Diabetes in Your School - Encouraging Healthy Nutrition Donna Amundson, RN, CDE Diabetes Care Center Medcenter One

Food (mainly carbohydrate) is one of the major influences on blood sugar levels in people with diabetes.

In 1994, the Position Statement of the ADA stated: “Today, there is no one ‘diabetic’ or ‘ADA’ diet. Medical nutrition therapy for people with diabetes should be individualized, with consideration given to usual eating habits and other lifestyle changes.”

The ideal diet for someone with diabetes (type 1 or type 2) is really just a healthy diet from which the entire family would benefit.

Objectives of the Nutrition Plan To balance insulin and carbohydrate intake to help keep blood sugars as close to normal as possible To keep cholesterol at desired levels To improve overall health by maintaining the best possible nutrition To help avoid long term complications

To help attain normal growth and development for children and achieve appropriate weight for everyone To help prevent severe low blood sugar reactions

The Six Major Nutrient Groups: Carbohydrate: One of the main energy nutrients. It supplies energy for the body and is further divided into starches (breads, noodles, pasta, rice, cereals and starchy vegetables such as corn, peas, potatoes and legumes) and sugars (sucrose or table sugar, fructose, lactose or milk sugar and syrups).

Fat: Another of the energy nutrients. Total fat includes: Protein: One of the energy nutrients. It is found in meat, eggs, fish ,milk, yogurt and, in lesser amounts, in vegetables and other non-meat products, such as nuts, seeds and beans. Fat: Another of the energy nutrients. Total fat includes: Polyunsaturated fat Monounsaturated fat Saturated fat Trans-fatty acids

Vitamins and Minerals: Important for growth, formation of blood cells, healthy skin, good vision and strong teeth and bones. Water: The most important nutrient for survival. It makes up much of the body’s blood, the body fluids and the body’s transport system. Serves as a coolant, shock absorber and waste remover. Our bodies are made up of about 2/3 water.

Fiber: Dietary fiber is the part of the plants that is not digested and not absorbed into the body. It supplies bulk to the diet without adding calories and helps satisfy appetite and keep the digestive system running smoothly.

The six main nutritional factors important for good glucose control are: Following some sort of meal plan Avoiding extra snacks Avoiding over-treatment of low blood sugars Promptly treating high blood sugars Adjusting insulin dosages for meals Consistent night snacks

The basic recommendation for the use of sugars for people with diabetes has changed over the years. It has gone from avoidance to allowing sugar in the context of a healthy meal plan.

Types of Meal Planning Approaches Constant Carbohydrate Meal Plan Carbohydrate Counting Meal Plan A third approach, the Exchange Meal Plan, is sometimes used for type 2 diabetes

The purpose of all meal plans is to achieve better control of blood sugar levels. The method that works best for one person may not be the best for another.

It’s important for the family to meet with a registered dietitian to develop a meal plan that meets the needs of the child.

Constant Carbohydrate Meal Plan The amount of carbs (types can vary) is kept about the same for each meal and snack from day to day to match a relatively consistent dose if insulin. Consistency is the key!

Carbohydrate Counting Meal Plan Involves counting the grams of carbohydrate that are to be eaten and then giving a matching dose of insulin. Allows for greater freedom and flexibility in food choices. Often used with intensified diabetes management with multiple daily insulin injections or insulin pump therapy.

Examples of Carb Counts Medium apple…15 gms Medium banana… 30 gms 1 cup milk………15 gms 1 cup chocolate milk…30 gms 1 slice bread……15 gms ⅓ cup pasta…… 15 gms ½ cup corn………15 gms Hamburger bun…30 gms 1 cup hotdish……30 gms 1 hard shell taco…15 gms 1/8 12” thin pizza…15 gms Small order fries…30 gms One 3” cookie……15 gms Frosted cupcake…30 gms 3 cups popcorn….. 15 gms ½ cup ice cream….15 gms 1 cup bean, noodle or vegetable soup…15 gms

Sample breakfast… 1 ½ cups unsweetened cereal 30 gms 1 medium banana 1 cup milk 15 gms Total Carbs: 75 gms

Sample Lunch… Total Carbs: 75gms Peanut Butter and Jelly Sandwich 30 gms for 2 slices of bread 15 gms for 1Tbsp jelly 1 cup milk 15 gms 15 taco chips Total Carbs: 75gms

Another example… 1 cup hamburger hotdish 30 gms 1 medium apple 15 gms 2 sugar cookies (3 inches across) 1 cup sugar free koolaid 0 gms Total Carbs: 75 gms

One more… 1 hamburger with bun 30 gms 1 small order french fries 1 medium apple 15 gms 1 can diet pop 0 gms Total Carbs: 75 gms

Insulin to Carb Ratio Refers to the amount of rapid acting insulin given for the amount of carbohydrate eaten at a meal or snack For example, for a carb ratio of 1:15, 1 unit of rapid acting insulin would be given for each 15 grams of carb eaten. If the meal consisted of 45 grams, 3 units of insulin would be given.

Every person is different in his or her need for rapid acting insulin, so carbohydrate ratios differ as well. The same person may even have different carb ratios for different times of the day.

How are insulin adjustments made for food and blood sugar levels?

Correction Factor When giving a dose of rapid acting insulin, thinking about the blood sugar level and the food to be eaten is always important. A correction (or sensitivity) factor can be used to determine how much extra insulin should be added to the insulin dose which will be given to cover the carb eaten. When giving a dose of rapid acting insulin, thinking about the blood sugar level and the food to be eaten is always important. To make dose decisions a bit easier, many families and care providers choose a correction (or sensitivity) factor to determine how much insulin should be added to the insulin dose which will be given to cover the carb eaten.

The correction (or sensitivity) factor refers to the amount of insulin needed to correct a blood sugar level The goal is to return the blood sugar level into the desired range

The most common correction dose is one unit of rapid acting insulin per 50mg/dl of blood sugar above 100mg/dl. So, if the child’s blood sugar was 180mg/dl, and 1 unit of rapid acting insulin was given, you could expect the blood sugar to drop to 130mg/dl.

Every child is different, however, so the correction factor must be individualized by the child’s family and diabetes healthcare team working together.

Roles and Responsibilities A key part of ensuring good diabetes care for children at school is a clear understanding of who will be responsible for each task. In general, the parents are responsible for providing all diabetes equipment and snacks.

The parents should also help the school staff learn what they need to know about their child’s individual diabetes care. A health care plan should outline the child’s treatment, his target blood glucose range, insulin schedule, eating plan and usual blood glucose testing times. It should also include instructions on what to do in various situations, such as treatment of hypoglycemia.

An adult and a back up adult should know how to test blood glucose know what to do if the blood glucose is out of range know how to give (or supervise) an insulin injection if that’s part of the child’s heath care plan

know how to recognize and treat hypoglycemia know when and how to give a glucagon injection know the child’s meal plan and work with the parents to coordinate it with the schedule of the other children in the class

Diabetes well managed not only helps young people avoid long term complications, it also allows them to feel better and to be happier and more productive at school and at play.

Resources Children’s Diabetes Foundation (800)695-2873 www.childrensdiabetesfdn.org Juvenile Diabetes Foundation International (212)785-9500 www.jdfcure.org American Diabetes Association (800)232-3472 www.diabetes.org