Download Carbohydrates Proteins Fats Carbohydrates

Topics for Today Include:
Basic healthy nutrition
Healthy weight
Portion Sizes
Carbohydrate counting
Label reading
Non-nutritive sweeteners
Gestational Diabetes
Insulin to carb ratios
Hyperglycemia in hospitalized patients
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Nutrition in
Diabetes Management
Kimberly Bihm, RD, LD, CDE VA Medical Center
Tammy Didion, RD, LDDiabetes Program Manager
Hennepin County Medical Center
Healthy Eating with Diabetes
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Maintain healthy weight
Balanced meals
Fruits, vegetables, whole grains
Low fat dairy
Fish, lean meats, skinless poultry
Healthy fats in moderation
Individualized approach
Mindset of eating healthy the majority of the
time and treating self occasionally
If overweight, start with losing
10% of your weight
Weight loss may improve:
blood glucose control
blood lipid control
blood pressure control
Energy Sources
Carbohydrates
Carbohydrates
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Proteins
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Fats
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The main source of energy to keep you and
your body moving
The main food that raises blood glucose
levels
A food you want to distribute over the day
and be careful not to overeat
It is recommended that the body have at
least 130 grams of carb per day
Advances in Diabetes Management
©TCHP Education Consortium, September 2006, Rev. July 2015
Carbohydrate Counting
 Budget approach
 15 grams of carbohydrate = 1 carb choice
 Consistent carbohydrate:
about the same amount of carb at meals
(spread carbs out throughout the day)
Carbohydrate choices or grams per meal
For weight
loss
To maintain
weight
If you exercise
5-7 x/week
Calories
per day
1100 -*1500
1600 -*2000
2100 -*2400
MEN
3 - 4 choices
(45 - 60 gm)
4 - 5 choices
(60 - 75 gm)
5 - 6 choices
(75 - 90 gm)
WOMEN
2 – 3 choices
(30 - 45 gm)
3 – 4 choices
(45 - 60 gm)
4 – 5 choices
(60 - 75 gm)
Fruit Group
15 grams of carbohydrate (1 carb choice) per serving
These numbers may vary depending on a persons weight, age, and/or activity level
*Is approximate calories for men
Snacks Optional: 1 carbohydrate choice (15 grams)
Adapted from IDC
Milk Group
12 grams of carbohydrate (1 carb choice)per serving
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Advances in Diabetes Management
©TCHP Education Consortium, September 2006, Rev. July 2015
Starchy Vegetables
Bread – Grain – Starch Group
15 grams of carbohydrate (1 carb choice) per serving
15 grams of carbohydrate (1 carb choice) per serving
Non-starchy Vegetables
Minimal effect on blood sugars
Foods that contain 5 grams of
carb or less do not need to be
counted if one serving consumed.
Example: 4 oz tomato juice
vs
12 oz tomato juice
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Protein
• Keeping a adequate level of protein in your
diet builds muscles, helps your body heal,
and gives it energy
Protein
• Protein does not raise blood glucose levels as
long as they are not breaded
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Advances in Diabetes Management
©TCHP Education Consortium, September 2006, Rev. July 2015
Fat
Protein
 Helps to provide energy
• In general, most adults need a total of 5-7 oz
of meat or meat substitutes per day
 Supports several bodily functions (absorption
of vitamins)
• Eating too much meat or meat substitutes can
lead to unwanted weight gain
 Fat has twice as many calories per gram as
protein and carbohydrates
 Fats do not raise blood glucose levels
Fat
What is a “Free Food”?
Butter
Margarine
Oils
This is a food that has less than
20 calories and 5 grams of
carbohydrate or less per serving
Salad dressing
Gravy
Mayo
Sour cream
Cream Cheese
Healthy fats include olive oil, canola oil, and tub margarines but still need to use
sparingly due to high in calories.
Find the serving size
24 pieces
Examples of “Free Foods”
Sugar-free jello
Sugar-free gum
Sugar substitutes
2 Tbsp sugar-free syrup
1 piece of sugar-free
hard candy
2 tsp low-sugar or light
jam/jelly
1 tsp sugar (4 gm carb)
Find the total
carbohydrate grams
22 grams
Tea
Coffee
Diet Soda
Club soda
Dietary fiber and sugar
grams are included in
the
Total Carbohydrate
Water
Sugar-free drink mixes
Broth or bouillon
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Advances in Diabetes Management
©TCHP Education Consortium, September 2006, Rev. July 2015
Sample Lunch Meal
How many grams of carbs ?
Meat Sandwich
Lettuce
2 slices of bread
Fruit
-15 grams per slice x 2 = 30
1 cup strawberries
Meat = 0
Lettuce Salad
1 cup lettuce = free
2 TBSP Italian= 3 gm
How many grams
Milk = 1 cup
of carbohydrates
or carb choices?
TOTAL: 60 grams
Gestational Diabetes
Non-Nutritive Sweeteners
• Gestational Diabetes is diabetes diagnosed in the
second or third trimester of pregnancy that is not
overt diabetes
• In pregnancy, insulin requirements are 2-3 times
higher
• Women who are not able to produce more insulin to
cover these needs develop Gestational Diabetes
• FDA approved with acceptable daily intakes
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Acesulfame potassium (Sweet one)
Aspartame (Nutrasweet, Splenda)
Neotame (made by Nutrasweet)
Saccharin (Equal, Sweet n Low, Sugar Twin)
Stevia (natural calorie free herbal sweetener)
Truvia is Stevia based
Gestational Diabetes – Carbohydrate
Counting
Basic Meal Plan for Gestational
Diabetes
• Principles
• Even distribution of carbohydrates (3 meals, 3 snacks)
• Increase protein and fats to provide adequate calories
and reduce hunger
• Protein, fats, and non starchy vegetables do not raise
blood sugar and can be added to snacks and meals if
patient is hungry.
• Avoid concentrated carbohydrates (juice, pop, syrup,
sugar, tortillas, etc.)
1 Carb Choice = 15 grams of total carbohydrates
• Breakfast* – 2 carb choices
• Snack – 2 carb choices
• Lunch – 4 carb choices
• Snack – 2 carb choices
• Dinner – 4 carb choices
• Snack – 2 carb choices
*Carbohydrate intolerance is greatest in the AM!
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Advances in Diabetes Management
©TCHP Education Consortium, September 2006, Rev. July 2015
Example
Give 1 unit rapid acting insulin for every 15 grams of
carbohydrate to be consumed BEFORE each meal
• Carbohydrate Based Insulin Dosing
- more flexibility with food choices
- help keep blood sugar levels within the target
range
Grams of carbohydrate eaten
• Patients on rapid acting insulin (Aspart/Novolog
or Lispro/Humalog) can be prescribed to give a
certain amount of insulin based on how many
carbs they plan on eating
For example, give 1 unit for every 10 or 15 grams of
carbohydrate to be consumed BEFORE each meal
Inpatient Hyperglycemia
and Patient Outcomes
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30 gm
Units of Aspart to give BEFORE
meal
2 units
45 gm
3 units
60 gm
4 units
75 gm
5 units
105 gm
7 units
120 gm
8 units
135 gm
150 gm
9 units
10 units
Inpatient Hyperglycemia
and Patient Outcomes
Several negative impacts
May increase stress hormones
May delay wound healing
May increase infection rates
• Possible reasons for hyperglycemia in patients
-Stress hyperglycemia
-Previously undiagnosed diabetes
-Known diagnosis of diabetes
• May increase morbidity and mortality
- New onset hyperglycemia linked to highest mortality
rates
- May increase chances for longer ICU stays
- May increase length of stay
• Challenges to Glucose Control
-Initiation or disruption of nutrition support
-Transition and progression of po diet
Summary
Education
• Carbohydrates are found in a variety of foods
• Offer outpatient classes
• Offer outpatient individual appointment with
a certified diabetes educator
• Include family whenever possible
• Our bodies need carbohydrate for energy but
people with diabetes need to monitor their
carbohydrate intake
• It is vital to know how much carbohydrate is in
the foods patients with diabetes eat
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Advances in Diabetes Management
©TCHP Education Consortium, September 2006, Rev. July 2015
Summary
Questions?
• Blood glucose control can be very challenging
especially in the inpatient setting
• Goals of Medical Nutrition Therapy
- Optimize blood glucose levels to meet patient
needs and promote healing
- Tailored to the individual patient
- Focus on good balanced nutrition
Thank you all for coming !
References
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American Dietetic Association, American Association of Clinical Endocrinologists and
American Diabetes Association Consensus Statement on Inpatient Glycemic Control,
Diabetes Care 2009:32(6)1119-1131
American Diabetes Association (2015). Standards of medical care in diabetes – 2015.
Diabetes Care 38 (Supplement 1), S77-S79.
Braithwaite SS, Magee MF, Sharretts JM, Schnipper JL, Amin A. Maynard G. The case for
supporting inpatient glycemic control programs now: the evidence and beyond. J Hosp
Med, 2008; 3(5) (suppl 5): S6-S16
Diabetes Care, Volume 32, Supplement 1. January 2009. American Diabetes Association
Clinical Practices Recommendations 2009
The Art and Science of Diabetes Self Management Education, A Desk Reference for
Healthcare Professionals. A Core Knowledge Publication of the American Association of
Diabetes Educators. 2006, Chicago, Illinois
ADA Exchange Lists for Meal Planning, 1American Diabetes Association Clinical Practice
Recommendations 2002, Evidence-Based Nutrition Principles and Recommendations for
the Treatment and Prevention of Diabetes and Related Complications, Diabetes Care,
January 2002, Supplement 1, vol.25, p S50.
VA/DoD Clinical Practice Guideline for Management of Diabetes Mellitus. Version
4,2010
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Advances in Diabetes Management
©TCHP Education Consortium, September 2006, Rev. July 2015