title: Improving dietary quality in youth with type 1 diabetes: randomized clinical trial of a family-based behavioral intervention.
abstract: BACKGROUND
  Diets of children with type 1 diabetes are low in fruits, vegetables, and whole grains, and high in foods of minimal nutritional value, increasing risk for future adverse health outcomes. This 18-month randomized clinical trial tested the effect of a family-based behavioral intervention integrating motivational interviewing, active learning, and applied problem-solving on the primary outcomes of dietary intake and glycemic control among youth with type 1 diabetes.
  
  
  METHODS
  A parallel-group study with equal randomization was conducted at an outpatient, free-standing, multidisciplinary tertiary diabetes center in the United States. Eligible youth were those age 8-16 years with type 1 diabetes diagnosis ≥1 year and hemoglobin A1c (HbA1c) ≥6.5% and ≤10.0%. Participants were 136 parent-youth dyads (treatment n = 66, control n = 70). The intervention consisted of 9 in-clinic sessions delivered to the child and parent; control condition comprised equivalent assessments and number of contacts without dietary advice. Dietary intake was assessed using 3-day diet records at 6 time points across the 18-month study. Dietary outcomes included the Healthy Eating Index-2005 (HEI2005; index measuring conformance to the 2005 United States Dietary Guidelines for Americans) and Whole Plant Food Density (WPFD; number of cup or ounce equivalents per 1000 kcal of whole grains, whole fruit, vegetables, legumes, nuts, and seeds consumed). HbA1c was obtained every 3 months. Overall comparison of outcome variables between intervention and usual care groups was conducted using permutation tests.
  
  
  RESULTS
  There was a positive intervention effect across the study duration for HEI2005 (p = .015) and WPFD (p = .004). At 18 months, HEI2005 was 7.2 greater (mean ± SE 64.6 ± 2.0 versus 57.4 ± 1.6), and WPFD was 0.5 greater (2.2 ± 0.1 versus 1.7 ± 0.1) in the intervention group versus control. There was no difference between groups in HbA1c across the study duration.
  
  
  CONCLUSIONS
  This behavioral nutrition intervention improved dietary quality among youth with type 1 diabetes, but did not impact glycemic control. Findings indicate the potential utility of incorporating such strategies into clinical care, and suggest that improvement in diet quality can be achieved in families living with this burdensome disease.
  
  
  BACKGROUND
  Clinicaltrials.gov registration number: NCT00999375.
authors.affiliation: Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6100 Executive Blvd. Rm 7B13R, MSC 7510, Bethesda, MD, USA. nanselt@mail.nih.gov.
authors.forename: Tonja R
authors.initials: TR
authors.lastname: Nansel
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA. lori.laffel@joslin.harvard.edu.
authors.forename: Lori M B
authors.initials: LM
authors.lastname: Laffel
authors.affiliation: Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6100 Executive Blvd. Rm 7B13R, MSC 7510, Bethesda, MD, USA. haynied@mail.nih.gov.
authors.forename: Denise L
authors.initials: DL
authors.lastname: Haynie
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA. sanjeev.mehta@joslin.harvard.edu.
authors.forename: Sanjeev N
authors.initials: SN
authors.lastname: Mehta
authors.affiliation: Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6100 Executive Blvd. Rm 7B13R, MSC 7510, Bethesda, MD, USA. lipskylm@mail.nih.gov.
authors.forename: Leah M
authors.initials: LM
authors.lastname: Lipsky
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA. lisa.volkening@joslin.harvard.edu.
authors.forename: Lisa K
authors.initials: LK
authors.lastname: Volkening
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA. deborah.butler@joslin.harvard.edu.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Butler
authors.affiliation: Pediatric, Adolescent, and Young Adult Section, Genetics and Epidemiology Section, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA. laurie.higgins@joslin.harvard.edu.
authors.forename: Laurie A
authors.initials: LA
authors.lastname: Higgins
authors.affiliation: Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6100 Executive Blvd. Rm 7B13R, MSC 7510, Bethesda, MD, USA. liua@mail.nih.gov.
authors.forename: Aiyi
authors.initials: A
authors.lastname: Liu
mesh_terms: D000293:Adolescent; D001521:Behavior Therapy / Q000379:methods*; D001786:Blood Glucose / Q000032:analysis; D002648:Child; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000451:nursing* / Q000628:therapy*; D004032:Diet / Q000592:standards*; D015930:Diet Records; D005190:Family; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D008297:Male; D018673:Nutrition Policy; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human