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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 • • • • • • • • • 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 • • • • • • • 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 • Proteins • Fats • • 1 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 2 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 I 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 3 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 4 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 - 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! 5 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 • - 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 6 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 • • • • • • • 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 7 Advances in Diabetes Management ©TCHP Education Consortium, September 2006, Rev. July 2015