ATTENDANCE AT TYPE 1 DIABETES CAMP IMPROVES NUTRITION KNOWLEDGE IN CHILDREN AND ADOLESCENTS

.......................................................................................ii ACKNOWEDGMENTS .........................................................................iv PREFACE ......................................................................................... vi TABLE OF CONTENTS...................................................................... vii LIST OF TABLES .............................................................................. viii MANUSCRIPT.....................................................................................

. Skills for monitoring signs and symptoms of hyper and hypoglycemia, checking blood glucose, and accounting for carbohydrates with a highly individualized insulin regimen must be taught from point of diagnosis in conjunction with diabetes specific and general nutrition education 1, 5 . Nutrition education is provided at diabetes camps and previous studies have found nutrition knowledge improves after attendance at camp 6 7 . Diabetes camps provide a safe and supportive environment for children and adolescents with T1DM to strengthen nutrition knowledge and develop fundamental self-management skills [7][8][9] .
In the few studies where nutrition knowledge was tested as a primary outcome, nutrition knowledge increased after attendance at a diabetes camp. However these studies failed to use validated instruments to assess nutrition knowledge. The Nutrition Knowledge Survey (NKS) was validated in the child and adolescent T1DM population 6 .
The NKS is a 23 item questionnaire including seven questions on general nutrition knowledge such as the benefits of fruits, vegetables and whole grains, seven questions assessing carbohydrate counting, seven questions on nutrition label reading, and three questions assessing blood glucose response to foods 10 . Although the NKS is a validated instrument, it has not been used to assess change in knowledge, nor has it been used in the setting of a diabetes camp.
A strong understanding of general and diabetes specific nutrition knowledge is necessary to maintain optimal glycemic control and prevent long-term health complications in individuals with T1DM. Maintaining optimal glycemic control can be compromised by physical growth, hormonal state, physical activity and diet quality.
Achieving optimal blood glucose control is particularly difficult in the child and adolescent due to physical and social maturation as well as diet quality [11][12][13][14] . Children and adolescents with T1DM typically consume a diet that does not include adequate amount of fruits, vegetables and whole grains but includes excessive amounts of total and saturated fat 13,15,16 . Most of the energy dense snacks that adolescents consume are processed foods that are high in added sugar and fat 13,17 . Adolescents with T1DM may choose processed foods to facilitate counting carbohydrates from food labels 13,14 .
Another challenge facing this population is the commonality of the dual diagnosis of Celiac Disease (CD) [18][19][20][21] . Celiac disease affects between of 9.2 to 11.1% of individuals that have T1DM compared to the general population where about 1 in 100, or 1% of individuals are diagnosed with CD 22 . This dual diagnosis means greater dietary restrictions and a great need for nutrition education.
Providing general nutrition as well as diabetes specific nutrition education from point of diagnosis provides a foundation to help individuals self manage their diabetes 12 .
A greater understanding of diabetes specific nutrition is related to better glycemic control, lower Hemoglobin A1c (A1C) and a reduced risk for developing cardiovascular disease 23,24 . After completing diabetes specific nutrition education sessions, children and adolescents have improved carbohydrate-counting accuracy, which was maintained at follow-up 25 26 . Nutrition education improves knowledge and management skills of children and adolescents with T1DM.
Physical activity is another factor that influences glycemic control. Regular physical activity provides a range of benefit especially in individuals with T1DM [27][28][29][30] .
Despite the beneficial effects of physical activity, only 4.7% of children and adolescents with T1DM achieve the recommended 60 min of moderate to vigorous physical activity per day 28,31,32 . This may be due to a fear of hypoglycemia, which could prevent them from believing that they are able to participate, or reduce their exercise self efficacy 27 .
Diabetes camps provide a safe setting for children and adolescents with T1DM to participate in physical activity, and therefore campers may have greater physical activity self-efficacy (PASE) in this setting compared to others 33,34 . However PASE has not been assess in relationship to diabetes camps.
Attendance at diabetes camps improves nutrition knowledge and glycemic control in children and adolescents with T1DM in a safe supportive environment with a controlled, diet and exercise regimen 8 33, 34 . However, the tools used to assess nutrition knowledge in previous research were not validated. The NKS was validated in the clinical setting in individuals age 10-17 with T1DM but has not been used to assess change or to assess knowledge in a diabetes camp 10 . The primary purpose of this study was to assess nutrition knowledge using the validated NKS after attending a diabetes camp with a 45-minute nutrition education. The secondary purpose is to analyze the relationship between previous camp experience physical activity self-efficacy.

Research design
This study used a single group pre post design. Participants attended a one-week summer camp at Camp Surefire, a camp specifically for children and adolescents with T1DM. Campers were exposed to standard nutrition and diabetes education from this staff. Campers also received an additional nutrition education session. Participants completed pre test of diabetes nutrition knowledge (Nutrition Knowledge Survey, NKS) 10 as well as a Physical Activity Self-Efficacy (PASE) questionnaire on the first day of camp and the post NKS at the end of camp 35  The answers to the NKS were not discussed at any point.

Intervention
The intervention was provided separately to younger campers age 10-12 and older campers age 13-17. The intervention for both age groups was exactly the same and lasted 45 minutes including a general nutrition lesson followed by a diabetes specific nutrition lesson including nutrition facts labeling, portion sizes, and insulin dose related to carbohydrate intake. The intervention was developed for this study but was not based directly off on the questions asked but rather the themes present in the NKS. Though the diabetes specific lesson was very similar to the format of the questions asked in this section of the NKS, the food examples were different and several portion sizes were discussed.
The general nutrition lesson used a lesson board with columns for each food group and two rows labeled "likes" for healthier options and "dislikes" for less healthy options. Campers were given food models and asked to get into groups based on the items that they had been provided. Once campers were in groups, they discussed why they chose their groups. The "Nutrition Likes and Dislikes" board was then presented to the group. Information about how important it is to eat foods from each food group every day was presented including how there are healthy "likes" and unhealthy "dislikes" in each food group depending on how the food was processed and prepared. Campers then placed their food model in the correct food group either as a "like" or "dislike" and explained to the group why they chose to place it where they did.
The next section used a large nutrition facts label with missing values, which was filled in during an interactive discussion about reading the food label, portion sizes and insulin dosages. Food models (including healthy and unhealthy items) with nutrition facts labels were printed and campers were responsible for filling out these on the nutrition facts label lesson board.

Analysis
Variables were assessed for normality using skewness and kurtosis and analyzed using SPSS (IBM 22.0. Armonk,NY). Demographic and medical data were compared between two age groups (10-12 years and 13-17 years) using independent t-tests and chisquared tests. Changes in NKS score for all participants as well as separate analysis by age group was assessed using a paired t-test. Data was again split into prior camp experience and no prior camp experience. Independent t-tests were used to compare prior camp experience with baseline NKS score as well as prior camp experience and PASE.
Based on the age effect found in the validation of the NKS, Analysis of Covariance (ANCOVA) explored controlling for age. Nonparametric bivariate spearman correlation was used to assess the relationship between baseline NKS score and PASE.

Results
Demographic and medical history data are presented in table 1. There was a significant increase in NKS score from pre to post (t=3.2, p=.002). Table 2 presents NKS pre and post scores. Scores were first analyzed by total campers (N=47) and then by age group (age group 1 (10-12 years n=16) and age group 2 (13-17 years n=31)). There was no effect of age on change in NKS score (ANCOVA f=0.7, t45=1, p=.724).
There was a significant correlation between baseline knowledge and PASE score compared to campers that did not have celiac (t=2.2, p=.03), however there was no effect of celiac disease on change in NKS score (ANCOVA f=0.6, 1,45df, p=.45).

Discussion:
As hypothesized, there was a significant increase in knowledge from pre to post in campers but this appears to be primarily due to 13 during the intervention and interactive. Some expressed how they had been exposed to the information presented to them before, but that it was presented in a different way, and the interactive lesson allowed them to learn and understand more. The  Those who reported celiac disease (CD) had higher NKS scores compared to those who did not. Individuals with CD must consume a gluten free diet in order to prevent inflammation and damage of the small intestine 22 . A dual diagnosis requires monitoring carbohydrate intake, while maintaining a gluten free diet that often contains high carbohydrate foods 22  The major limitation of this study is a lack of a control camp. Without a control camp, it is impossible to separate the effects of camp from the effects of intervention.
Future research is needed using an experimental design. Another limitation is the selfreporting of medical history data such as celiac disease. Medical data from primary care physicians office may be more accurate. The final limitation is that there was no followup. Previous studies found campers retained the knowledge learned at camp for 6-12 months after camp but these did not use a validated knowledge instrument 6 .
The prevalence of T1DM is increasing rapidly in children and adolescents resulting in the need for additional research in nonclinical settings such as diabetes camps. Children and adolescents with greater nutrition knowledge have been shown to have greater glycemic control as well as better overall management of their T1DM. As individuals transition from childhood to adolescence, they begin to gain independence and make more of their own decisions and self manage their diabetes 12 3 . Diagnosis occurs due to an autoimmune response that impairs insulin production from the beta cells of the pancreas 2 . Beta cells both sense blood glucose levels and produce insulin to keep glucose levels in control. Without these cells producing insulin, there is an unregulated amount of glucose in the blood. Glucose can therefore not enter the red blood cell to be used for energy, and the cell becomes coated with excess glucose, or glycated, which leads to further health complications such as heart disease, nerve damage, blindness and other organ damage 2 . Prior to diagnosis and insulin therapy, the individual will experience hyperglycemia, which presents itself with the classic symptoms of polydipsia, polyphagia, and polyuria 9 . Diagnostic criteria for T1DM include a fasting blood glucose level of 126mg/dL, a post prandial blood glucose greater than 200mg/dL along with symptoms of hyperglycemia, or an abnormal glucose tolerance test 10,11 . These results are combined with a hemoglobin A1C (HbA1c) test result, which is an average of blood glucose levels over the last 3 months 10,11 . Normal HbA1c range is 4.5-6%, which is an average blood glucose level of about 95-126mg/dL. Pre-diabetes HbA1c range is 5.7-6.4%, which is an average blood glucose level of about 115-140mg/dL 10,11 .
An HbA1c of 6.5% or higher, a blood glucose of 140mg/dL or greater on two separate occasions is considered a diagnostic criterion for diabetes 10,11 . In diabetes management, an HbA1c test should be administered every three months 10,11 . As HbA1c increases, the risk of developing complications from diabetes also increases 10,11 . Management of blood glucose levels and HbA1c is dependent on insulin injection therapy.
Insulin administration, through injection or pump, is the primary therapy for the delay and prevention of health complications such as cardiovascular disease, macular degeneration, and neuropathy 5 . Insulin regimens are individualized based on diet, physical activity, and physiology 8 . Blood glucose levels must be kept in control in order to prevent episodes of hyper or hypoglycemia. Without insulin therapy, the individual with T1DM will experience long-term help complications that will greatly affect quality of life and could lead to death.
Complications and challenges in the T1DM population The increased risk of hyperglycemia, vascular complications, and excess weight can be eliminated with insulin therapy and a healthy diet 6,12 . Though blood glucose ranges may be individualized to each individual with T1DM, normal fasting blood glucose range is 70-100mg/dL. Without insulin therapy, the individual with T1DM will experience chronic hyperglycemia, which leads to oxidative stress and increased inflammation due to the production of Advanced Glycosilation Endproducts (AGEs) 6 .
This is the major cause of vascular complications responsible for damage to the blood vessels, causing retinopathy, neuropathy and nephropathy, most commonly 6 . These vascular complications put individuals with T1DM at an increased risk for blindness, kidney disease, lower limb amputations and cardiovascular disease 6 . Also adding to this increased risk is excess weight [13][14][15] . As the rate of T1DM increases in the child and adolescent population, the rate of overweight and obesity is simultaneously increasing in this population 4,14 . As part of Medical Nutrition Therapy (MNT), the American Diabetes Association (ADA) and the International Society of Pediatric and Adolescent Diabetes (ISPAD) recommend a healthy overall diet along with exercise for the management of T1DM 8, [16][17][18] . A healthy diet and exercise regimen will help maintain weight and glycemic control and reduce risk for cardiovascular disease and dyslipidemia 18,19 .
Therefore, children and adolescents with T1DM especially need nutrition education that stresses the importance of an overall healthful diet as well as physical activity.
An additional challenge facing this population is the commonality of the dual diagnosis of Celiac Disease (CD) [20][21][22][23] . Celiac disease affects 9.2 to 11.1% of individuals that have T1DM 24 . Celiac disease is defined by an immune response that causes inflammation and damage to the mucosal walls of the intestine following ingestion of gluten, a protein found in wheat, barley and rye 25 . Therefore, the primary therapy for those that have CD, is a gluten free diet 25  Twenty-five Italian participants age 7-14 years using CSII were followed for 18 months.
During this time, standard ADA and ISPAD education programs were delivered, participants checked blood glucose six times per day, and routinely met with a multidisciplinary team to manage their glycemic control 18 . Results at the end of the follow-up period, showed that in individuals with significant improvements in HbA1c, total carbohydrate intake was significantly higher while fat and protein intake significantly decreased compared to baseline 18 . Proper nutrition education on the overall healthful diet along with carbohydrate counting, will improve the food choices that children and adolescents make. This will improve glycemic control and promote a nutrient-rich and healthful diet.

Nutrition Education
There is a need for diabetes specific and general nutrition education for children and adolescents with T1DM from point of diagnosis. Clements et al. gathered longitudinal information on T1DM care from a children's hospital. Overall, average HbA1c increased with the age of diagnosis with the greatest increases occurring in individuals diagnosed at age 10 or older 12 . Patients that were diagnosed at younger ages had better glycemic control and less of a rise in HbA1c as they aged compared to the older individuals 12 . Across all age groups, there was a significant rise in HbA1c after the start of insulin therapy during the first one and a half years after diagnosis 12 . These results can be explained by the multifaceted ways that T1DM need to manage their diabetes.
First, if diagnosed at a younger age, there may be more parental involvement in diet and insulin therapy, which would result in better glycemic control 12 . Children and adolescents are a high-risk population for poor glycemic due to peer pressure, lack of knowledge and rebellion. In addition, age of diagnosis may be related to blood glucose control 12 .
If diagnosed earlier in life, individuals will be exposed to education and support to manage their diabetes for a longer period of time than those diagnosed later in life.
Exposure to nutrition education as early as possible helps children and adolescents develop the skills and practices they need to best manage their diabetes. This population can be particularly challenging and the need for nutrition education is great.
T1DM: Childhood to Adolescence Children and adolescents are particularly challenging age groups in terms of general health care due to physical and social changes 1 . Prior to reaching adolescence, children have limited management options and parents have primary involvement in treatment decisions. However, these children must receive multiple doses of insulin throughout the day, sometimes at school or other places without their parents. This requires an understanding of insulin administration from all of the child's caretakers.
Transitioning from childhood to adolescence involves physical and social growth. This is a particularly challenging time for the adolescent with T1DM, especially during years of puberty when insulin dosages need to be constantly monitored. Insulin dosages will change daily and physiological response to the insulin may also vary greatly due to hormonal status affecting insulin sensitivity 27 . Monitoring blood glucose therefore proves to be frustrating, especially while the adolescent is developing social skills and wants to act as their peers do. However, it is during adolescence where self-management skills are developed and solidified to be carried into adulthood 27 . Adolescents begin to take responsibility for their health and are able to make their own decisions such as when, how, and how much insulin they are going to take as well as what foods they are going to eat. Information is easily attainable from sources that are unreliable and peers easily influence decisions 1 . Adolescents with T1DM need have access to reliable diabetes management information in order for them to make decisions that will benefit their health and to understand the short and long-term consequences of self-management behaviors.
Aside from proper diabetes management techniques, these individuals also need to have general nutrition education to promote an overall healthful diet due to their consumption of a typically nutrition poor diet.
Despite the importance of dietary quality and diabetes education, individuals with T1DM typically have a diet of less nutritional quality then the general population of adolescents 28 . All children and adolescents are recommended to maintain calorie balance in order to support normal growth. The recommended macronutrient distribution ranges for individuals age 4-18 are 45-65% carbohydrate, 10-30% protein and 13-15% fat 29,30 .
In the general adolescent population, sodium, saturated fat, sugars and refined gains are all consumed in excess and replace nutrient dense foods, which increases risk of obesity and cardiovascular disease 29,30 . Individuals T1DM should consume a diet similar to healthy individuals, rich in whole grains, fruits, vegetables, and low fat dairy while limiting trans and saturated fat consumption 31,32 . The American Diabetes Association to prevent the progression of heart disease and vascular conditions that often result from unmanaged diabetes 32 . A diet that includes carbohydrates from fruits, vegetables, whole grains and low-fat milk is recommended for tight glycemic control 32 . Adolescents with T1DM typically do not consume adequate amount of fruits, vegetables and whole grains but consume excessive amount of total and saturated fat [33][34][35] . Most of the nutrient poor foods that adolescents eat are snacks in-between meals that are high in added sugar and fat 33,36 . Snacking is important in order to maintain stable blood glucose levels, however Another reason for poor diet in adolescents with T1DM is the perception that it is easier to count carbohydrates that are listed on the nutrition label of packaged food items rather than foods without a label 28 . Lipsky et al. conducted a study looking at food preference and availability related to dietary intake and quality in children and adolescents ages 8-18 years with T1DM 28 . Preferences were assessed using a survey with a rating scale and dietary intake was assessed using three-day food records. Availability of food items was assessed using a yes/no survey given to the parents. The results showed that mean preferences were overall higher for refined grains, fats and sweets than for whole grains and vegetables. Children and adolescents in this study were 2-6 times more likely to rate refined grains, fats and sweets higher than fruits, vegetables and whole grains 28 . This demonstrates the need for nutrition education for the individual to know the importance of choosing healthy food options. There was also a positive correlation between fruit and whole grain intake with preference and availability demonstrating that families and care takers of the children and adolescents with T1DM have the responsibility providing access to foods of high nutritional quality 28 .
Children and adolescents with T1DM need exposure to fresh foods in order to become familiar with them and more easily count carbohydrates. If children and adolescents have access to these types of foods constantly, they are more likely to choose and prefer these items, which will decrease the stress of carbohydrate counting fresh food items. This may lead to a more healthful diet, and thus prevent detrimental health aliments in the future. In order to make these conscious decisions, individuals with T1DM must have access to education both in the clinical setting as well as in the nonclinical, less controlled setting amongst their peers.. Diabetes specific and general nutrition education is the foundation for achieving successful health-related outcomes 5 .
Education Impact on Children and Adolescents with T1DM Although there are many techniques, carbohydrate counting is the most common nutrition education incorporated into MNT for children and adolescents with T1DM.  38 . Results showed at baseline, more than half of the participants in the intervention group significantly over or underestimated carbohydrate amounts in foods such as milk, orange juice, carrots, broccoli, chicken nuggets, and mixed meals. Results also showed that individuals exposed to nutrition education who had assistance from their parents, had a significantly lower HbA1c (r 0.264, P 0.008) 38 . Another study showed similar results in the child and adolescent population 39 . Children and adolescents ages 8-18 with T1DM were asked to count the amount of carbohydrates in several different, common food items. Seventy-five percent of the study population over or underestimated the amount of carbohydrates by 10-15g. Prepared foods and foods that did not have a nutrition label were more likely to be incorrectly estimated, but foods that had a nutrition label were estimated with the most accuracy 39 . Both of these studies concluded there as a need for providing skills to estimate carbohydrates in foods without nutrition labels.
In order to facilitate monitoring the amount of carbohydrate in foods, children and adolescents tend to choose foods that have a nutrition label 37 . Foods that have nutrition labels are typically processed and have elevated amounts of fat, sodium and added sugar.
Fresh fruits and vegetables such as apples, oranges, lettuce and peppers are not labeled 37 .
A diet that includes more processed foods than fresh foods is easier for carbohydrate counting, but does not provide a healthful diet 4 . The focus on carbohydrates distracts from other macronutrients such as fat 18,40 . Choosing foods that are low in carbohydrates but high in fat also has a negative effect on glycemic index and weight 18,40 .
Carbohydrate counting must be taught to the individual with T1DM and their parents or caregivers, however this should be taught in conjunction with general nutrition and how to properly count carbohydrates in foods that do not have a nutrition label.
Upon diagnosis, education should focus on "basic survival skills" such as carbohydrate counting to control blood glucose and prevent hyper and hypoglycemia, and progress to diabetes self-management education (DSME) 1 . Diabetes self-management education should be highly individualized, detail oriented, and constantly reinforced to have a positive effect on adolescents with T1DM 1 . A fundamental aspect of DSME is self-monitoring of blood glucose (SMBG) 8 . Understanding SMBG is essential for individuals with T1DM to recognize their specific normal blood glucose ranges and how their bodies react to meals and insulin therapy. Ideally, SMBG should occur before and after meals, prior to exercising or any activity where a low blood glucose would be especially dangerous such as driving or before bedtime, and at any time when the individual feels that they are experiencing a high or low blood glucose 8 . This extensive checking of blood glucose will help maintain blood glucose control and serve as a guide for the multidisciplinary care plan team to adjust insulin and diet regimens if necessary.
Along with DSME and SMBG, the individual with T1DM must also have diabetes self-management support (DSMS) from family, peers and a multidisciplinary team that specializes in diabetes to develop a management plan that takes into consideration all aspects of the individual's lifestyle: age, school, work, physical activity, and social situations 8 . Children and adolescents experience many changes, physically and socially, and tend to find managing their diabetes burdensome. Therefore, motivation and support are critical to prevent acute hyper and hypoglycemic events, which, if left untreated will lead to the long-term complications previously discussed 41 . All of these forms of education and support are necessary for individuals with T1DM to gain knowledge of the condition and develop the ability to self-manage, make informed decisions and actively collaborate with a medical support team 8 . Collectively, DSME, SMBG, and DSMS will improve diabetes self-care, given that medical care and daily management are consistent but flexible due to the demanding nature of insulin, glucose monitoring and diet regimens 41 .
Physical Activity and T1DM Regular physical activity provides a range of benefits that prevent against risk not modified for physical activity, the individual will experience hypoglycemia during or immediately following exercise or during the night, which is of the most concern 42 . Yardley and colleagues found that a day that included 75 minutes of moderate-intensity exercise at 55% of peak fitness (VO2peak) more than doubled the incidence of having a hypoglycemic event overnight 42 . Hypoglycemia is prevented by limiting pre-exercise insulin, providing carbohydrate during exercise, and reducing insulin dose at night 42 .
In order to participate in physical activity, the individuals must believe that they are able, which is measured by self-efficacy. Self-efficacy is critical for the initiation of an activity in both adults and children 48 . Self-efficacy is dependent on past experience, familiarity, control over the situation, and support from peers 48 . Self-efficacy is typically measured on a numerical score where as score increases, self-efficacy increases. Parcel et al. developed and validated a self-efficacy instrument in healthy third and fourth grade students 49 . The questionnaire includes 5 questions about physical activity with three options, "not sure" for one point, "a little sure" for two points or "very sure" for three points 49 . The maximum score is 15 points, therefore, higher scores are associated with greater PASE. The average PASE score was 12.25 ± 2.07 (KR-20 coefficient alpha = 0.569). If the individual with T1DM has great physical activity self-efficacy and believes that they can participate in physical activity, such activity must be adequately monitored in order to have beneficial health effects. The potential hormone and stress response that physical activity evokes needs to be accounted for to prevent hypoglycemic events 50,51 .
These scores were observed in healthy children in a safe school environment. Scores of children and adolescents with T1DM may differ.
Faulkner et al., conducted a study to promote physical activity in the T1DM adolescent population 52 . Adolescents 12-19 years old who were not routinely active were recruited from a pediatric clinic and given individualized exercise plans. Perceived selfefficacy was measured using a 10-item questionnaire developed for the study assessing barriers to exercise. Each item was scored on a Likert scale from one (not true at all) to five (very true) 52 and means were calculated. Different from typical self-efficacy scales like the one validated by Parcel, on this scale, a lower score (less perceived barriers) was interpreted as greater self-efficacy 52 . The mean score of the self-efficacy was 3.79 ± 0.64 52 . This is greater self-efficacy than to be expected because this population does not typically participate in the recommended amount of physical activity. These scores also may be better than predicted because of the safe environment and sense of support the subjects had.
The optimal management of T1DM is multifaceted and an ideal setting to incorporate nutrition education, DSME, SMBG, DSMS and physical activity is a with one another while they learn to be more responsible for their condition" 55 . These camps are specifically tailored for children and adolescents with T1DM and provide a safe environment for the campers to enjoy themselves while being exposed to general and diabetes specific nutrition education. Diabetes camps are the ideal setting for campers to thrive with, DSME, SMBG and DSMS 41,54 . The camp environment provides an environment for campers to learn how to control their blood glucose levels, carbohydrate intake and insulin regimens. Attendance at a diabetes camp allows the campers to become more independent in the management of their diabetes 41,54 In addition to providing nutrition education to improve knowledge and T1DM management, another goal during attendance at diabetes camp is to avoid blood glucose extremes in an environment where there is increased physical activity 55 . All diabetes camps are staffed by a multidisciplinary team that specialize in diabetes management as well as protocols for normal blood glucose ranges and how to treat signs and symptoms of hyper and hypoglycemia. 55  and after camp was 32 ± 6 , p <0.001 57 . This study also found that HbA1c decreased significantly after camp 57 .
Bundak assessed nutrition knowledge at a diabetes camp that focused on insulin regimens and glycemic control 58 . The insulin regimens of the campers were adjusted using rapid and short acting insulin. Campers were also exposed to nutrition and diabetes education. This study showed that there was a significant decrease in HbA1c at 6 and 12 months post-camp 58 . This study focused mainly on the improvement of glycemic control.
Knowledge was tested using a tool developed for the study that included 25 questions covering topics such as timing and composition of meals and snacks, and the food groups with each question worth four points 58 . There was a significant increase in knowledge between pre 69.5±20.0 and post 79.5±16.0, p<0.05 58 . Although education is provided at all diabetes camps, the studies reviewed above did not use a validated to assess knowledge after attendance at camp.

Description of the Project:
The purpose of the study is to evaluate the impact of nutrition education given at camp.

My Participation as a Parent/Guardian
A parent/guardian must sign a HIPPA form authorizing use, for research purposes, of the following private medical information from the camp forms: demographic information, height, weight, age, duration of diabetes, insulin regimen and administration, hemoglobin A1c level, gastrointestinal symptoms and other medical problems, prior nutrition education and prior attendance at camp. A parent/guardian must sign this Parental Consent/Child Permission form, and the study HIPPA release form. These forms will take about 10 minutes to complete.

What will be done:
If you agree to have your child participate, he/she will be asked if they are also willing to participate. If both you and your child agree, your son or daughter will take a short Nutrition Knowledge Survey (NKS) at the beginning and end of camp to determine their nutrition knowledge related to diabetes. Participants will also take a short Physical Activity Self-efficacy questionnaire at the beginning of camp. These forms should take about 15 minutes to complete both. All children will be receive a 45-minute nutrition education session at Camp Surefire presented by Kaitlyn Whipple, a Nutritional Sciences graduate student from the University of Rhode Island, but only participants will take NKS to see if the program was successful. After camp is over, you will not be asked for any further information or time commitment.

Risks or discomfort:
The knowledge survey and physical activity self-efficacy survey should take no more than 15 minutes to complete and contain no questions that should be a problem. There is no risk or discomfort.

Benefits of this study:
There are no direct benefits to you or your child by participating but information about the effectiveness of nutrition education should help other children with diabetes. If we find the educational program is associated with improved knowledge about nutrition, the educational program is likely to be repeated next year at Camp Surefire and may be used by other camps for children with diabetes.

Confidentiality:
Your son/daughter's part in this study is confidential. All information from the camp medical forms will be recorded on forms identified by code number only. Surveys will have the child's name listed during camp, but these names will be replaced by ID numbers after camp is over. None of the information collected for this study will identify you or your son/daughter by name. The consent forms will not be linked to identification numbers. These consent, child assent and HIPPA release forms will be maintained in a locked cabinet in Dr. Greene's office for five years as required by law. Similarly, survey and abstract forms with ID numbers and no names will be maintained in Dr. Greene's lab. All information used for data analysis will be identified by code numbers and will not include any link to your child's name.

Decision to quit at any time:
Your son/daughter will be given the opportunity to decide whether or not to participate in this study. His/her decision to participate will not affect your or his/her present or future relationship with Camp Surefire. S/he will have the right to stop participating at any time. You have the right to withdraw your permission for your son/daughter to participate at any time.

Rights and Complaints:
If you are not satisfied with the way this study is performed, you may discuss your complaints with Dr. The investigator will respect the confidentiality of the health information, however, should the health information be disclosed by the investigator, to someone outside of this study, it may no longer be protected by the HIPAA regulation.
Signing your name at the bottom of this form means that you have read or listened to what it says and you understand it. Signing this form also means that you agree to authorize the use and disclosure of personal health information. You will be given a copy of this form after you have signed it. General nutrition education: "Likes" and "Dislikes". Pass out food models from each food group to the campers at random. Have campers get into groups based on the food models. Discuss the groups (should be 5 groups, one for each food group). Present the 5 food groups and talk about how it is important to have foods from every group every day but not every food in each group is healthy for us. Have the campers place their food models in the food group under "like" or "dislike" and talk about why they chose to put the food model where they did 5min Discussion 15min Diabetes specific education: Present the nutrition facts label board and have a discussion about portion sizes and insulin regimens. Have campers bring up their food models and fill out the nutrition facts label.