Nutrition-related management of pediatric insulin resistance in the inpatient psychiatric setting

By Kellie Blake, RDN, LD, IFNCP

Childhood obesity rates have skyrocketed and now affect nearly one in five children and adolescents in the United States.  Obesity is the main cause of insulin resistance (IR) in this population and IR is an important precursor to adult disease.  Obese children and adolescents will likely experience poor health as they age if IR isn’t recognized early and addressed quickly. Lifestyle modification is the most effective treatment for the reversal of IR long-term, however, helping this age group make healthy lifestyle-related decisions can be challenging, especially in the inpatient psychiatric setting. 

While the prevalence of IR in overweight and obese children and adolescents is higher than in their normal-weight peers, IR can be seen in this population independent of weight during puberty.   Decreased insulin sensitivity leads to increased insulin production, but this transient IR returns to normal after puberty. However, obese children and adolescents can develop a pathological IR, which places increased stress on the pancreas and is responsible for the development of type 2 diabetes and other chronic diseases. 

The appropriate medical nutrition therapy intervention can have a powerful effect on future outcomes but can be difficult to implement in the inpatient psychiatric setting. In addition to the lack of physical activity and limited access to functional lab testing, the menu served is often the Standard American Diet (SAD), highly processed and low in nutritional value.  Patients frequently have access to refined carbohydrates, sugar and artificially sweetened beverages, concentrated sweets, and unhealthy fats, all of which affect glucose and insulin status. In addition, healthy nutrition decisions can be challenging for children and adolescents who have had poor nutritional guidance in their home environments.   

Ideally, a whole food, plant-based, healthy fat diet would be provided for those with pediatric IR.  The intake of refined carbohydrates, unhealthy fats, processed foods, and added sugars would be minimal.  But, drastic diet-related changes can set the stage for undesirable behaviors in the inpatient psychiatric setting. 

While overall diet quality is of utmost importance in the treatment of IR, several specific nutrients can be utilized to help reverse pediatric IR when in challenging circumstances. According to a 2019 study published in Nutrition Research and Practice, significant improvement in fasting glucose and HgbA1c was found in subjects who consumed 45 grams of walnuts per day for 16 weeks, even with no other diet related change.  Walnuts contain polyunsaturated fatty acids, fiber, antioxidants, and phytosterols, which have been associated with less insulin production and better glucose regulation. 

Inflammation is a key risk factor for IR. Olive oil contains monounsaturated fatty acids and biophenolic compounds that provide antioxidant and anti-inflammatory benefits. In a 2018 study in the International Journal of Molecular Sciences, olive oil was found to positively impact glucose regulation by affecting the digestion and intestinal absorption of glucose and enhancing tissue glucose uptake.  Olive oil also works to improve IR via antioxidant and immunomodulatory routes.  In this study, olive oil consumption was associated with the prevention of type 2 diabetes. Olive oil combined with both cardiovascular and strength training exercises was promising for an even greater impact.

Cinnamon can also be used to target IR. In a 2010 review in the Journal of Diabetes Science and Technology, the authors reported that cinnamon can improve insulin efficiency and decrease inflammation by decreasing the expression of mRNA involved in the production of pro-inflammatory factors. 

The gut microbiome has an important role as well. In a 2010 study in the British Journal of Nutrition, the use of L. acidophilus NCFM for four weeks by patients with type 2 diabetes, preserved insulin sensitivity. One explanation is related to the impact the gut flora have on energy regulation and obesity, which are important risk factors for IR. 

Case Study

Matthew is a 15-year-old male admitted to an inpatient psychiatric unit for residential treatment. Upon admission he was 14 years old, weighed 278 pounds with a body mass index (BMI) of 39.3. His BMI indicated he was greater than the 95^th percentile of BMI for age, which placed him in the obese category. Initial labs indicated IR with HgbA1 of 6.1 percent and Matthew reported having been diagnosed with “borderline diabetes” prior to admission.  In addition, his family history is positive for type 2 diabetes in both parents.

Nutrition history for Matthew included daily consumption of regular soda, processed and fast foods, and his vegetable intake was extremely limited. During the initial interview, Matthew was skeptical of any significant dietary change and he was especially hesitant to give up soda and concentrated sweets.   Matthew was educated on the importance of nutrition in disease prevention and when faced with the possibility of developing type 2 diabetes he agreed to a no concentrated sweets diet. He was encouraged to increase his non-starchy vegetable intake and physical activity.  After one month, his weight had dropped to 273 pounds.  Matthew stated “the diet is more enjoyable than I thought” and he reported less difficulty walking up the stairs.

After several weeks on the program his weight remained above 270 pounds with no change in the HgbA1c. Fasting insulin and glucose levels were requested, but only fasting glucose levels were ordered by his physician.  Fasting glucose readings were elevated at 114, 113, and 110mg/dL. Matthew agreed to walk for ten minutes after every meal, consume one half teaspoon of cinnamon daily at breakfast, and he was placed on a multivitamin with b complex and 1,000 milligrams of omega-3 fatty acid due to his psychiatric diagnosis and still limited nutrient intake. An attempt was made to add walnuts and olive oil to his plan, but Matthew was resistant to this recommendation. 

One month later, there had been no change in his weight.  After significant education, he agreed to a calorie-controlled, consistent carbohydrate meal plan that included 45 grams of carbohydrate per meal with double non-starchy vegetables.  A probiotic,  Lactobacillus acidophilus, was added.  One month later his weight had dropped to 260 pounds. Matthew reported having more confidence and stated he was surprised he had made such progress. 

One year after admission, his HgbA1c is 5.9 percent, weight is 243 pounds, and BMI has decreased to 34.3. Matthew reports being happy with his 35 pound weight loss and states he feels much better every day. 

Matthew has had some significant barriers related to manipulative behaviors and his food intake has been difficult to control. The inpatient nature has made it challenging to provide a more complete medical nutrition therapy, but Matthew has been successful in reducing his overall health risk. After seeing his progress and providing much encouragement, Matthew has now agreed to the addition of one-quarter cup of walnuts (not the therapeutic dose, but a step in the right direction) and two tablespoons of olive oil per day. His HgbA1c will be monitored after one month on the walnuts and olive oil and his plan will be adjusted accordingly. 

Matthew continues to attend nutrition groups monthly and has frequent individual follow up nutrition sessions for monitoring and encouragement. Being creative, flexible, supplying specific nutrients, and allowing Matthew to participate in his own plan have been successful interventions.  With continued diligence, he is hopeful to prevent type 2 diabetes.

A whole food, plant-based diet is indicated for pediatric IR, however, is not always possible in the inpatient psychiatric setting. Empowering kids and teens to make healthier choices is the ultimate goal but can be difficult initially. Providing nutrition education and frequent monitoring throughout the process, as well as allowing the pediatric patient to have input into their own care plan can improve compliance and produce more desirable outcomes.