Lectures

The care of children and young people with type 1 diabetes can present a variety of particular problems compared with adults. Many aspects of care and decision-making are taken by parents/carers until the child is mature enough to demonstrate increasing independence in the management of their diabetes. Dietary management is complex because it has many aims: to optimise growth, development and glycaemic control; reduce hypoglycaemia and macrovascular risk and maintain ideal body weight. These are difficult targets when the dietary intake of young people with diabetes is influenced by many factors e.g. age, peer group, indigenous diet, cost, family eating patterns, food availability, trends/fads. Over the last two decades the emphasis has changed in the theoretical basis of nutritional interventions, moving towards not simply imparting knowledge but to changing behavior and influencing factors such as self-care and readiness to change. This is a radical change from the old acute prescriptive medical model to a newer chronic disease approach that involves a collaborative self-management plan. The new approach now focuses on the process of change. This includes a trusting, equal, non-judgemental and supportive relationship between the health professional and child/family. The basis of this relationship promotes the patient as the decision-maker and self-carer. Past evidence suggested that children and young people found it difficult to achieve dietary targets with traditional teaching methods. The results from studies that have used a behavioral approach have been more successful. The findings from the adolescent group in the Diabetes Control and Complications Trial (DCCT) produced more favorable results showing that the development of a good relationship between the dietitian and the patient was necessary to negotiate treatment goals and achieve HbA1c targets. Pediatric diabetes centers have also demonstrated that improved HbA1c levels can be achieved, without an increase in levels of hypoglycaemia, through close attention to a patient-centered relationship with the health professional and a problem solving approach. Dietary interventions are always more successful when they have a degree of personalisation with goals tailored to the individual’s dietary intake. It is important that dietary goals are not perceived as imposed by the heath professional but were self-initiated and personally endorsed by the child or young person. The benefit of this approach is that autonomous motivation is expected to yield the long-term adherence required in dietary change. A behavioral approach to goal setting has been found useful in pediatric diabetes to achieve successful dietetic outcomes. A useful technique is described by the acronym ‘SMART’: Specific, measurable, achievable, relevant to the goal of treatment, and time specific. This technique is useful as setting unrealistic goals would set the child up for failure. L1 Diagnosis and treatment of monogenic diabetes in children A. T. Hattersley Professor of Molecular Medicine, Peninsula Medical School, Exeter, UK