Addressing food insecurity and nutrition challenges in pediatric type 1 diabetes care

Managing type 1 diabetes can be overwhelming for children and families. As children learn to live with the disease, many cut back on visits to their nutritionists. Others face barriers like food insecurity that make it difficult to maintain a balanced diet. And without the proper professional support and access to healthy foods, children’s overall health and diabetes management can suffer.

Recent research from Katharine Garvey, MD, MPH, director of the Boston Children’s Diabetes Program, and her team aims to help endocrinologists better understand — and address — these gaps in pediatric type 1 diabetes care. 

Understanding gaps in nutrition service

Dietitians play an important role in helping children with type 1 diabetes manage their condition through medical nutrition therapy (MNT). In MNT programs, dietitians tailor nutrition and physical activity strategies to meet the individualized needs of the child and their family in order to manage their blood glucose levels and stay properly fueled for their daily lives. As children grow and their nutritional needs change, dietitians can adapt those strategies accordingly.

“We have these overarching recommendations that nutrition therapy is important; it’s a major part of diabetes care,” explains Erin N. Gordon, a senior clinical nutrition specialist in the Diabetes Program. “Yet we have fairly low engagement numbers with nutrition appointments.”

To learn more about the discrepancy between the importance of nutrition therapy and low patient engagement with nutrition services, Gordon and her colleagues surveyed the parents and guardians of Boston Children’s patients with type 1 diabetes. As summarized in this PubMed article, they found that families newer to diabetes — within three years of diagnosis — were more likely to find nutrition services helpful. These families valued guidance on managing their child’s diet, as they had less experience with blood glucose management and the dietary complexities of type 1 diabetes. However, families who had experienced the disease for longer (three years or more) often felt that the information provided at nutrition visits was too basic, and that ongoing visits wouldn’t be as helpful. Beyond that, families of children with diabetes are often overwhelmed by frequent medical appointments.

Adolescents with type 1 diabetes presented another unique challenge: While parents recognized the importance of nutrition, engaging teens in nutrition appointments proved difficult. Many respondents agreed that nutrition appointments felt less useful or less meaningful over time.

“Families with teens acknowledge the importance of nutrition, but their engagement with nutritionists as disease duration goes on doesn’t necessary correlate with that,” Erin explains. “We have to think about how to engage with teenagers, and how to make those appointments more meaningful.”

Why food insecurity screening matters

Food insecurity affects almost one in five U.S. households with children. For children with diabetes, the stakes are even higher: Proper nutrition is essential for blood glucose management, and inconsistent access to healthy food can lead to unpredictable glucose levels, challenging diabetes control, and increased stress for families.

In a second study, Erinn T. Rhodes, MD, MPH, director of Endocrinology Healthcare Research, Quality, and Safety at Boston Children’s, and her colleagues conducted two surveys regarding screening for food insecurity (which were summarized in this PubMed article): One of parents and guardians of patients in the Diabetes Program, and another focusing on medical providers in the Diabetes Program, including physicians and diabetes nurse educators. The Diabetes Program planned the surveys to guide the development of a food insecurity screening program.

“We found that most providers reported not routinely screening for food insecurity, but all noted that screening had some importance for diabetes visits,” she explains. These providers cited barriers such as uncertainty about how to screen and not knowing the next steps to take if a family screened positive.

“Among parents and guardians, a minority had been asked about food insecurity during an appointment,” Dr. Rhodes adds. “However, few disliked the idea of being asked during an endocrine medical encounter.”

Building a better system

What steps can teams take to address these gaps in care without overwhelming patient families or their providers?

Dr. Garvey and her team sought to answer that question as well. They’ve developed a comprehensive, adaptable model for patient care designed to equip patients and families with the tools and resources they need to better understand and meet their nutritional needs. Their model includes:

• Educational materials and group classes tailored to families at all stages of their diabetes journey, covering a range of topics from basic nutrition to advanced concepts like managing high-fat, high-protein meals, and interpreting continuous glucose monitoring trends.
  
• Professional development opportunities for dietitians and providers, including regular training on advanced diabetes management, food insecurity, and strategies for addressing positive food insecurity screens.
  
• Tools and resources to support families, such as the Hunger Vital Sign Screener (integrated into pre-visit check-ins), community food resource guides, and referrals to social work and nutrition teams for additional support when needed.

“Nutrition has always been there,” says Dr. Garvey. “It’s always at the forefront. A lot of the focus in recent years has been on diabetes technology and getting people on advanced devices, which are life changing. But I think they’re also showing us that at the end of the day, it comes back around to food. To optimally manage this condition, you have to understand the nutrition principles and be able to apply them.”