1. Diabetes Nutrition Management In Long Term CareBy
Liz McAllister, RD, LD
Consultant Dietitian, Long Term Care

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

3. 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

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

5. 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”

6. 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

7. 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

8. 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)

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

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

11. 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

12. 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

13. Other CHO sources Regular Dessert 30 grams Regular Pop 30-40 grams
Diet Pop grams
Diet Pudding 12 grams
Regular Pudding 28 grams
Pie grams

14. 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

15. 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

16. 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

17. 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)

18. 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.

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

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