Diabetes Nutrition Management In Long Term Care By Liz McAllister, RD, LD Consultant Dietitian, Long Term Care mcalfam@comcast.net

Overview Overall Goals of Diabetes Nutrition Therapy Nutrition Recommendations for people with Diabetes How to make them work in the LTC setting Obstacles

Goals of Diabetes Nutrition Management Blood glucose levels in normal range Lipid and Lipoprotein profile that reduces the risk of macorvascular disease Blood Pressure levels that reduce the risk of vascular disease Preventing and treating the chronic complications of diabetes Improved health Addressing individual nutrition needs

Historically nutrition recommendations have been based on: Scientific evidence Clinical experience Expert consensus

American Diabetes Association Published a position statement in January 2002: “Evidence Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications” www.diabetes.org

Blood Glucose levels Is good control of blood glucose levels really important? “Blood Glucose control is the most important factor in preventing or delaying the chronic complications of diabetes” American Diabetes Association

Diabetes Control & Complications Trial The DCCT was a controlled, clinical trial Lasted 10 years 1441 participants (ages 14-39) Randomized into 2 groups Conventional Therapy Intensive Therapy

DCCT Results There were major differences in the 2 groups with respect to complications: The intensive management group had: 76% reduction in retinopathy 60% reduction in neuropathy 54% reduction in albuminuria (severe kidney damage) 39% reduction in microalbuminuria (early signs in people with no previous renal disease)

What affects BS Levels: Food intake Illness,Infection Stress, Trauma Change in exercise Medications

What controls BS levels: Medication Controlling CHO intake Weight loss Exercise

Sugar is not the culprit! “Because sucrose does not increase glycemia to a greater extent than isocaloric amounts of starch, sucrose and sucrose-containing foods do not need to be restricted by people with diabetes. However, they should be substituted for other CHO sources, or if added be covered with insulin or other glucose lowering medication.”—Diabetes Care It is the total amount of CHO consumed that determines the effect on Blood Sugar levels

Carbohydrate 1 Cup Milk 12 grams 1 Slice Bread 15 grams ½ cup Juice 15 grams Small piece Fruit 15 grams ½ Cup Vegetables 5 grams Starchy Vegetables 15 grams ½ cup Rice, pasta 15 grams

Other CHO sources Regular Dessert 30 grams Regular Pop 30-40 grams Diet Pop 0 grams Diet Pudding 12 grams Regular Pudding 28 grams Pie 30-50 grams

Liberalizing Diets “It is the position of the American Dietetic Association (ADA) that the quality of life and nutritional status of older residents in long term care facilities may be enhanced by a liberalized diet.” ADA Position Statement September, 2002

Liberalizing diets (cont.) “Nutrition care for older adults in long term settings must meet two goals: maintenance of health through medical care and maintenance of quality of life.” “Overall health goals may not warrant the use of a therapeutic diet because of its possible negative effect on quality of life” ADA Position Statement September, 2002

Long Term Care Setting CHO content of meals ~ same from day to day Portions sizes are controlled and usually consistent Meals are served at regular times

Restricted diets in LTC? “Stringent diet restrictions that limit familiar foods and eliminate or modify seasonings in food may contribute to poor appetite, decreased food intake, and increased risk of illness, infection and weight loss” (ADA position statement) “It may often be preferable to make medication changes to control blood glucose than to implement food restrictions” (American Diabetes Assoc. position statement)

Why Not? May contribute to Depression (may already be sadness over lost independence, poor health, etc.) May contribute to weight loss and malnutrition due to the diet being less palatable, not allowing as much choice. An estimated 35 – 85% of Nursing Home residents suffer from malnutrition of dehydration.

Why Not? (cont.) Older people less likely to make up for poor food and fluid intake at one meal by eating more at subsequent meals Quality of life: restricted diets make if feel less like home. Many LTC residents stay in institutions for a long time.

Benefits Improved dietary compliance Improved psychosocial status of residents Improved appearance and flavor of the food Enhanced calorie and nutrient intake Increased accuracy and efficiency at tray line

Benefits (cont.) Improved or maintained Fasting Blood Glucose levels Improvement in ability to maintain acceptable weight and nutritional parameters Improved quality of life Happy, healthy and satisfied residents Decreased food & labor costs

NCS, NAS, ADA diets “…...there is no evidence to support ‘no concentrated sweets’ or ‘no added sugar’ diets” “it is recommended that the term ‘ADA diet’ no longer be used, since ADA no longer endorses any single meal plan” Translation of the Diabetes Nutrition Recommendations for Health Care Institutions – Diabetes Care

CCHO Controlled Carbohydrate or Consistent Carbohydrate Achieved by: Omitting sugar packet Giving ½ desserts or some diabetic desserts Substitute Sugar free beverages High CHO meal – omit a fruit or bread Maintaining fairly consistent amount of CHO from day to day, meal to meal

Obstacles to liberalizing diets Resident or family resistance MD resistance (less likely now) Staff resistance (old habits die hard!) Resident gaining weight on Regular or CCHO diet

How to implement a change Decide what your facility’s policy will be, what diets will be offered RD review and adapt menus Letter to MD explaining philosophy Educate staff Educate residents

Be Brave…… YOU ARE DOING THE RIGHT THING!!