Download Nutrition Guidelines Diabetes Outline

5/10/2013
Nutrition Guidelines For
Diabetes
Joan Morris, MS, RD, CHES, LD
No financial relationship to disclose.
Outline

History of Nutrition Recommendations

Role of Medical Nutrition Therapy

Nutrition Care Plan

Nutrition Recommendations

Implementing Behavior Change

Debunking Nutrition Myths
HISTORY OF
NUTRITION
RECOMMENDATIONS
1
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History of Nutrition
Recommendations
Starvation Diets
Exchange Lists For Meal Planning
 Caloric Level Meal Plans
 ADA Diet
 Principles of Nutrition and Dietary
Recommendations for Individuals With
Diabetes Mellitus
 Carbohydrate Counting


Starvation Diets

Also called the Allen Plan, after Frederick Allen
and Elliott Joslin.

Used from 1915 to 1922, before the discovery of
insulin.
◦ The
Th only
l treatment
t t
t for
f diabetes
di b t att this
thi ti
time.

Based on repeated fasting and prolonged
undernourishment.

Fasting reduced glucose levels, but prolonged
calorie restriction led to inanition.
(Muzur, 2011).
Starvation Diets
(Bliss 1982)
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Before & After Insulin Therapy
(Bliss 1982)
Exchange Lists for Meal Planning

Published in 1950 by the joint effort of the
American Diabetes Association, Academy of
Nutrition and Dietetics, and the U.S. Public Health
Service.

Meal planning method in which foods are grouped
into six lists- starch, fruit, milk, vegetables, meat
and meat substitutes, and fat.
◦ Each list is a group of measured foods of
approximately the same nutritional value.
◦ Foods on the same list can be “exchanged” for one
another.
(Mahan 2008)
Exchange Lists for Meal Planning
(Mahan 2008)
3
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Calorie Level Meal Plans

Shortly after the Exchange Lists for Meal Planning was
published, meal plans with specific calorie levels were
created to accompany the exchange list meal plan for
diabetes.

Meal p
plans:
◦ 1,200, 1,500, 1,800, 2,200, 2,600 became available for adults
and children.
◦ Meals plans included:
 Tables detailing grams of carbohydrate, protein, and fat for each
calorie levels.

Purpose of these preplanned diets were to assist
nutrition educators.
(Schafer, et al 1997)
American Diabetes Association Diet
(ADA)

Before 1994, the ADA diet focused on prescribed
percentages of macronutrient intake:
 Example:
 1800 ADA diet
 50% carbohydrate (255 g)
 20% protein (90 g)
 30% fat (60 g)

Shortcoming to this approach is that the prescribed
“diet” cannot be individualized:
◦ lacks relevance to the patient’s lifestyle
◦ does not consider the patient’s culture
◦ disregards the patient’s socioeconomic status
(Mahan 2008)
American Diabetes Association Diet
(ADA)

After 1994, the ADA began recommending
individualized nutrition prescriptions:
◦ Metabolic profiles
◦ Treatment goals
◦ Willingness to change
◦ Predetermined calorie levels
◦ Macronutrient percentages
(Mahan 2008)
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Principles of Nutrition and Dietary
Recommendations for Individuals With
Diabetes Mellitus

Published in 1979 by the American Diabetes
Association.

Goal was to discourage the use of the preprinted,
standardized “ADA diets,” and encourage individualized
nutrition counseling.

“Each diabetic person should have the opportunity to
discuss reasons for the diet and to set diet goals with a
professional diet counselor.”
(Caughron 2002)
Principles of Nutrition and Dietary
Recommendations for Individuals With
Diabetes Mellitus








1. Goals
2. Protein
3. Total Fat, Saturated Fat, and Cholesterol
4. Carbohydrates and Sweeteners
5. Fiber
6. Sodium
7. Alcohol
8. Micronutrients:Vitamins and Minerals
(Caughron 2002)
Carbohydrate Counting

Also called “Carb Counting”

A meal planning technique to help manage blood
glucose levels.

Carbohydrates raise blood glucose.

By keeping track of how many carbohydrates to eat and
setting a limit for the maximum amount to eat, carb
counting can help to keep blood glucose levels in
normal range.
(American Diabetes Association 2013).
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Carbohydrate Counting

Patients need to know:
◦ What foods have carbohydrates?
◦
◦
◦
◦
How much carbohydrates can I have a day? At meals? At snacks?
y
g are in these foods?
How manyy carbohydrates
servings
How do I read a nutrition label?
Why is carbohydrate counting important?
(American Diabetes Association 2013).
Carbohydrate Counting

Sources of Carbs:

Grains
Fruit & fruit juice
Milk & yogurt
Starchy vegetables
Beans, peas, and soy
products
◦ Sweets and snacks
(American Diabetes Association 2013).
How Much Carbs:
◦ Women:
◦
◦
◦
◦
◦
 45-60 grams/meal
 15-30 grams/snack
◦ Men:
 60-75 grams/meal
 15-30 grams/snack

An RD or CDE can
determined the exact
amount of carbohydrates
you need based on your
age, weight, gender, activity
level, medications, and
other health conditions.
Carbohydrate Counting

How much carbs is in
this?
◦ 1 carb choice = 15 grams
◦
◦
◦
◦
1 slice of bread
1 piece of fruit
½ cup starchy vegetables
1/3 cup rice or pasta
◦ ½ cup oatmeal
◦ 2 small cookies
◦ 1 Tbsp sugar, jelly, honey
(American Diabetes Association 2013).
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Nutrition Labels


1. Serving Size
2. Total Carbohydrates (g)
◦ Reading nutrition labels
helps determine how many
carb choices are in each
serving
◦
◦
◦
◦
1 carb = 15 grams
2 carb = 30 grams
3 carb = 45 grams
4 carb = 60 grams
◦ 5 carb = 75 grams
(American Diabetes Association 2013).
MEDICAL NUTRITION
THERAPY
Medical Nutrition Therapy

Medical Nutrition Therapy (MNT)
◦ is the term for the specific nutrition services provided to treat
diseases and conditions.

People at risk for diabetes and those with diabetes
should receive individualized MNT to achieve treatment
goals, preferably provided by a Registered Dietitian.
(Mahan 2008)
7
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Medical Nutrition Therapy

MNT includes:
◦ 1) Performing a comprehensive nutrition assessment
determining the nutrition diagnosis.
◦ 2) Planning and implementing a nutrition intervention using
evidence-based nutrition practice guidelines.
◦ 3) Monitoring and evaluating an individual’s progress over
subsequent visits with the RD.

RDs provide MNT and other nutrition services for a
variety of diseases and conditions including:
◦ Type 1 Diabetes
◦ Type 2 Diabetes
◦ Gestational Diabetes
(Mahan 2008)
MNT for Preventing Diabetes

“Decrease the risk for
type 2 diabetes and
cardiovascular disease by
promoting healthy food
choices and physical
activity leading to
moderate weight loss
that is maintained.”
(Mahan 2008)
MNT for Managing Diabetes

1. To the extent possible, achieve and maintain:
◦ Blood glucose levels in the normal range or as close to normal
as is safely possible.
◦ A lipid and lipoprotein profile that reduces the risk for vascular
disease.
◦ Blood pressure levels that reduce the risk for vascular disease.

2. To prevent, or at least slow the rate of development
of the chronic complications of diabetes by modifying
nutrient intake and lifestyle as appropriate.
(Mahan 2008)
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MNT for Managing Diabetes

3. To address individual nutrition needs, taking into
account personal and cultural preferences and
g
g
willingness
to change.

4. To limit food choices based only on evidence and to
maintain the pleasure of eating.
(Mahan 2008)
NUTRITION
CARE
PLAN
Nutrition Care Plan


Communicates the
specific steps used to
deliver MNT for
diabetes.
Can be used in individual
and group sessions.
Nutrition Care Plan:
1. Nutrition Assessment
2 Nutrition Diagnosis
2.
3. Nutrition Intervention
4. Nutrition Monitoring
and Evaluation
(Mahan 2008)
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Nutrition Care Plan

1. Nutrition Assessment
◦ Histories: nutrition, medical, social, and family
◦ Baseline for outcomes monitoring

2. Nutrition Diagnosis

3. Nutrition Interventions
gy symptoms
y p
( ) format
◦ Problem, etiology,
(PES)
◦
◦
◦
◦
◦
Food and meal plan
Behavioral changes
Short-term and long-term goals
Self-management training
Educational topics covered and materials provided
(Mahan 2008)
Nutrition Care Plan

4. Nutrition Monitoring and Evaluation
◦ Registered Dietitian’s impressions related to patients acceptance
and understanding
◦ Anticipated compliance
◦ Successful behavior changes
◦ Additional needed skills or information
◦ Additional recommendations
◦ Plan for ongoing care
(Mahan 2008)
Nutrition Care Plan: Interventions

1. Develop a Meal Plan
◦ Begin with modifying the patient’s usual intake as necessary, do
p
p
NOT start with a set calorie or macronutrient prescription.
 Feasible for the patient?
 Appropriate for diabetes management?
 Encourage healthful eating?
(Mahan 2008)
10
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Nutrition Care Plan: Interventions

2. Self-Management Training
◦ Purpose: identifying strategies for behavioral change that
increase motivation and adherence to necessary lifestyle
changes.
◦ Numerous
meall planning
N
l i approaches
h are available:
il bl




Diabetes nutrition guidelines
Menu approaches
Carbohydrate counting
Exchange list
◦ No single meal planning approach has been shown to be more
effective than any other.
(Mahan 2008)
Diabetes SelfSelf-Management Training

Essential Self-Management Nutrition Education Skills:
◦
◦
◦
◦
◦
◦
Sources of carbohydrates, protein, fat
Understanding nutrition labels
Modification of fat intake
Use of blood glucose monitoring for problem solving
Adjustments in carbohydrate intake or insulin for exercise
Guidelines for eating out
◦
◦
◦
◦
◦
Alcohol consumption guidelines
Snack choices
Use of nonnutritive sweeteners
Grocery shopping guidelines
Vitamin, mineral and botanical supplements
(Mahan 2008)
Nutrition Care Plan: Interventions

3. Facilitating Behavioral Changes and Goal Setting
◦ Successful behavioral changes requires comprehensive education,
skill development, and motivation.
◦ Different intervention strategies may be needed for patients in
different stages of change process.
 Transtheoretical Model
◦ Goals should be:




The patients priority
Specific
Realistic
Written in behavioral language
(Mahan 2008)
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CURRENT NUTRITION
RECOMMENDATIONS
FOR TYPE 2 DIABETES
Registered Dietitian (RD)

According to the American Association of Diabetes
Educators and the Academy of Nutrition and Dietetics:
◦ “The team member with the most expertise and demonstrated
effectiveness in fostering healthy eating for diabetes is the
registered dietitian.”

RD’s effectives has been documented in several studies:
◦ Decreases A1C:
 1% in newly diagnosed type 1 diabetes
 2% in newly diagnosed type 2 diabetes
 1% in patients who have had type 2 diabetes for at least 4 years
◦ Reduction in use of health services and costs
(Mensing 2011)
Key Concepts to Address

Key nutrition concepts to facilitate healthy eating:
◦
◦
◦
◦
◦
◦
1. Meal Planning
2. Grocery Shopping
3. Cooking
4. Food Labels
5. Modifying Recipes
6. Eating Out
◦
◦
◦
◦
7. Snacking
8. Travel
9. Alcohol
10. Parties/Special Events
(Mahan 2008)
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Recommendations for Type 2 DM

First Priority:
◦ Adopt lifestyle changes that improve:
 Metabolic abnormalities of blood glucose
 Dyslipidemia
 Hypertension

Emphasize:
◦
◦
◦
◦
Blood glucose control
Improved food choices
Increased physical activity
Moderate calorie restriction rather than weight loss
(Mahan 2008)
Recommendations for Type 2 DM
The key principle of diabetes
nutrition
recommendations is
optimal nutrition through
healthy food choices.
A healthy meal plan
includes the following:
Multiple servings of
fruits and vegetables,
whole ggrains, legumes,
g
low-fat dairy foods, fish,
lean meats, poultry, and
healthy fats.
(Mahan 2008)
Choose My Plate
Building Blocks for a
Healthy Diet
Focus on fruits
Vary your veggies
V
i
 Make at least half
your grains whole
 Go lean with protein
 Get your calciumrich foods


(Choosemyplate.gov 2013)
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Recommendations for Type 2 DM

Dietary References
Intakes (DRIs)
◦ 45-65% of calories
from carbohydrates
◦ 10-35% of calories
from protein
◦ 20-35% of calories
from fat
(Mensing 2011)
Carbohydrates and Glycemia

What to focus on when counseling a patient:
◦ 1. sources of carbohydrates
◦ 2. recommended portion sizes
◦ 3. servings of carbohydrates per meal

Totall amount off carbohydrate
T
b h d
consumed
d at meals,
l
regardless of the source (starch or sucrose) is the
primary factor of postprandial glucose levels.

Carbohydrate counting or the exchange system are two
methods to monitor total grams of carbohydrates to
achieve glycemic control.
(Mensing 2011)
Carbohydrates and Glycemia
Consistency is key!
◦ Be consistent with the timing of meals and snacks.
◦ Be consistent with eating carbohydrates at every
meall and
d snack.
k
◦ Be consistent with the total amount of
carbohydrates consumed at meals.
◦ Be consistent with matching carbohydrate intake to
insulin regimens.
(Mensing 2011)
14
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Carbohydrates and Glycemia

According to the American Association of Diabetes
Educators, American Diabetes Association, and the
Academy of Nutrition and Dietetics:
y
◦ “Low-carbohydrate
diets are not recommended
for persons with diabetes- safety and efficacy for
improved glycemia and weight loss are unproven.
Foods containing carbohydrate are important
components of a healthy eating pattern.”
(Mensing 2011)
Protein and Glycemia

Encourage:
◦
◦
◦
◦
Lean protein
Protein low in saturated fat
High in omega-3 fatty acids
Follow recommended portion sizes

Glucose produced from protein does not increase
blood glucose concentrations.

Ingestion of protein stimulates acute insulin secretion
but does not have long-term effects on insulin
requirements.
(Mensing 2011)
Fat and Glycemia

Dietary fat is believed to alter the predicted
postprandial response to a carbohydrate containing
meal.

Dietary fat
D
f is presumed
d to slow
l
glucose
l
absorption
b
and
d
delay the peak glycemic response to ingestion of
carbohydrate containing foods.

However…dietary fat has minimal effects on decreasing
postprandial glucose, altering insulin requirements, and
slowing gastric emptying.
(Mensing 2011)
15
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Fat and Glycemia

Encourage:
◦ Reduced intake of saturated and
trans fatty acids
 Butter, lard, bacon, sausage, poultry
skin, baked goods, fried foods,
doughnuts cookies
doughnuts,
cookies, etc.
etc
◦ Replace with monounsaturated fats
and omega-3 fatty acids
 Have beneficial effects on insulin
action.
 Canola, olive, & peanut oil
 Most nuts
 Fish oil, salmon, mackerel, herring
(Mensing 2011)
Alcohol and Glycemia
Moderate amounts of alcohol (less than 1 drink per day
for women, less than 2 drinks per day for men) consumed
with food has minimal effect, if any, of glucose and insulin
concentrations.
 Type of alcohol consumed does not make a difference.
 1 drink = 12 oz beer, 1.5 oz distilled spirits, 5 oz wine

(Mensing 2011)
Weight Management

High incidence of overweight and obesity is a major challenge in
diabetes care.

Weight loss is an important goal for patients who are overweight
or obese.

Moderate weight loss of 5%-10% can improve glycemia.

Moderate weight loss reduces the risk of developing cardiovascular
disease by reducing blood pressure, improving lipids, and decreasing
total cholesterol.

Combine reduced energy intake, physical activity, and behavioral
changes are the most effective strategies for weight loss and
management.
(Barclay, A. et al 2010)
16
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Nutrition Recommendations for
Weight Management

Most patients with type 2 diabetes are overweight and
insulin-resistant.
◦ ALL educators should emphasize:
 Healthy Eating
 Reduction of calories, saturated and trans fat, cholesterol and sodium
 Weight
W i h LLoss
 500-1000 kcal/daily reduction in calories
 1000-1200 kcal/day for women
 1200-1600 kcal/day for men
 Physical Activity
 Modest and based on patient’s willingness and ability to change
 30-45 minutes of moderate aerobic activity, 3-5 days a week
(Klein, S. et al 2004)
Weight Management

Effective nutrition interventions for weight management:
◦ 1. individualized reduced energy diet
◦ 2. total caloric intake distributed evenlyy throughout
g
the dayy
 4 to 5 meals/snacks per day, including breakfast
◦ 3. portion control emphasized
◦ 4. meal replacements for patients who struggle with food
selection and/or portion control
(Mensing 2011)
Weight Management

Weight loss is associated
with:
◦
◦
◦
◦
Energy deficit
Diet adherence
Enthusiasm of the counselor
Improved behavioral
strategies:





Self-monitoring
Stress management
Stimulus control
Problem solving
Social support
◦ NOT- nutrient composition
(Mensing 2011)
17
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IMPLEMENTING
BEHAVIOR CHANGE
Behavior Change

The goal of behavior
change is to produce
positive outcomes.

The patient’s goal should
be a priority to the
patient- not the educator’s
perceived priority that the
patient should have.

Goals should be: specific,
realistic, measureable,
attainable, and a priority
to the patient.
(Mensing 2011)
Behavior Change
Transtheoretical Model of
Behavior Change
Precontemplation
Contemplation
 Preparation
 Action
 Maintenance

Nutrition interventions need
to match the patient’s stage of
behavior change to support
healthy eating.

A behavior change is
something a patient can work
on that will influence their
blood glucose or weight.

Educators: Focus on behavior
change not the outcome.


(Mensing 2011)
18
5/10/2013
Behavior Change

Goal Setting Considerations:
◦
◦
◦
◦
◦
◦
◦
◦
◦
1. Educator and patient mutually set goals
2. Respect each patient as an individual
3. Patient investment
4. Remember the patient’s
patient s agenda
5. Individualize the goals
6. Focus on the behavior not the outcome
7. Create a written agreement
8. Include family and friends for support
9. Keep in mind cultural and financial considerations
Behavior Change Goals
Example Behavior Change Goals

Immediate Outcome:
◦ Goal is learning

Intermediate Outcome:
◦ Goal is behavior change

Post-Intermediate
Outcome:



◦ Goal is clinical improvement

Long-Term Outcome:
◦ Goal is improvement in
health status and cost
savings.


1. I will measure my food and
beverages for 3 days and
record the amounts.
2. I will check my blood
glucose 2 hours after each
meal every day for the next 3
days.
3. I will substitute sweet tea
for unsweet tea with a sugar
substitute.
4. I will not skip my breakfast
meal for the next 7 days.
5. I will portion out my
carbohydrate snacks to assist
with portion control.
(Mensing 2011)
DIABETES SUPPORT
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5/10/2013
Helpful Resources

Academy of Nutrition and Dietetics
◦ www.eatright.org

American Diabetes Association

American Association of Diabetes
Educators
◦ www.diabetes.org
www diabetes org
◦ www.daibeteseducators.org

United States Department of Agriculture
◦ www.choosemyplate.gov
DEBUNKING
NUTRITION MYTHS
Sugar Causes Diabetes

FACT: Sugar intake will not cause you to develop diabetes.

FACT: The main risk factors for type 2 diabetes are:
◦ diet high in calories
◦ being overweight
◦ inactive lifestyle

TIP: If you have diabetes you should watch your intake of
carbohydrates, including sugar.
(Steyn, NP. 2004)
20
5/10/2013
Skipping Meals Can Help Me Lose
Weight

FACT: If you skip a meal, your
body will think that you are in
starvation mode and therefore
slow down your metabolism to
compensate.You then tend to
overeat at the next meal.

FACT: Often,
Often skipping a meal and
then eating too much at the next
meal means that you have a
higher total caloric intake than if
you just ate more frequently
throughout the day.

TIP: A better approach is to
eat smaller frequent healthy
meals and snacks to keep
your blood sugar balanced.
(Mahan 2008)
Certain Foods, like Grapefruit, Celery,
Vinegar, or Cabbage Soup, Can Burn
Fat and Make You Lose Weight.

Fact: No foods can burn fat. Some foods with
caffeine may speed up your metabolism (the way
your body uses energy, or calories) for a short time,
but they do not cause weight loss.

Tip:The best way to lose weight is to cut
back on the number of calories you eat and
be more physically active.
(Mahan 2008)
Fruit has Too Much Sugar

FACT: Fruit is a healthy
choice. It's true that fruit
has naturally occurring
sugar, but it is also full of
vitamins, minerals and fiber
that are important for good
health
health.

TIP: Choosing more
vegetables and fruit,
naturally sweetened by
Mother Nature can help
you maintain your
weight and reduce your
risk of developing
chronic diseases.
(Mahan 2008)
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Avoid Carbohydrates to Lose Weight

FACT: Many low-carb diets actually do not provide sufficient
carbohydrates to your body for daily maintenance. Therefore, your
body will begin to burn stored carbohydrates (glycogen) for energy.
When your body starts burning glycogen, water is released. The
drastic initial drop of weight at the beginning of a low-carb diet is
mostly the water that you lose as a result of burning glycogen.

FACT: The truth is that low-carb diets are also often calorierestricted! Followers only eat an average of 1000 - 1400 calories
daily, compared to an average intake of 1800 - 2200 calories for
most people.
◦ To lose one pound a week, you only need to eat 500 fewer calories per
day in your normal diet.

TIP:Therefore, it doesn't matter if you eat a high- or lowcarb diet, you will lose weight if you decrease your calorie
intake to less than needed to maintain your weight.
(Mahan 2008)
Don’t Eat Anything White

FACT: Foods that contain
white flour and white sugar
do typically contain more
calories and carbohydrates.
However, they can be part
of any healthy diet when
eaten in moderation.

TIP: Make sure to eat white
foods like low-fat milk,
yogurt, potatoes,
mushrooms, cauliflower, and
rice.
(Mahan 2008)
Dietitians Never Eat Junk

FACT: Dietitians eat all
sorts of different foods,
even chocolate, french
fries, chips and candy...on
occasion.

FACT: Dietitians believe
that healthy foods are
delicious foods.

FACT: And we also
believe that there's
nothing wrong with the
occasional treat.
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5/10/2013
Questions
“As we say in the American Institute of
Wine and Food, small helpings, no
seco
s. A little
tt e bbitt o
yt g. No
o
seconds.
of eve
everything.
snacking. And have a good time.”
- Julia Child
References




American Diabetes Association. (2008). Nutrition
Recommendations and Interventions for Diabetes: A position
statement of the American Diabetes Association. Diabetes Care,
31(1).
American Diabetes Association. (2013). Carbohydrate Counting.
Retrieved on May 1,
1 2013 from <www.diabetes.org/food-and<www diabetes org/food and
fitness/food/planning-meals/carb-counting>
Barclay, A., Gilbertson, H., Marsh, K., et al (2010). Dietary
Management in diabetes. Australian Family Physician, 39(8).
Bliss, M. (1982).The Discovery of Insulin. May 3, 2013 from
<http://www.bio.davidson.edu/Courses/Molbio/MolStudents/s
pring2003/Williford/girlwithdiabetes.jpg>
References




Caughron, K., Smith, E. (2002). Nutrition Recommendations and
Principles for People with Diabetes Mellitus-Medical Nutrition
Therapy (MNT). Southern Medical Journal. 95(1). Retrieved on
May 1, 2013 from
<http://www.medscape.com/viewarticle/426920_7>
Klein, S., Sheard, N., Pi-Sunyer, X., et al. (2004). Weight
Management
g
Through
g Lifestyle
f y Modification
f
for
f the Prevention
and Management of Type 2 Diabetes: Rationale and Strategies.
Diabetes Care, 27(8).
Mahan, L., and Escott-Stump, S. (2008). Krause’s Food &
Nutrition Therapy. (12 ed). Saunders Elsevier, St. Louis,
Missouri.
Mazur, A. (2011). Why were “starvation diet” promoted for
diabetes in the pre-insulin period?” Nutrition Journal, 10(23).
Retrieved on April 29, 2013 from
<http://www.nutritionj.com/content/10/1/23>
23
5/10/2013
References


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