 111mnol/L by 18.). To convert ng/dL glucose to rmmnol/L, multiply Ing/d b 0.0555. (Glucoseof i6.0 miol1=108 mg/dL.
Table 2 Food combinations for the alternative snack system Snack category Mini
Food combination /2
'/2
Little
Big
Super-Big
Bread,
112fat
Fruit, 2meat
Possible selections Animal crackers-4 Apple-/2, cheese---/2 oz
V2Milk (2%)
Milk--/2 c
1 Bread, 1 fat
Vanilla wafers-6 Toast-1 slice, margarine-1 tsp
1 Fruit, 1 meat
Diet pear halves-2. cottage cheese-14 c Apple-1 small, cheese- oz
'/? Milk (2%), 1/';bread
Milk--12 C, cereal-'/2 serving Milk-'/2 C,vanilla wafers-3
1 Bread,
Bread-1 slice, thin-sliced ham-/2 oz, mustard (if desired) Saltines-6, wafer-thin lean beef-'/2 oz
L/2meat
1 Milk (2%)
Milk--1 c Plain yogurt with artificial sweetener and cinnamon-- 1 c
2 Breads, 2 fats
English muffin-i, margarine-2 tsp French fries---20 (1 small order)
1 Fruit, 1 meat. 1 bread
Apple-1 small, peanut butter-i Tbsp, popcorn-3 c Orange juice--"2 c turkey-1 oz, bread-1 slice
1 Milk (2%), 1 bread
Pain yogurt- 1 c, fat-free granola-/4 c Milk-1 c, graham crackers-3 squares
213reads. 1 meat
Pizza-3.5 o02 Bread-2 slices, peanut butter-1 Tbsp, sugar-free jelly-2 tsp
3 Breads, 2 fats
Bagel-1 whole (3 oz), cream cheese-2 Tbsp
1 Fruit, 1 meat, 1 bread, 1 milk (2%)
Grapes-15. cheese--i oz, rice cakes-2, milk-- c
1 Milk (2%), 2 breads 1 meat
Milk-1 c, hamburger bun-1, meat-1 oz Milk- 1 c, pizza--3 5 oz
2 Breads, 1 meat, 1 fruit, 1fat
hypoglycemia and seizures. In our program, we recommend that the evening snack contain protein, either milk or meat, to provide a delayed source of glucose during the night when the child is not eating. In addition., we advise monitoring blood glucose concentrations before the evening snack to help the parents decide whether additional carbohydrate is needed. For children aged 6 years and older, if the blood glucose concentration before the evening snack is between 4.4 and 6.7 mmol/L, the addition of a Little snack to the usual snack is recommended. For example, a Little snack would be increased to a Big snack and a Big snack would be increased to a Super-Big snack. If the child's blood glucose concentration is less than 4.4 mmol/L, one fruit exchange of juice would be given immediately. The blood glucose concentration would be remeasured in 15 minutes to ensure that it has increased before giving the usual snack plus the additional Little snack. Children 5 years old or younger should have blood glucose goals slightly higher than those of older children before bedtime to further minimize the risk of hypoglycemia. For this age group, we recommend increasing the usual evening snack by one half if the blood glucose concentration is less than 8.3 mrol/l and adding an additional fruit exchange of juice if the blood glucose concentration is less than 5.5 mmol/L. These guidelines usually provide adequate, but not excessive. carbohydrate during the night.
Bread-2 slices, thin-sliced turkey-1 oz, orange juice-r2 c mayonnaise -1 tsp
CONTRIBUTION TO NUTRITION EDUCATION OF CHILDREN AND TEENAGERS WITH DIABETES AND THEIR FAMILIES Toddlers and Preschoolers Children in the toddler and preschool age range are preoperational and egocentric in their thinking. Toddlers are also at a stage when they may exert their independence rather than eat (10), and the amount of food eaten at meals and snacks may vary considerably depending on their activity level during that particular day. A more flexible, alternative snack system increases choices, thereby potentially averting food battles and rejection of food. This can be extremely helpful in reducing the risk of hypoglycemia, a major goal of diabetes management in children of this age. A younger child may have some difficulty recognizing and verbally labeling symptoms of insulin reactions (eg, "I feel shaky or sleepy"). Thus, parents need to discriminate between ageappropriate behavior, such as contrariness, and true insulin reactions; the discrimination process is assisted by monitoring blood glucose levels. Children in this age group usually have Mini or Little snacks in their meal pattern and increase to a Little or a Big snack in situations involving additional exercise. A toddler may increase "exercise" by going to special places or events (eg, zoo, carnival. OI()TRNAL OF THE AMERICAN D)IETETI('
ASSOCIATION / 1147
family reunion) where he or she is unusually active. The alternative snack system allows snack choices to be readily adapted to available foods. School-Aged Children Children become more emotionally independent during the ages of 6 to 12 years. Motor, reading, mathematical, and reasoning skills increase quickly as do independence and pride in one's accomplishments. Parents can facilitate the child's involvement in his or her own diabetes care by allowing the child to choose and prepare appropriate snacks from the options within a category.
The alternative snack system isa teaching tool that enables children to become active participants intheir own diabetes management Snacks at school need to be managed carefully to promote a child's sense of well-being. Children may be reluctant to eat snacks that require special preparation and draw attention from other students. The Little snack choices, typically one starch/ bread and one fat, can be eaten easily and inconspicuously in the classroom. Popular choices with children in our program are one granola bar, or three peanut butter and cheese crackers, or eight animal crackers. Those children with an early lunch period (ie, 10:30 to 11 AM) may have two Little snacks in the afternoon: one to be eaten at school (between 1:30 and 2 PM) and one to be eaten with siblings when they get home (between 3:30 PM and 4 PM). Children in this age group usually have Little and Big snacks in their meal pattern, and for situations involving exercise, they increase to a Big or Super-Big snack. Some older or more active school-aged children eat Super-Big snacks and increase to a Super-Big plus a Little snack for exercise situations. Teenagers Teenagers struggle with an evolving self-concept and the need for autonomy and independence. Because social activities often revolve around food, teenagers need a flexible meal plan that allows choice and spontaneity so they can eat as their peers do. The alternative snack system offers teenagers a way to fit a variety of popular foods into an allotted snack size. A teenager who is with friends at a fast-food restaurant can eat several food combinations for a Big snack: one slice of pizza (about 3'/2 oz=two starches/ breads and one meat) and a diet soft drink, or a small hamburger (two starches/breads and one meat) and a diet soft drink, or a small order of french fries (two starches/breads and two fats) and a diet soft drink. The size of snacks consumed by teenagers varies according to energy needs, sports activities, and stage of maturation. Teenage girls who are not very active or have achieved their adult height frequently need Little snacks or no snacks during the day (except at night) to control their weight. If a teenager requests that the midmorning snack be omitted, blood glucose concentrations can be managed by adding carbohydrate to breakfast or by adjusting the morning dose of short-acting insulin to reduce the risk of hypoglycemia. Active teenagers or those who are still growing often have Big, Super-Big, or Super-Big plus a Little snack to help them meet greater energy needs. The alternative snack system allows teenagers to choose the snack size according to activity 1148 / OCTOBER 1994 VOLUME 94 NUMBER 10
level; the choices within each category allow independence in selecting the foods desired. Families The alternative snack system is a flexible teaching tool that can be adapted to the learning readiness of the family. Some families think more concretely and do better with the day-to-day management of their child's diabetes when the environment is more structured and they do not have to make frequent decisions. These families are taught about the different sizes of snacks, but are given only one or two choices. If the child tires of a particular choice, then the dietitian offers another choice until all the combinations have been presented gradually over time. Some families, as well as some teenagers, reason more abstractly and are more cognitively mature. They enjoy being able to choose from several snack combinations and look forward to making their own decisions. The alternative snack system, therefore, allows dietitians to individualize the educational approach to best suit the child or teenager and the family. APPLICATIONS Snacks are an integral part of a healthful meal pattern for children and teenagers with IDDM. They supplement nutrient and energy intake for toddlers who are picky eaters, school-aged children who have hectic sports schedules, and teenagers who have increased energy requirements during their adolescent growth spurt. The alternative snack system is an effective teaching tool that provides variety and flexibility in food choices and a method to adjust carbohydrate intake as needed to balance insulin and exercise requirements in children and teenagers with diabetes mellitus. The system facilitates age-appropriate nutrition education and provides teaching opportunities that are meaningful to the child or teenager and the family. The alternative snack system can be avaluable addition to the nutrition management of children and teenagers with IDDM. · This study was supported, in part, by Maternaland Child Health Bureau, Adolescent Health Training GrantMCJIN 189596. References 1. Exchange Lists for Meal Planning. Alexandria, Va: American Diabetes Association, and Chicago, Ill: American Dietetic Association; 1986. 2. Pastors JG. Alternatives to the exchange system for teaching meal planning to persons with diabetes. DiabetesEducator.1992; 18:57-62. 3. Diabetes Care and Education Practice Group. Meal PlanningApproachesfor DiabetesManagement. 2nd ed. Chicago, Ill: The American Dietetic Association; 1994. 4. Connell JE, Thomas-Dobersen D. Nutritional management of children and adolescents with insulin-dependent diabetes mellitus: a review by the Diabetes Care and Education dietetic practice group. JAm Diet Assoc. 1991; 91:1556-1564. 5. Thom SL. Protein: The last macronutrient frontier. Diabetes Spectrum. 1993; 6:332-333. 6. Golden MP, Ingersoll GM, Brack CJ, Russell BA, Wright JC, Huberty TJ. Longitudinal relationship of asymptomatic hypoglycemia to cognitive function in IDDM. Diabetes Care. 1989; 12:89-93. 7. Ryan CM, Atchison J, Puczynski S, Puczynski M,Arslanian S, Becker D.Mild hypoglycemia associated with deterioration of mental efficiency in children with insulin-dependent diabetes mellitus. J Pediatrics. 1990; 117:32-38. 8. Maynard T. Exercise, part 1: physiological response to exercise in diabetes mellitus. Diabetes Educator. 1991; 17:196-204. 9. MacDonald MJ. Postexercise late-onset hypoglycemia in insulindependent diabetic patients. Diabetes Care. 1987; 10:584-588. 10. Satter E. Child of Mine-Feeding with Love and Good Sense. Palo Alto, Calif: Bull Publishing; 1986.
Alternative snack system for children and teenagers with diabetes mellitus EMILYLOGHMANI, MS, RD; KARYL A. RICKARD, PhD, RD
utritionmanagementis awidely recognized cornerstone of ABSTRACT An alternative snack system facilitates diabetes management and provides a teaching tool for age-appropriate nutrition education of children and teenagers with diabetes mellitus. The system consists of four snack sizes: Mini - 7 to 10 g available glucose, Little - 15 to 20 g, Big - 30 to 35 g, and Super-Big 50 to 55 g. Within each category, several snack patterns are equivalent to each other in terms of available glucose and energy. By using this system, a child or teenager can eat snacks that contain different food groups and still adhere to the overall meal plan. When additional carbohydrate is needed for exercise or the prevention of nighttime hypoglycemia, a snack from the next largest category will increase available glucose by approximately 15 g and energy intake by approximately 100 kcal. Generally, for every hour of extra physical activity, a Little snack is added. When blood glucose concentrations before a nighttime snack are 4.4 to 6.7 mmol/L, a Little Snack is added to the usual bedtime snack, and when levels are less than 4.4 mmol/L, a Big snack is added. Further adjustments are made for children younger than 5 years old. The alternative snack system is a valuable nutrition education tool for the management of diabetes in children and teenagers. JAm Diet Assoc. 1994; 94:1145-1148.
the medical management of diabetes mellitus. Snacks are of particular importance for children and teenagers with insulin-dependent diabetes mellitus (IDDM) because these patients usually receive a combination of short-acting and intermediate-acting insulin twice daily and eat three meals and one to three snacks to enhance metabolic control. An alternative snack system, developed at J. W. Riley Hospital for Children, is an effective teaching tool for children and adolescents. The system is simple to learn, allows young people of all ages to be independent in creating their own snacks, and is easy to use. The system also offers flexibility and variety for usual snacks and additional food eaten to prevent hypoglycemia related to increased exercise or low concentrations of blood glucose at bedtime. Furthermore, daily adjustments in types of food eaten as snacks can be made depending on food availability. Use of the alternative snack system may promote decision-making skills related to diabetes management, enhance growth and development, and nurture self-esteem. Most importantly, children and teenagers are intrigued by the snack names - Mini, Little, Big, and Super-Big and quickly become active participants in figuring out how their favorite snacks can be eaten. A discussion of alternative snacks can lead to a desire to learn more about exchanges, food groups, and portion sizes. The alternative snack system contributes to meeting the educational objectives for children and families in our diabetes education program. At diagnosis, a detailed nutrition history is obtained to learn about the child's school and activity schedule, food likes and dislikes, and family eating patterns. An individualized meal plan is developed with this information, and the family learns about meal planning with the use of the food exchange lists (1). A dietitian helps the family write sample menus to be used at home. Often children are passive listeners to the meal-planning discussion, but their ears perk up when the alternative snack system is introduced. When the child is shown how favorite snack foods can be incorporated into the snack patterns, the concepts of food groups and portion sizes become more meaningful. ChilE. Loghmani (correspondingauthor) is a pediatric dietitianand certified diabetes educatorand K A. Rickard is professor of nutrition and dietetics in the Department of Nutrition and Dietetics, Indiana University School of Medicine, James Whitcomb Riley HospitalforChildren, 702 BarnhillDr, Room 1010, Indianapolis,IN46202-5200. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 1145
PISPCIVWEs H PRCTICE
Table 1 Available glucose and approximate energy provided in each category of the alternative snack system Snack category
Available glucose (g)
Approximate energy (kcal)
Mini
7-10
50-75
Little
15-20
100-135
Big
30-35
200-250
Super-Big
50-55
300-350
dren who are referred to our program because of poor glycemic control often have difficulty following the prescribed meal plan; this may be related, in part, to lack of variety in food choices. Once taught how to use the alternative snack system, families report increased satisfaction with the recornuended meal pattern. The purpose of this article is to describe the alternative snack system and ways to adjust snacks to account for children's increased exercise and lower blood glucose concentrations at night. We also discuss how the alternative snack system contributes to age-appropriate nutrition education of children and teenagers with IDDM. DESCRIPTION OF THE ALTERNATIVE SNACK SYSTEM The alternative snack system consists of four sizes of snacks: Mini, Little, Big, and Super-Big (Table 1). Within each snack category, three to five food combinations (Table 2) have an equivalent amount of available glucose and energy. For example, a Little snack of one bread exchange and one fat exchange has 17 g available glucose and 125 kcal, whereas a Little snack of one fruit exchange and one meat exchange has 20 g available glucose and 135 kcal. The available glucose was calculated based on the premise that 100% of the grams of carbohydrate, 58% of the grams of protein, and 10% of the grams of fat in each food combination are converted to glucose after digestion (2,3). Energy content was calculated with 2% milk and medium-fat meat exchanges. Children and family members are taught that the food combinations in each list provide similar available glucose and total energy. The specifics of the total available glucose (TAG) system for meal planning is not part of the educational process because of its inherent complexity. Generally, meal patterns for children and teenagers with IDDM contain 50% to 55% carbohydrate, 12% to 20% protein and 25% to 30% fat. The protein in the alternative snack system is calculated into the meal plan to avoid excessively high protein intakes, which may be associated with deterioration in kidney function (4,5). Usually, the morning snack is calculated with no meat or milk exchange; the afternoon and evening snacks are calculated with one meat or one milk exchange for the Little and Big snacks and two meat or one meat and one milk exchange for the SuperBig snack. If a child or teenager routinely eats more protein in snacks than what is calculated, the meal plant is adjusted to keep protein intake at a reasonable level. With the alternative snack system, a child or teenager can eat snacks from different food groups while following his or her meal pattern. For example, a child who has a Little snack in the moring may choose to eat six vanilla wafers for one starch/bread and one fat exchange on Monday, /4-c cottage cheese with two diet peach halves for one fruit and one meat exchange on Tuesday, and '/z meat sandwich for one starch/bread and 'h meat exchange on Wednesday. Given a variety of possible food combinations for snacks, children learn how to flexibly manage and control available glucose at home, at school, at sports events, or with friends. 1146 / OCTOBER 1994 VOLUME 94 NUMBER 10
Adjustments in Snacks for Increased Exercise The alternative snack system is a useful tool for deterrninirg how to increase food intake in those situations that may lead to hypoglyceitia, such as increased activity or lower blood glucose concentrations at night. Generally, the child and amily members are taught to increase the usual snack by adding a Little snack (15 to 20 g available glucose) for each hour of activity or exercise that is not in the normal routine. For activities of short duration (less than an hour) or activities such as baseball during which physical exertion starts and stops, a Mini snack (7 to 10 g available glucose) in addition to the usual snack is sufficient in most instances to prevent exercise-induced hypoglycenmia. For longer, more strenuous sports, such as swimming, cross-country r running, or basketball, a Big snack (30 to 35 g available glucose) may be added to the usual snack eaten before the activity, andl additional carbohydrate-containing foods should be available to add as needed. For activities of short duration, a snack that is mainly car)ollydrat, (eg, granola bar, crackers, or fruit) is recorrmended; for sports of' longer duration, that is those lasting 2 hIours or mliore, anlalterriative snack with protein and carbohydrate is re( omlnmended (eg, meat sandwich, peanut butter and crackers). The alternative snack system is used to prevent rather than treat hypoglycemia, because even asymptonmatic hypoglycemia may be related to neuropsychological changes (6,7), and recovery of mental efficiency may take longer than the physiologic increase in blood glucose concentrations to normal (7). If hypoglycermiia occurs during exercise (or otherwise), families have specific and different guidelines for treating the condition with quick-acting carbohydrate (eg, glucose tablets) rather thal more complex combinations of food. Exercise-induced hypoglycemia related to sporadic activity canl often be preventedi by adding a Little snack (15 to 20 g available glucose) to the usual snack for every hour of activity. Some situations, however, require a reduction i insulin dose or additional blood glucose monitoring before, during, and after exercise to determine the glycendc pattern (4,8). A child who plays soccer 2 days a week front 6 to 7 f, can add a Little snack to the evening meal before the game. A teenager who trains for competitive volleyball 5 days a week from 3 to 6 I'M will need to begin with an additional Super-Big snack (50 to 55 g available glucose) that contains protein and may need( to decrease the morning dose ofintermediat c-actinginsulin. Sonme athletes prfelr to decrease the insulin dose instead of eating extra food. This is especially true for athletes who prefer not to exercise after eating or for those who are weight conscious and want to avoid the additional energy in extra snacks. (Children and teenagers can explerielnce nexpe tedl hypoglycermia 12 to 24 hours after exercise as the body repletes glycogen stores in the liver (4,9). Extra monitoring f blood glucose concentration is the best. way to ascertain and avoid the risk of delayed hypoglycemnia. Postexercise hypoglycemia or an increased frequency of hypoglycemia nmay occur at t:he beginning of an active vacation or the start of the school year. Blood glucose monitoring also provides information about times when blood glucose is high (>13.9 nrmol/L) 1 and the addition of extra carbohydrate may be counterproductive. Adjustments in Snacks at Night Adjustments in the alternative snack system have been extremely valuable in managing blood glucose (concentrations during the night and in relieving parents' anxiety about nighttime 'To convert minot/L glucose Io to n/dL, lltiplt 111mnol/L by 18.). To convert ng/dL glucose to rmmnol/L, multiply Ing/d b 0.0555. (Glucoseof i6.0 miol1=108 mg/dL.
Table 2 Food combinations for the alternative snack system Snack category Mini
Food combination /2
'/2
Little
Big
Super-Big
Bread,
112fat
Fruit, 2meat
Possible selections Animal crackers-4 Apple-/2, cheese---/2 oz
V2Milk (2%)
Milk--/2 c
1 Bread, 1 fat
Vanilla wafers-6 Toast-1 slice, margarine-1 tsp
1 Fruit, 1 meat
Diet pear halves-2. cottage cheese-14 c Apple-1 small, cheese- oz
'/? Milk (2%), 1/';bread
Milk--12 C, cereal-'/2 serving Milk-'/2 C,vanilla wafers-3
1 Bread,
Bread-1 slice, thin-sliced ham-/2 oz, mustard (if desired) Saltines-6, wafer-thin lean beef-'/2 oz
L/2meat
1 Milk (2%)
Milk--1 c Plain yogurt with artificial sweetener and cinnamon-- 1 c
2 Breads, 2 fats
English muffin-i, margarine-2 tsp French fries---20 (1 small order)
1 Fruit, 1 meat. 1 bread
Apple-1 small, peanut butter-i Tbsp, popcorn-3 c Orange juice--"2 c turkey-1 oz, bread-1 slice
1 Milk (2%), 1 bread
Pain yogurt- 1 c, fat-free granola-/4 c Milk-1 c, graham crackers-3 squares
213reads. 1 meat
Pizza-3.5 o02 Bread-2 slices, peanut butter-1 Tbsp, sugar-free jelly-2 tsp
3 Breads, 2 fats
Bagel-1 whole (3 oz), cream cheese-2 Tbsp
1 Fruit, 1 meat, 1 bread, 1 milk (2%)
Grapes-15. cheese--i oz, rice cakes-2, milk-- c
1 Milk (2%), 2 breads 1 meat
Milk-1 c, hamburger bun-1, meat-1 oz Milk- 1 c, pizza--3 5 oz
2 Breads, 1 meat, 1 fruit, 1fat
hypoglycemia and seizures. In our program, we recommend that the evening snack contain protein, either milk or meat, to provide a delayed source of glucose during the night when the child is not eating. In addition., we advise monitoring blood glucose concentrations before the evening snack to help the parents decide whether additional carbohydrate is needed. For children aged 6 years and older, if the blood glucose concentration before the evening snack is between 4.4 and 6.7 mmol/L, the addition of a Little snack to the usual snack is recommended. For example, a Little snack would be increased to a Big snack and a Big snack would be increased to a Super-Big snack. If the child's blood glucose concentration is less than 4.4 mmol/L, one fruit exchange of juice would be given immediately. The blood glucose concentration would be remeasured in 15 minutes to ensure that it has increased before giving the usual snack plus the additional Little snack. Children 5 years old or younger should have blood glucose goals slightly higher than those of older children before bedtime to further minimize the risk of hypoglycemia. For this age group, we recommend increasing the usual evening snack by one half if the blood glucose concentration is less than 8.3 mrol/l and adding an additional fruit exchange of juice if the blood glucose concentration is less than 5.5 mmol/L. These guidelines usually provide adequate, but not excessive. carbohydrate during the night.
Bread-2 slices, thin-sliced turkey-1 oz, orange juice-r2 c mayonnaise -1 tsp
CONTRIBUTION TO NUTRITION EDUCATION OF CHILDREN AND TEENAGERS WITH DIABETES AND THEIR FAMILIES Toddlers and Preschoolers Children in the toddler and preschool age range are preoperational and egocentric in their thinking. Toddlers are also at a stage when they may exert their independence rather than eat (10), and the amount of food eaten at meals and snacks may vary considerably depending on their activity level during that particular day. A more flexible, alternative snack system increases choices, thereby potentially averting food battles and rejection of food. This can be extremely helpful in reducing the risk of hypoglycemia, a major goal of diabetes management in children of this age. A younger child may have some difficulty recognizing and verbally labeling symptoms of insulin reactions (eg, "I feel shaky or sleepy"). Thus, parents need to discriminate between ageappropriate behavior, such as contrariness, and true insulin reactions; the discrimination process is assisted by monitoring blood glucose levels. Children in this age group usually have Mini or Little snacks in their meal pattern and increase to a Little or a Big snack in situations involving additional exercise. A toddler may increase "exercise" by going to special places or events (eg, zoo, carnival. OI()TRNAL OF THE AMERICAN D)IETETI('
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family reunion) where he or she is unusually active. The alternative snack system allows snack choices to be readily adapted to available foods. School-Aged Children Children become more emotionally independent during the ages of 6 to 12 years. Motor, reading, mathematical, and reasoning skills increase quickly as do independence and pride in one's accomplishments. Parents can facilitate the child's involvement in his or her own diabetes care by allowing the child to choose and prepare appropriate snacks from the options within a category.
The alternative snack system isa teaching tool that enables children to become active participants intheir own diabetes management Snacks at school need to be managed carefully to promote a child's sense of well-being. Children may be reluctant to eat snacks that require special preparation and draw attention from other students. The Little snack choices, typically one starch/ bread and one fat, can be eaten easily and inconspicuously in the classroom. Popular choices with children in our program are one granola bar, or three peanut butter and cheese crackers, or eight animal crackers. Those children with an early lunch period (ie, 10:30 to 11 AM) may have two Little snacks in the afternoon: one to be eaten at school (between 1:30 and 2 PM) and one to be eaten with siblings when they get home (between 3:30 PM and 4 PM). Children in this age group usually have Little and Big snacks in their meal pattern, and for situations involving exercise, they increase to a Big or Super-Big snack. Some older or more active school-aged children eat Super-Big snacks and increase to a Super-Big plus a Little snack for exercise situations. Teenagers Teenagers struggle with an evolving self-concept and the need for autonomy and independence. Because social activities often revolve around food, teenagers need a flexible meal plan that allows choice and spontaneity so they can eat as their peers do. The alternative snack system offers teenagers a way to fit a variety of popular foods into an allotted snack size. A teenager who is with friends at a fast-food restaurant can eat several food combinations for a Big snack: one slice of pizza (about 3'/2 oz=two starches/ breads and one meat) and a diet soft drink, or a small hamburger (two starches/breads and one meat) and a diet soft drink, or a small order of french fries (two starches/breads and two fats) and a diet soft drink. The size of snacks consumed by teenagers varies according to energy needs, sports activities, and stage of maturation. Teenage girls who are not very active or have achieved their adult height frequently need Little snacks or no snacks during the day (except at night) to control their weight. If a teenager requests that the midmorning snack be omitted, blood glucose concentrations can be managed by adding carbohydrate to breakfast or by adjusting the morning dose of short-acting insulin to reduce the risk of hypoglycemia. Active teenagers or those who are still growing often have Big, Super-Big, or Super-Big plus a Little snack to help them meet greater energy needs. The alternative snack system allows teenagers to choose the snack size according to activity 1148 / OCTOBER 1994 VOLUME 94 NUMBER 10
level; the choices within each category allow independence in selecting the foods desired. Families The alternative snack system is a flexible teaching tool that can be adapted to the learning readiness of the family. Some families think more concretely and do better with the day-to-day management of their child's diabetes when the environment is more structured and they do not have to make frequent decisions. These families are taught about the different sizes of snacks, but are given only one or two choices. If the child tires of a particular choice, then the dietitian offers another choice until all the combinations have been presented gradually over time. Some families, as well as some teenagers, reason more abstractly and are more cognitively mature. They enjoy being able to choose from several snack combinations and look forward to making their own decisions. The alternative snack system, therefore, allows dietitians to individualize the educational approach to best suit the child or teenager and the family. APPLICATIONS Snacks are an integral part of a healthful meal pattern for children and teenagers with IDDM. They supplement nutrient and energy intake for toddlers who are picky eaters, school-aged children who have hectic sports schedules, and teenagers who have increased energy requirements during their adolescent growth spurt. The alternative snack system is an effective teaching tool that provides variety and flexibility in food choices and a method to adjust carbohydrate intake as needed to balance insulin and exercise requirements in children and teenagers with diabetes mellitus. The system facilitates age-appropriate nutrition education and provides teaching opportunities that are meaningful to the child or teenager and the family. The alternative snack system can be avaluable addition to the nutrition management of children and teenagers with IDDM. · This study was supported, in part, by Maternaland Child Health Bureau, Adolescent Health Training GrantMCJIN 189596. References 1. Exchange Lists for Meal Planning. Alexandria, Va: American Diabetes Association, and Chicago, Ill: American Dietetic Association; 1986. 2. Pastors JG. Alternatives to the exchange system for teaching meal planning to persons with diabetes. DiabetesEducator.1992; 18:57-62. 3. Diabetes Care and Education Practice Group. Meal PlanningApproachesfor DiabetesManagement. 2nd ed. Chicago, Ill: The American Dietetic Association; 1994. 4. Connell JE, Thomas-Dobersen D. Nutritional management of children and adolescents with insulin-dependent diabetes mellitus: a review by the Diabetes Care and Education dietetic practice group. JAm Diet Assoc. 1991; 91:1556-1564. 5. Thom SL. Protein: The last macronutrient frontier. Diabetes Spectrum. 1993; 6:332-333. 6. Golden MP, Ingersoll GM, Brack CJ, Russell BA, Wright JC, Huberty TJ. Longitudinal relationship of asymptomatic hypoglycemia to cognitive function in IDDM. Diabetes Care. 1989; 12:89-93. 7. Ryan CM, Atchison J, Puczynski S, Puczynski M,Arslanian S, Becker D.Mild hypoglycemia associated with deterioration of mental efficiency in children with insulin-dependent diabetes mellitus. J Pediatrics. 1990; 117:32-38. 8. Maynard T. Exercise, part 1: physiological response to exercise in diabetes mellitus. Diabetes Educator. 1991; 17:196-204. 9. MacDonald MJ. Postexercise late-onset hypoglycemia in insulindependent diabetic patients. Diabetes Care. 1987; 10:584-588. 10. Satter E. Child of Mine-Feeding with Love and Good Sense. Palo Alto, Calif: Bull Publishing; 1986.