Hidden hunger and altered growth trajectories in Indian children and adolescents living with type 1 diabetes mellitus

Children and adolescents with type 1 diabetes mellitus (T1DM) face risks of impaired growth and nutritional inadequacies. While macronutrient intake is often prioritised in clinical care, micronutrient deficiencies may adversely affect their growth. These inadequacies represent hidden hunger, and longitudinal data on their associations with growth in India are limited. Therefore, we aim to longitudinally assess growth and nutrient intakes in Indian children and adolescents with T1DM, and to examine the associations between growth outcomes and nutrient intake. A secondary analysis was performed on data from 435 children and adolescents aged 5–19 years with T1DM, drawn from a 9-year single-center, retrospective, longitudinal observational study (2015–2024). Annual assessments included dietary intake, anthropometry, and body composition. Nutrient adequacy was evaluated using ICMR-NIN Estimated Average Requirements, 2020. Growth deficits (stunting and wasting) were defined according to WHO and IAP standards. Associations of nutrient adequacy with growth and body composition were analyzed using generalized estimating equations. Mean height, weight, and BMI Z-scores were consistently below reference values across age groups, with persistently high prevalences of stunting (14%-baseline to 20%-endline) and wasting (8–13%). Energy adequacy was low, especially during puberty (66%). Micronutrient inadequacies were widespread: calcium, iron, zinc, folate, and riboflavin were consistently suboptimal and declined further during puberty. Stunting was associated with lower adequacy of B-vitamins, including thiamine (OR: 0.98), riboflavin (OR: 0.98), niacin (OR: 0.98), folate (OR: 0.98), and minerals such as iron, zinc, copper, sodium, potassium, manganese, and phosphorus (OR range: 0.96–0.99). Wasting was associated with inadequate energy intake, and deficiencies in thiamine (OR: 0.99), fiber (OR: 0.98), iron (OR: 0.98), copper (OR: 0.98), manganese (OR: 0.98), niacin (OR: 0.98), and overall micronutrient deficiency (OR: 0.98). Lean body mass was positively associated with calcium and folate intakes (both OR: 1.01). Fat% was associated with iron (OR: 1.01), sodium (OR: 1.01), copper (OR: 1.01), and thiamin (OR: 1.01). Indian children and adolescents with T1DM exhibit persistent widespread micronutrient inadequacies, which are associated with stunting and wasting, independent of glycaemic control. These findings highlight the need to integrate routine micronutrient assessment and optimisation into standard diabetes care to support optimal growth.