Learning Objectives. ADA Diet vs. Medical Nutrition Therapy. In Diabetes, Food IS Medicine: Current Trends In Diabetes Nutrition Management

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1 In Diabetes, Food IS Medicine: Current Trends In Diabetes Nutrition Management Laurel Najarian RD, CDE, M.ED Learning Objectives 1. Discuss the rationale and importance for the use of carbohydrate counting in diabetes self-management. 2. Identify the main focus of meal planning for patients with Type 1 or Type 2 diabetes. 3. Describe the nurse s responsibility in helping his/her patient make good food choices and pitfalls to be avoided. ADA Diet vs. Medical Nutrition Therapy Prior to 1994 Nutrition recommendations of 1994: Diabetes Control and Complication Trial (DCCT) 1

2 Nutrition Recommendations present Evidence-based guidelines American Diabetes Association Academy of Nutrition 2014 Medical Nutrition Therapy Goals Achieve and maintain: Normal (or close to normal) blood glucose levels Healthy lipid profile Normal blood pressure 2014 Medical Nutrition Therapy Goals (cont.) Prevent or delay the development of complications by modifying nutrient intake and lifestyle Address individual nutritional needs, considering personal and cultural preferences and willingness to change Achieve a healthy weight 2

3 2014 Medical Nutrition Therapy Goals (cont.) Maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence Diabetes Care, January Nutrition Recommendations Carbohydrate Select from a variety of food choices Carbohydrate control (count grams or food groups) Consume sucrose containing foods in moderation Increase fiber intake 2014 Nutrition Recommendations (cont.) Fat Low saturated fat Low cholesterol Eliminate trans fats Protein 3

4 Carbohydrate Counting Supported by research The carbohydrate (carb) is the primary nutrient affecting post-prandial blood glucose levels and insulin requirements Attention to quantity and distribution of carbs can improve metabolic control ALL carb sources in equal gram amounts have an effect Meal Planning Methods Carb choice Carb (gram) counting 3 Major Nutrient Sources Carbohydrates Protein/meat Fats 4

5 Starch/grains Fruits Milk Carbohydrate Foods Other carbs (sweets) Carb Choices 1 carb choice = 15 grams Examples: 8 ounces skim milk 1 slice of wheat bread 1 small apple 3 cups of popcorn ½ cup of frozen yogurt Women Daily Carb Goals 3-4 choices (45-60 grams) per meal Men 4-5 choices (60-75 grams per meal * Goals are individualized as appropriate 5

6 Basic Carb Counting Identify carb foods in each meal Carb consistency Portion control Meal regularity Label reading Sample Breakfast 2 slices wheat toast 30 grams/2 choices 1 scrambled egg 0 grams/0 choices ½ grapefruit 15 grams/1 choice 8 oz. skim milk..12 grams/1 choice 1 tsp. margarine 0 grams/0 choices TOTAL 57 grams/4 choices Advanced Carb Counting Pattern management Carb:insulin ratio (match insulin to carb intake at meals) 6

7 Type 2 Education Focus What is the patient willing/able to do? Carb consistency Portion control Meal spacing Weight reduction (weight loss of 5% - 10% may improve insulin resistance) Type 1 Education Focus (cont.) What is the patient willing/able to do? Carb counting Label reading Portion control Record keeping *If on intensive therapy, carb:insulin ratio or pump therapy is often used. Outpatient Referral Recommendations New Type 1 or Type 2 diagnosis Education update if not at blood glucose goal If major change in therapy, i.e., starting insulin 7

8 Diabetes Self-Management Programs ADA recognized MDCH certified Programs in Northern Michigan Assessment Patient self-assessment questionnaire Individual assessment Develop teaching plan 10 Content Areas 1. Understand disease process 2. Nutrition management 3. Physical activity 4. Diabetes medication 5. Blood glucose monitoring 8

9 10 Content Areas (cont.) 6. Preventing, detecting, and treating acute complications 7. Preventing, detecting, and treating chronic complications 8. Goal setting 9. Psycho-social adjustment 10. Preconception care and management during pregnancy Program Components Initial appointment with RN and RD Follow-up appointment(s) Follow-up phone call (after education is complete) Inpatient Diabetic Diet Protocol Mrs. Smith is admitted to the hospital and the doctor orders a diabetic diet. What does she receive for her meals? Standard for women is 3-4 carbohydrate servings/meal which is grams Snack: currently every patient on a diabetic diet receives 1 carb for HS snack 9

10 Sample Diet for Women BREAKFAST Orange juice (1 carb choice) Cheerios (1 carb choice) 2% milk (1 carb choice) 1 slice whole wheat toast (1 carb choice) Canadian bacon 1 pat butter Total: 4 carbs Protocol for Men Mr. Smith is admitted and is also put on a diabetic diet. Is it the same? Standard for men is 4-5 carb choices/meal (or grams) HS snack is currently 1 carb choice Sample Diet for Men LUNCH Meatloaf Baked potato (2 carb choices) Broccoli Sour cream Cheesecake with cherry sauce (3 carb choices) Total 5 carbs 10

11 At Your Request Menus All items on the menu that contain carbohydrates are shown with a C or multiple C s depending on the carbohydrate content of the item. The patient can decide how he/she wants to use his/her allotted carb servings. Carb Content of Items One carbohydrate One pancake, breakfast potatoes, cream of wheat or cream of rice cereal, oatmeal, Cheerios, grapes, melon cup, light yogurt, juice, milk, soy milk, one slice of bread, chili, most soups, peas, coleslaw, dinner roll, pudding, Lorna Doone cookies Carb Content of Items (cont.) Two carbohydrates Frosted Flakes, raisin bran, French toast, stewed prunes, fruit yogurt, English muffin, chocolate milk, cream of potato soup, grilled cheese, hot dog, baked potato, spaghetti, beef stew, chocolate chip cookie, fruit crisp, brownie, custard 11

12 Bedtime Snack No longer necessary because: Most hospitalized diabetics have high blood sugars Most hospitalized diabetics are overweight Most hospitalized diabetics are on Lantus and Novolog - does not cause hypoglycemia Survival skills: Inpatient Diabetes Education Basic carb counting Label reading Weight management skills, if needed Portion control Diabetic Education Important to order appropriate consults Appropriate referrals to out-patient programs 12

13 Nursing Responsibilities Document meals and carbs in that meal Double check the blood glucose before the meal is eaten Be aware of additional food items in the room that could affect blood glucose level, i.e., snacks that the family may have brought in Nursing Pitfalls Avoid these common practices which can negatively affect the patient s blood glucose: Allowing extra carbs at meals Allowing bedtime snacks when not ordered or when blood glucose levels are high Case Study 13

14 QUESTIONS??? 14