Improving Diabetes Care: The Role of Nutrition, Exercise, and Education

Objectives: Describe the current standards of nutrition care for patients with diabetes. Explain common meal planning approaches. Describe the role of exercise in blood sugar management. Describe the value of a dietitian and/or diabetes educator as a standard of care.

Evolution of the “Diabetes Diet”…… 1950: First ADA Exchange System Published  Diabetes insulin-dependent and non insulin-dependent was just defined  Diets based on total calories with set macronutrient % ranges  Patients weighed all foods and followed rigid plans 1970’s: Exchange System updated to include CHO  Research, but no way for consumers to determine carbohydrate content of foods Early 90’s: Term “Carbohydrate Counting” introduced  FDA food labeling for all US foods -Carbohydrate content now uniformly regulated and easily accessible  DCCT trial published documenting carbohydrate counting as a method of effective dietary intervention  Home glucose monitors become widely used and standard of care Late 90’s-2000: Advances in insulin and oral med therapy  First analog (Humalog), and peakless basal (Lantus) were approved by FDA  Carbohydrate Counting gained scientific support and consumer popularity 2001 to current: Move to Evidence Based Nutrition Care  ADA no longer endorses “ADA calorie diets” due to scientific evidence of no benefit and potential harm  Focus moves to consistent carbohydrate, individualized MNT

Clinical Goals of “Modern” Diabetes Diet Plan Manage disease process: assist in achieving/maintaining blood glucose levels within target range, lipid and lipoprotein profile that reduces the risk for vascular disease, and blood pressure levels To prevent complications of diabetes, or at least slow the rate of development, by modifying nutrient intake and lifestyle Address individual needs and strive to maintain the pleasure of eating by only limiting choices when indicated by scientific evidence. Encourage ongoing healthy behaviors. Develop a plan for continuing self management training and follow up care. 1.Clement et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care, 2004;27: Franz et al. Nutrition Principles and recommendations in diabetes. Diabetes Care, 2004;27(Suppl 1):S36-S46. 3.Nutrition Recommendations and Interventions for Diabetes. Diabetes Care, 2008;31 (Suppl 1):S61-S78.

Translating “Clinical Goals” …into “Productive Change” Diabetes Self-Management is NOT about RULES!! It is about CHOICES! Important choices that are made daily, by the patient, not the care provider! Providing written RULES, does not produce change in most patients. Introducing relevant information and skills that allow patients to better understand how their CHOICES impact their blood sugars, risks, and ultimately quality of life does promote change.

Power of MNT? MNT has proven ability to lower A1c: –~1% in newly diagnosed Type 1 –~2% in newly diagnosed Type 2 Goes down to ~1% in Type 2 diagnosed >4 years Any time is a good time to refer to an RD, but the BEST time is NEW diagnosis…don’t wait!! Nutrition recommendations and interventions for diabetes. Diabetes Care 2007;30;S48-S65

Common Meal Planning Methods: Plate Method –Can be used in addition to CHO counting –Can be used alone for patient with low literacy, language barriers, etc.

Common Meal Planning Methods: Consistent CHO or “CHO Counting” –Focused on BG control: carbohydrate identification, moderation, and consistency – not –Can be adapted to a range of literacy levels but requires higher level learner than plate method –Works well with all treatment types lifestyle controlled oral meds MDI insulin pumps –Has proven higher long term compliance than calorie based “ADA” type diet plans

Moderation –Eat total carbohydrate appropriate for caloric needs, and spread evenly over the course of the day. Consistency –Eat consistent amounts of carbohydrates each day. Maximums –Avoid over eating carbohydrate at any given sitting. Matching –If patient is on MDI or insulin pump, carbohydrate and insulin doses should be matched as evenly as possible.

What is a moderate amount? Male 60-75g CHO per meal (4-5 CHO servings/meal) 15-30g CHO per snack (1-2 CHO servings/snack) Female 45-60g CHO per meal (3-4 CHO servings/meal) 15g-30 CHO per snack (1-2 CHO serving/snack) Ideally CHO intake should be individualized, but general recommendations are as follows:

Common Meal Planning Methods: ADA Exchange System There is no longer endorsed use of “ADA Calorie Based Diets”. The American Diabetes Association does not endorse any single meal plan or specified percentages of macronutrients. 1 An individualized diet plan based on moderate and consistent carbohydrate intake is recommended. There is no longer endorsed use of “ADA Calorie Based Diets”. The American Diabetes Association does not endorse any single meal plan or specified percentages of macronutrients. 1 An individualized diet plan based on moderate and consistent carbohydrate intake is recommended. 1 “Diabetes Nutrition Recommendations for Health Care Institutions.” American Diabetes Association. Diabetes Care 27.1 (2004) 2Moghissi, ES, Hirsch, IB. “Hospital Management of Diabetes.” Endocrinology and Metabolism Clinics of North America 34 (2005) 3 “Nutrition Care Manual”. American Dietetic Association. (2011)

A closer look….ADA Calorie Plans are Consistent Carbohydrate Plans! Calorie level Target CHO grams (calc. at ~50% total kcal) Carbohydrate Servings* Breakfast Lunch Dinner HS (10) 3 1 (13) 4 1 (15) (16-17) (18) (21) Specific fruit, starch, and milk choices will vary by patient preference. Meats2 (4oz) 2 (5oz)3 (6oz) 4 (8oz) Fats g/servings40/447/554/660/774/983/12

What about protein? Protein Usual daily protein intake has minimal effect on BG, lipids, or insulin secretion For those with normal renal function, protein intake recommendations are: –0.8-1 g/kg/day –15-20% total kcal/day Along with CHO counting, teach patients healthy portion size, lean protein choices Protein is still important to overall health, but they have much less impact on direct blood glucose changes than carbohydrate ingestion. 1. “Diabetes Nutrition Recommendations for Health Care Institutions.” American Diabetes Association. Diabetes Care 27.1 (2004) 2.“Nutrition Care Manual”. American Dietetic Association. (2011) 3.““Evidence for MNT in Type 1 and Type 2 Diabetes in Adults.” Journal of American Dietetic Association. 2010;110:

What about fat? Fat Moderate fat intake has minimal effect on BG –30% kcal or less total fat –7% kcal or les total saturated fat Along with CHO counting, include cardio-protective MNT Reduction of saturated, trans fat, and dietary cholesterol –Inclusion of healthy foods ie. Omega 3’s, poly and mono unsaturated fats, more fiber –Sodium and potassium adjustments for BP Fat is still important to overall health, but they have much less impact on direct blood glucose changes than carbohydrate ingestion. 1. “Diabetes Nutrition Recommendations for Health Care Institutions.” American Diabetes Association. Diabetes Care 27.1 (2004) 2.“Nutrition Care Manual”. American Dietetic Association. (2011) 3.““Evidence for MNT in Type 1 and Type 2 Diabetes in Adults.” Journal of American Dietetic Association. 2010;110:

What about Weight Management? Over 80% of patients with Type 2 Diabetes are overweight/obese It is estimated that only 1-5% of people who successfully lose weight are able to the maintain loss During pre-diabetes, a weight loss of 5-7% of current body weight has been shown effective to prevent or delay onset of overt DM Mild weight loss of 5-10% current body weight has been shown to improve insulin sensitivity,especially in patient with new onset DM. Obesity is a huge challenge, but is NOT an excuse for poor blood sugar control!

Benefits of Physical Activity and Exercise Exercise can lower blood pressure and cholesterol levels Exercise strengthens your heart and circulatory system Exercise can decrease body fat and increase muscle tone Exercise can make you feel more relaxed, relieves tension and stress

How Does Exercise Effect Blood Glucose Activity will lower your blood glucose because the body cells take in glucose more efficiently In Type 2 exercise may increase cells’ sensitivity to the effects of insulin Exercise helps reduce the amount of glucose released by the liver Regular exercise may reduce insulin requirements

Choosing an Exercise Program Choose something you enjoy and will do regularly ADA recommends 30 min a day/5 days a week Consult your health professional before starting and exercise program Start slow and gradually increase your activity Set realistic goals

Diabetes Self Management Education (DSMT) ADA 7 Self-Care Behaviors Healthy Eating Being Active Monitoring Taking Medications Problem Solving Reducing Risks Healthy Coping

Are You In The Top 1%??? 8.5 Million Medicare recipients are eligible for DSMT/MNT Only 58,000 – Less than 1% have utilized the covered benefit

Medicare Coverage Medicare patients are eligible for 10 hours of DSMT initial class and 2 hours for a refresher every year. Medicare patients are eligible for 3 hours of Medical Nutrition Therapy (MNT) the first year and 2 hours every year

Role of a Diabetes Educator Integral to the multidisciplinary diabetes care team Facilitate behavior change by counseling patients and families on how to adopt informed lifestyle decisions and incorporate healthier choices into their self- management (7 Self-Care Behaviors) Assist the healthcare providers with Medication management, insulin titration and instruction Insulin pump education/pre-pump, pump start and post-pump

Value of Outpatient Diabetes Self Management Training (Case Study) Newly Diagnosed Type 2 – A1C 12.4 started on one oral medication Referred to outpatient education At completion of class his A1C was – ?????

Value of Outpatient Diabetes Self Management Training A1C Because he came to class! Learned how to make better choices Incorporated lifestyle changes he could live with

Presented By: Cristin McKinley, R.D., C.D., C.D.E. – Johnson Memorial Hospital Carla Duncan, R.N. – Johnson Memorial Hospital