2. The Diabetes Champion Your Role in Medical Nutrition Therapy

3. Do you know? Based on statistics from the Centers for Disease Control website, 17.0 million people in the United States, approximately 6.2% of the population, have diabetes. Of this 17 million people, 11.1 million are diagnosed and 5.9 million are undiagnosed.

4. Why are we concerned? Cost of care Complications of the disease Quality of life

5. Objectives: The RN will be able to identify patients nutrition learning needs The RN be able to identify the foods that are classified as carbohydrates The RN will learn the relationship between foods, macronutrients, and blood glucose control The RN will be able to reinforce medical nutrition therapy for diabetes

6. Factors that affect Blood Glucose Insulin and medications Emotions Activity Sickness DIET

7. What Carbohydrate Counting is Not Based upon a system of food exchanges Inflexible Difficult to follow Without consideration for each persons individualized needs

8. The ADA Nutritional Guidelines Goals: Focus upon achieving optimal metabolic outcomes as related to glycemia, lipid profiles, and blood pressure Promote consumption of a healthy diet consisting of multiple servings of fruits, vegetables, whole grains, low- fat dairy products, fish, lean meats, and poultry Provides guidelines so that the patient can Maintain a consistent day-to-day carbohydrate intake at meals and snacks Enables the patient to Consume a calorie level to promote achievement of ideal body weight

9. Glucose Targets RMC, AACE, AADE ADA Before Meals70 to 11090-130 2 hours post meals less than 140less than 180 A1CLess than 6.5% less than 7%

10. Meal Planning

11. True/False All white foods are bad for you? People with diabetes can never eat sugar Karo Syrup will cause diabetes People with diabetes should not eat bread People with diabetes can eat from all groups of foods

12. What nutrient drives serum glucose?

13. Classification of Foods Vitamins and mineral provide the nutrients we need for metabolic functions, but no calories (energy) The amount of carbohydrate, fat, and protein a food contains determine its food class and total calories (according to the portion size) Carbohydrate, fat, and protein provide calories (energy) and also play significant roles in achievement of good health

14. Food Classifications CHO grams Protein grams Fat grams Carb Group 12 to 15 g3 to 8 g1 to 8 g Protein Group 0 g7 g0 to 8g Fat Group 0 g 5 g

15. Carbohydrate Another name for starches and sugar Body uses for energy 100% of most types of CHO turns into glucose within 1 to 2 hours of eating Provides 4 calories per gram

16. Protein Little impact on glucose Builds and repairs muscles, skin, all cells Includes both animal and vegetable sources Can be too high in fat Provides 4 calories per gram

17. Fat Small amounts needed for healthy skin and vitamin transport Heart Healthy vs. Not Heart Healthy Provides 9 calories per grams

18. Carbohydrates Include: Starches (whole grain and refined) including snacks Starchy vegetables Fruits and fruit juices Milk, yogurt, and milk like (soy) foods Foods that contain sugars

19. Simple vs. Complex What does the word sugar mean to you? What type of sugars are used in food? What words come to your mind?

20. These words mean simple CHO or sugars High Fructose Corn Syrup Sucrose Corn Syrup Manitol Sorbitol Dextrin Crystallized Cane Sugar or Evaporated Cane Sugar Invert Sugar Molasses and Honey

21. Simple carbohydrates are: Chemically very simple Easily digested and absorbed by your body Move quickly into your blood stream Limit to less than 10% of total CHO intake Tip 1: Its easier to say no once in the store than 50 times at home!

22. Complex Carbohydrate Starches and Fiber More complex chemically Spend longer time in digestion and absorption Contribute to energy, slowly and healthfully

23. Complex Carbohydrate Provide rich sources of vitamins and minerals, especially in the low carbohydrate vegetables Excellent source of fiber, most people need between 3 to 5 grams in a serving Choose whole grain over refined CHO

24. Great Sources of Complex Carbohydrate Include:

25. Tip 2 Portion Size Matters!

26. Why carbohydrate counting? Carbohydrate is the nutrient that affect serum glucose Its a precise method to limit carbohydrate Carbohydrate counting controls portion size Portion size is how carbohydrates are controlled and counted Portion estimation can be used once the patient learns portion control as opposed to always weighing or measuring foods Its portable, no measuring cups or scales

27. Portion size examples: One cup= 1 baseball or a fist ½ cup= ½ a baseball Piece of fruita tennis ball 1 oz cheese4 dice 3 oz meata deck of cards 1 tablespoona book of matches

28. Label Reading Counting Carbohydrates per serving- one Serving= 15 grams

29. Label Reading Tip Tip 3 Always look for total carbohydrate If the item contains 5 grams of fiber of more, subtract 5 grams of carbohydrate from the total So---- if a product has 20 grams of carbohydrate per serving and 5 grams of fiber, you will count the total carbohydrate grams as_______.

30. Summary: the key to carbohydrate control is Following the meal plan each day, limiting the total carbohydrate to only the allowed number of servings Eating at the same time each day Checking blood sugar level each day and according to plan Planning ahead for any special event each day

31. Or tip 4: Consistency Which means the same amount of CHO at each meal and snack

32. My Doctor told me to stop having intimate dinners for four….unless there were three other people Orson wells

33. Meal Planning Carbohydrate Counting Method 1800 kcal 210 grams of carbohydrate Meal B CHO 4 PR0 1 oz Fat 2 Free Foods of choice L 43 oz 2 1&1/2 cups D 43 oz 2 1&1/2 cups Snack 2 As desired

34. Tip 5 Use this phone number to remember the basic meal plan: 444-133-2222 Or 4 carbohydrates with each meal (444) 1 ounce of protein at Breakfast3 and 3 at Lunch and Dinner (133) And 2 fats with each meal (222) adding 2 Carbs for as snack (2222)

35. Meal Planning Basic Principles Keep all food portions moderate in size Make meal size similar from day to day Eat meals and snack at the same time everyday Eat 3 meals everyday Choose foods in the sweets category less often

36. Meal Planning Basic Principles Space meals about 5 hours apart Match meal times to your activity and medication action time. Manage carbohydrate intake Limit refined carbohydrate foods: White bread, pasta, rice, crackers and cereal Added sugars or corn syrup Plan meals with high fiber foods: Solid fruit rather than juice. Cooked and raw vegetables. Cooked dried beans, peas, or lentils. Whole grainsMake half your grains whole!

37. Meal Planning Basic Principles Solid fruit rather than juice. Cooked and raw vegetables. Cooked dried beans, peas, or lentils. Whole grainsMake half your grains whole! Plan meals with high fiber foods

38. Many tips for portion control Dont purchase foods that tempt you Use smaller plates, bowls, glasses Take ½ of restaurant food home Avoid all you can eat buffets Take only one portion, and

39. Considerations for Sick Days Illness raises glucose, continue meds Increase glucose monitoring to every 2 to 4 hours Increase fluid intake Follow meal plan if able If unable to tolerate solid food, swicth to regular sugar liquid items at meals, and sugar free items between meals

40. Considerations for Sick Days Contd If glucose > 250m usual carb is not needed but get at least 140 grams carb daily For nausea and vomiting, sip small amounts of fluids Check urine for ketones DM1 with urination & gluc > 250 DM2 if vomiting or too sick to get out of bed or if glucose is >250 & insulin is used

41. Carbohydrate adjustment for exercise If at risk for hypoglycemia: intensitydurationglucose+carb low to moderate 30 min or less < 10010 to 15 grams CHO low to moderate 30 min or less > 1000 CHO moderate30 to 60 minutes < 100 25 to 50 g CHO before+ 15g/hr 100-17915 g/hour 180-2490 g CHO

42. Planning Protein When planning a meal the protein is always the center of the plate Vegetables MilkFruit Bread/ Starch Meat/Protein

43. Choose lean cuts of meat Limit red meat to three times weekly Cook by baking, broiling, stewing, braising, or grilling Save fatty meats such as ribs for very special occasions Tip 6 And dont forget about vegetable sources of protein such as peas, beans, soy Think Heart Smart

44. Heart Smart Fats Include: Mono-unsaturated such as: *Nuts and seeds *Avocados *Olive oil *Canola oil *Peanut oil *Tube or squeeze margarine

45. Heart Smart Fats Include: Omega-3 fatty acids such as : * Fish (salmon, mackerel, tuna) * Walnuts * Flaxseed *Fortified Foods

46. Fats not heart smart: Butter Margarine Shortening Lard Full fat dairy products Any fat that is a solid at room temp Coconut, palm, palm kernel oil Shelf stable food such as pastries, chips, cake mixes, donuts, snacks

47. Type II Diabetes Mellitus is improved by weight loss Multitude of studies support gradual weight loss Even 10 to 15 pound weight loss has proven to improve serum glucose levels The patient is best treated with a lifestyle approach. Very low carbohydrate diets are problematic.

48. Meal Planning and Learning Readiness: Patient interview role play Lets count carbs

49. In summary: Make change one step at a time Set goals Count those carbs Practice Happy Heart Habits Never give up- if you eat that piece of candy, get back on the wagon and move forward! Work towards ideal body weight