1. Nutrition Therapy in Diabetes Mellitus A Guide for the Nurse Marion Technical College NUR 1021 Spring 2016

2. Objectives of Nutritional Therapy in DM 1. Control of total caloric intake to attain or maintain reasonable weight 2. Control of blood glucose to maintain health and prevent complications 3. Address individual nutritional needs 4. Normalization of lipids and BP to reduce risk for cardiovascular disease 5. Modify lifestyle as needed to treat obesity, hyperlipidemia, CV disease, and nephropathy

3. For patients on insulin… Important to maintain consistency in amount of calories and carbs at each meal, AND Throughout the day

4. Nutritional Therapy in Diabetes Cornerstone of care for the person with diabetes, Also the most challenging for many people. Nutritional therapy -greatest impact on the person with diabetes if provided at the onset of diagnosis Registered dietician – responsible for design of diet & education Nurses are supportive of diet plan & reinforce guidelines

5. Plan Nutrition Therapy to Achieve Target Blood Glucose Level Emphasize to the patient and family members Diet is a balanced meal rather than eating a “diabetic diet” If patient has type 2 diabetes mellitus and is obese Emphasize positive benefits of nutritional changes Helps lower blood glucose levels Decrease lipid levels Lower BP & will help in losing weight.

6. For Type 2 diabetics… Obesity is a major factor 80-90% are overweight Obesity is also associated with increased insulin resistance Weight loss is the key to treatment Weight loss -increases insulin sensitivity & helps normalize liver glucose production Result is less need for medications to control blood glucose

7. What is overweight??? A BMI of 25-29 (BMI is a height-to-weight ratio) Obesity is 20% or more over ideal body weight

9. For both types of diabetics… Skipping meals is undesirable For insulin-dependent persons, hypoglycemia may result Even for Type 2 persons, pacing food more evenly tends to equalize demands on pancreas WHAT DO YOU THINK IS OFTEN A CHALLENGE IN MANAGING THE DIET FOR A PERSON WITH DIABETES ? Consistency in eating habits

10. Considerations when doing meal planning with diabetics Food preferences Lifestyle Usual eating times Ethnic and cultural practices Who buys the food? Who cooks the food? Can they afford food? Others in household? Is transportation for food-buying an issue?

11. Caloric distribution Meal plan focus- Determining % of calories for CHO, fats & protein Carbs (CHO) have the most impact on blood glucose – they are digested and converted to glucose quicker Per the American Dietetic Association (ADA): CHO 50-60% Fat 20-30% Proteins (PRO) 10-20%

12. CHO, Fat & Protein guidelines Recommended most of CHO come from whole grains CHO should be eaten in moderation to avoid high postprandial blood sugar Concentrated sweets not totally eliminated but can be eaten in moderation (up to 10% of total calories)

13. Fat- should be less than 30% of total calories Limit of 10 % saturated fats; dietary cholesterol<300 mg/day Benefit of ↓ coronary artery disease- leading cause of death & disability among people with diabetes Protein – include non-animal sources of protein (legumes & whole grains) Assists in reducing sat. fat & cholesterol intake Protein may be reduced in people with early kidney disease

14. Fiber- increase in diet may improve blood glucose level May reduce need for insulin- intake of 25 grams/day Also helps in lowering total cholesterol & LDL’s Soluble fiber (legumes, oats, some fruits) – better at lowering blood glucose Results from slower rate of glucose absorption

15. Food Classification Systems & Tools Exchange lists Nutrition labels Food Guide Pyramid Glycemic index – how much a given increases the blood glucose compared to a given amount of glucose

16. Exchange Lists Meal plans based on recommended number of choices from each exchange 6 main exchanges Bread/starch Vegetable Milk Meat Fruit Fat Food exchanges on combination foods such as pizza – available from the American Dietetic Association

17. Sample Menu from Exchange Lists ExchangesSample Lunch #1Sample Lunch # 2Sample Lunch # 3 2 starch2 slices breadHamburger bun1 c. cooked pasta 3 meat2 oz sliced turkey& 1 oz low fat cheese 3 oz lean beef patty3 oz boiled shrimp 1 vegetableLettuce, tomato, onionGreen salad½ c. plum tomato 1 fat1 tsp mayonnaise1 TB salad dressing1 tsp olive oil 1 fruit1 med apple1 ¼ c. watermelon1 ¼ c. fresh strawberries “Free” items (optional) Unsweetened ice tea, mustard, pickle, hot pepper Diet soda 1 TB catsup, pickle, onions Ice water with lemon Garlic, basil

18. Let’s Plan a Meal: Exchanges Sample Lunch 2 starch 3 meat 1 vegetable 1 fat 1 fruit “Free” items (optional)

19. Nutrition Labels Reading labels – very important Note grams of CHO in serving 1 unit of insulin for 15 g. CHO Use as a guide for dose of premeal insulin Recommended budget of 40-60 g CHO /meal CHO Counting- main influence on blood glucose Less complicated than exchange lists Offers more flexibility

20. Glycemic Index – Describes how much a given food increases the blood glucose level compared to an equal amount of glucose 2 hrs after ingestion(postprandial) Guidelines for dietary recommendations: Combine starchy foods with protein & fat-containing food- slows its absorption→ lowers glycemic index Whole fruit decreases the glycemic response as opposed to fruit juice – fiber slows absorption

21. Benefits of glycemic index Foods with sugar should be eaten with more slowly absorbed foods → lowers glycemic index Glycemic index helps avoid sharp increases in blood sugar after meals are eaten If doing frequent monitoring of BS- can use GI to adjust insulin doses with variations in food intake

22. Target Blood Glucose Levels for People with Diabetes Before meals90-130 1-2 hours after the start of a mealLess than 180

23. Alcohol Consumption Moderate (usually defined as 1/day) is ok Must be calculated into meal plan Alcohol is absorbed before other nutrients and does not require insulin for absorption Alcohol has an inhibitory effect on glucose production by the liver

24. Sweeteners and Sugar- Free Food Examples of non-nutritive sweeteners include Splenda, NutraSweet, and Sunnette Moderation in use- avoids potential complications Read all food labels carefully so you know what you are getting- may still provide calories if made with nutritive sweeteners (sorbitol)

25. Non-Nutritive Sweeteners

26. THINK LIKE A NURSE: If a patient has symptoms of a hypoglycemic reaction what is the first action to take? Obtain a serum capillary blood glucose reading If a blood glucose was below normal what should the nurse do next? Provide a snack that includes CHO & protein- cheese & crackers, half a sandwich or milk & crackers

27. EXERCISE Essential part of diabetes management Recommended exercise 3 x/week Follow a consistent schedule Usually after meals when BS ↑ Important to self-monitor BS before, during & after If BS <100mg/dl eat a 10-15 g CHO snack before exercise If BS>250mg/dl and ketones are present, DO NOT exercise May result in further elevated blood glucose Important to monitor for hypoglycemia several hours after exercise – eat a snack at end of exercise to avoid this

28. Remember - Sick Day Rules Most important guideline: NEVER eliminate insulin when n/v occur Take usual dose of insulin Attempt to consume small frequent portions of CHO This includes foods “avoided”- soda, gelatin, juices Blood glucose & urine ketones = assess @ 4-6 hr intervals Contact HCP if not able to retain fluids or ↑BS & ketones persist