Nutrition and nutrition education at diabetes camps: Past and present
Morgan, Wanda A
Nutrition and nutritional professionals have played an important role at diabetes youth camps since the earliest camps in the 1920s Every summer since the first camps, dietitians have supervised and directed the nutritional management, education, and preparation of food for children with diabetes in camps across the United States Many times, these individuals have been volunteers (Hooker, 1960; John, 1946). Earlier published accounts of diabetes camps have centered on the children attending the camps; nutrition practice and the role of registered dietitians have not been the focus of previous reports The purposes of this review are to highlight the history of diabetes camps with a particular emphasis on nutrition and nutritional professionals and relate their current role and applications of nutrition education in this unique setting.
Purpose and Goals of Camps for Children with Diabetes
The first camps were designed to offer children with diabetes a summer camp experience that paralleled that of other children. Early camp directors (John, 1948; Marble, 1952; Smelo & Eichold, 1955) recommended that medical matters be kept in the background while recreation be the primary goal. Fun and recreation remain the most important goal of camps for children with diabetes today. Travis, Johnson, McMahon, Brouchard, and Cunningham (1981) recommended these objectives for camps with children with diabetes: (a) provide personnel and facilities to assure enjoyable recreational camping experiences; (b) provide appropriate site and program (recreational and medical); (c) ensure peer interactions; (d) facilitate learning for effective living with diabetes; (e) promote independence and self-reliance; (f) facilitate smooth reentry to home environment; and (g) provide a respite for parents. Additional objectives that some camps may include are: (a) assist children in establishing diabetic control; (b) facilitate maturation; (c) provide educational experiences for health professionals; (d) assist children wishing to enter nondiabetic camping programs; and (e) conduct research designed to benefit children with diabetes (Travis et al., 1981).
History of Diabetes Camps
Summer camps for children with diabetes began soon after the clinical usage of insulin injections started in 1922.The first summer camp in the United States for children with diabetes was begun in 1925 by a Detroit physician, Dr. Leonard Wendt (John,1948). Early diabetes camps included Camp Ho Mita Koda in Ohio, which opened in 1929; the Clara Barton Birthplace Camp for Diabetic Girls in Massachusetts, founded in 1932; and camps located in Pennsylvania, New York, Washington, and California (Gabriele & Marble, 1949; John, 1946, 1948). Many camps closed during World War II due, in part, to the physician shortage caused by the war effort (John,1948). Following World War II, many camps reopened, and many more were established. By 1952, there were 18 diabetes camps located in 14 states attended by 1,300 children (Marble, 1952). By the 1980s, there were more than 90 camps for diabetic children in North America attended by almost 10,000 children (Travis & Schreiner, 1984).
In earlier decades, many summer camps excluded children with diabetes. For many communities, the operation of a separate camp for diabetic youths was the only way to offer these children the camp experience. With the passage of the Americans with Disabilities Act in 1992, more access was gained for children with diabetes to mainstream summer camps. Despite this law, the need for camps that serve the special requirements of boys and girls with diabetes still exists Currently, the American Diabetes Association sponsors more than 60 camps, with numerous other camps sponsored by divergent associations, groups, and individuals (American Diabetes Association,1992,1995).
History of Nutrition at Diabetes Camps
The first discussion of the role of a dietitian at diabetes camp was at Ohio’s Camp Ho Mita Koda. The camp medical director, Dr. Henry John, stated that food at the camp needed to be prepared by a good cook under the supervision of a dietitian (John, 1946). In early camp settings, dietitians were mainly involved with menu planning, supervision of food preparation, and calculation of diets. The Elliot P. Joslin Camp for Diabetic Boys in Massachusetts had each child on a separately calculated diet (Gabriele & Marble, 1949). Early on, this was recognized as impractical (McMullagh, Russell, & Schneckloth, 1950). Most camps began serving a set number of standardized diets, and campers were assigned to the most appropriate calorie level. Camp Ho Mita Koda had five standardized diets in the 1940s (John, 1946). Camps in New York and West Virginia used five to six standardized diets, ranging from 1,800 to 3,500 kcal (Hooker, 1960; Jacobi, 1953; Rabinowitz & Kuhnlein, 1958). Colorcoded plates and trays were often used to differentiate the calorie levels.
Another standard feature of the nutritional management of these children in the early camps was the use of weighed portions of foods. Gram and ounce scales were used either by the kitchen staff setting up the trays or the counselors at the campers’ dining tables (Gabriele & Marble, 1949; John, 1946; McCullagh et al., 1950; Sweeney,1951). Doris Graves, MD, (personal communication, July 1991) recalled that the dietitians at Camp Chinnock in the 1950s would only allow the serving of three fourths of a hot dog bun to get the bread exchange weight to be exact. Standardized measuring scoops, spoons, ladles, and portion control in slicing and serving have replaced the tedium of weighing (Hooker,1960).
Applications for Professionals
As nutritional recommendations and principles for children with diabetes have evolved, so have the nutritional strategies used at camps (ADA,1998; Holler & Pastors, 1997; Jacobi, 1954a, 1954b). As the practice of dietetics has grown and changed through the years, so has the role of dietitians at diabetes camps Registered dietitians were originally included in the staff of diabetes camps to manage food service and conduct diet calculations. Today, registered dietitians are involved at diabetes camps as nutrition and diabetes educators in the clinical management of diabetes while still assisting with food management issues. Franz (1981) recommended the following goals for registered dietitians working in the diabetic camp setting: (a) to improve the campers’ awareness of the importance of diet; (b) to help campers acquire additional dietary knowledge; and (c) to assist campers in the practice of dietary management in a supervised setting. Skyler (1976) recommended a staffing level of two dietitians for every 100 diabetic campers.
Food Service Systems Management
Many diabetes camps have used food service techniques similar to those of the school lunch program. As nutrition principles for people with diabetes no longer necessitated the tedium of weighing food portions, camps also stopped using this method of food portioning. Three meals and three snacks daily have been the standard meal pattern. Two methods of food service have been used predominantly in diabetes camps. One is a cafeteria-style service whereby trays are set up in the camp kitchen and given to children as they walk by a serving line (Hooker, 1960; John, 1946; Sweeney, 1951). Family-style meal service is another serving option. Using this method, large platters and serving bowls of foods are placed on the tables where the campers eat. Staff members then serve food to the campers seated at that table (Parker, 1968; Stephens & Marble, 1951). Using portion control when serving, carbohydrate and calories can be adjusted for each child. Counselors and dietetics staff can monitor serving sizes and ensure that balanced meals are eaten by the youngsters. Children wanting additional servings can balance these extra calories and carbohydrates into meal times with the assistance of the dietitians.
The availability of menu substitutions is important to allow for the wide variability of food preferences of children. Peanut butter, sliced cheese, and cottage cheese make good protein substitutes for children who do not like the entree on the menu. Cereals, ready-made breads, crackers, and a variety of fruit choices can be appropriate carbohydrate substitutions for finicky eaters. Simple carbohydrates are now included in camp meals when balanced within a healthy meal plan. Dessert items such cakes, cookies, and brownies are now included on many camp menus.
Nutritional Guidelines at Diabetes Camps
Many different options are available to implement food choices at diabetes camps. The American Diabetes Association (1998) recommends nutritional guidelines for people with diabetes that emphasize near normal blood glucose levels, preventing and treating acute and long-term complications of diabetes while maintaining adequate calories for growth and development of children with diabetes These guidelines govern nutritional strategies of professionals who work with children with diabetes.
As with all children, children with diabetes have individual food preferences in addition to cultural and family food habits. Diabetes camps with centralized food service operations must cope with this diversity and individual preference. Holler and Pastors (1997) have recommended that foods for children with diabetes should be flexible, fun, and healthful. Basic meal planning approaches such as the food guide pyramid and exchange system may be used as the nutritional intervention strategy and as educational tools. Many children with diabetes are employing more in-depth nutritional intervention approaches such as carbohydrate counting (Dillinger & Yass, 1995; Gregory & Davis, 1994). A sample menu from Camp Challenge in New Mexico using carbohydrate counting is shown in Table 1. By giving the children access to camp menus and planned activities, carbohdyrate:insulin ratios can be taught and used in the camp setting when also coordinated with self blood glucose monitoring. Children can be taught carbohydrate counting if carbohydrate exchanges are noted on camp menus, and this can be reinforced at meal times.
Nutrition Education for Children with Diabetes
The nutrition education of children is primarily the responsibility of teachers in schools. The nutrition teaching strategy of school teachers is often the Food Guide Pyramid (Chalmers, 1994). Children with diabetes need nutrition education beyond the basics. Foods as fuels, good food choices versus poor food choices, and food effects on blood glucose levels is information needed by children with diabetes (Chalmers, 1994).
Successful nutrition education for children with diabetes needs to be flexible and fun. Children with diabetes are children first (Holler & Pastors, 1997). Games and nutritional activities such as “Nutritional Jeopardy” and “Nutritional Family Feud” can provide excellent learning experiences (Barry, 1995). Educational strategies that foster cognitive coping strategies such as problem-solving skills are the most effective for children with diabetes in fostering good metabolic control. Children who use emotional coping strategies often have poor metabolic control (Bosland & Grey, 1996). All of these strategies can be helpful to teachers and nutritionists who work with children with diabetes.
Nutrition Education at Diabetes Camps Diabetes camps offers unique educational opportunities to teach children with diabetes about diet, insulin, and selfmonitoring (Delameter, Smith, Kurtz, & White, 1988; Harkavy et al., 1983; Lebovitz, Ellis, & Skyler, 1978; Moffatt & Pless, 1983). Parents of children attending Camp Utada reported that wanting their children to learn about their diabetic diets was the number one learning experience they wanted their children to receive from camp (Parker, 1968).
Travis and Schreiner (1984) recommended age-appropriate education programs. Campers ages 6 to 9 years old can be taught basic nutrition skills and knowledge, especially with games, arts, and crafts. Children between 9 and 14 can be taught cause-and-effect relationships in the nutritional management of diabetes (Barry, 1995); teams with group and individual competitions can be used with these ages. Teenagers have developed cognitive skills of abstract thinking and are interested in adolescent issues such as alcohol, drugs, eating disorders, and sexuality. Small group discussions and role playing can be effective with teens. Various components of the education program can be delegated to the health care team assembled at camp, including the physicians, nurses, dietitians, and psychologists.
Dietitians as Diabetes Educators at Camp
Many registered dietitians who participate as staff members at diabetes camps have expanded roles as diabetes educators. Dietitians now participate fully in medical rounds with physicians and nurses. At diabetes camps as well as in clinical practice, dietitians who are certified diabetes educators make insulin dosage adjustments, treat hypoglycemia, and do clinical coverage. Dietitians have a long history of participation at diabetes camps, but now, as diabetes educators, they are full members of the health care team whose role has evolved far beyond menus and food management. Although the inclusion of registered dietitians on diabetes camp staffs is not required by the American Diabetes Association, it is recommended (ADA, 1992). The unique contributions that dietitians make to a camp staff is not duplicated by registered nurses or other members of the health care team. A health care team consisting of dietitians, nurses, physicians, and psychologists gives a balance of professionals to assist children with the clinical management of diabetes while at camp.
Diabetes camps since their founding in the 1920s have filled a special role in the lives of children with diabetes, providing excellent opportunities for children with diabetes to learn about their disease while having fun. Nutrition professionals have an important contribution to make in this effort. Dietitians have a unique role to play as food service managers and nutrition educators, and these dietitians who are certified diabetes educators also serve in the clinical management of diabetes.
Copyright American Association of Family & Consumer Sciences Summer 1998
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