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Unit 7
Nutritional Counseling
Stacey Day, MS, RD
Kaplan University
Counseling
Which stages are best suited for using
motivational interviewing?
Motivational Interviewing
The best stages for
using motivational
interviewing are the
preaction stages of
change–
precontemplation,
contemplation, and
prepartion
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What are the four general principles that
guide MI?
Motivational Interviewing
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Express Empathy
Develop discrepancies
Roll with resistance
Support self-efficacy
It’s your turn!
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Write an example that
expresses empathy in
a diabetic counseling
session.
It’s your turn!

Write an example that
develops
discrepancies in a
diabetic counseling
session.
It’s your turn!

Write an example that
rolls with resistance in
a diabetic counseling
session.
It’s your turn!

Write an example that
supports self-efficacy
in a diabetic
counseling session.
Questions?
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What are the warning signs of kidney
disease?
Warning Signs of
Kidney Disease
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High blood pressure
Swelling of the face
and ankles
Puffiness around the
eyes
Frequent urination
(especially at night)
Acute Renal Failure (ARF)
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ARF – alteration in
ability to excrete
metabolic waste
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Oliguria
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Production of less than
500mL in 24 hours
OR normal urine flow
decreases
Occurs in healthy
kidneys
Lasts few days –
several weeks
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GFR – The quantity of
glomerular filtrate
formed per unit in all
nephrons of both
kidneys.
Oliguria – Reduction
of urine output
Chornic Renal Failure (CRF)
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Inability of kidney function to return
normal after ARF or progressive renal
decline from disease.
Causes permanent reduction in fxn,
leading to ESRD.
Azotemia is common in CRG
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Excess urea and nitrogenous wastes in the
bloodstream.
CRF Causes
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Diabetes
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Causes 15% new
cases per year (1995)
Hypoparathyroidism
Regurrent acute or
chrnoic
glomerulonephiritis
Tubular disease
Chronic
hypercalcemia
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Chronic hyperkalemia
Vascular disease
Pyelonephritis
Renal caculi or
neoplasms
Systemic lupus
erythematosus,
Amyloidosis
Analgesic abuse
CRF: Signs and Symptoms
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Severe headache
Dyspnea
Pitting Edema of the
hands and legs
Failing vision
Poor appetite
N/V
Abdominal pain
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Mouth ulcers
Hiccups
Boing and joint pain
Fatigue
Uremic convulsions
Pericarditis
CRF: General Cautions
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Decrease risks
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Early nutritional intervention
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Smoking, Chronic anemia, and HTN in renal
pts may reduce death rates from CHD.
Delay or prevent rapid progression of disease
in some patients.
The Modified Diet in Renal Disease
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Study significantly correlates the delay of
disease progression with control over protein
and Phospohorous.
CRF
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Chronic dialysis may be needed with pts
who have bone disease or malnutrition.
Mortality  with Alb < 3.5 mg/dl
Low Chol ( 100) = severe malnutrition
Infants and Children may need TF to meet
catch-up growth needs.
CRF: Objectives
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Control uremic symptoms and
complications from accumulation of
nitrogenous waste.
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Restore and maintain electrolyte balance
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Correct acidosis and anemia
Limit further renal impairment
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AA = minimal RDAs
Reduce kidney workload
Minimize tissue catabolism
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Negative nitrogen balance
CRF: Objectives Continued...
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Maintain
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Nutritional status
Weight
Morale
Appetite
Postpone dialysis
Maintain growth
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Calories
Vits
Minerals
CRF: Dietary and Nutritional
Recs
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Adequate calories to prevent tissue
catabolism
If edemic
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Restrict sodium 1-3g NA, Restrict
Phosphorous if needed: 8-12mg/kg IBW
(mainly dairy foods).
If K , limit dietary K and salt substitutes.
CRF: Dietary and Nutritional
Recs
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Severe stages of CRF
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Fluid Intake
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Restrict Protein – 0.6 -0.6 g/kg IBW
60-70% HBV, 30-40% LBV
Output + 500 – 1000 ml for insensible losses.
CHO intolerance common
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Fructose, galactose, and sorbitol are well
tolerated.
CRF: Dietary and Nutritional
Recs
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Adequate B6, folic acid, vitamin C.
Calcium 1200 – 1600 mg/day
TPN be careful with excess of
micronutrients.
TF use special products such as Nepro or
Suplena.
CRF: Patient Education
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Indicate which food sources must be
restricted or used more frequently.
Referral to a renal dietitian, especially if
on dialysis.
Use more milk and eggs than meat.
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Meat produces more nitrogenous waste.
HBV proteins consumed daily.
CRF: Patient Education
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Taste changes may occur
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Sharp, distinct flavors may be better
tolerated.
Lack of red meats is common.
Low-protein wheat starch, hard candy,
and jelly
Dietary restriction is a vital element in
therapy.
CRF: Patient Education
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Have pt. weigh themselves daily.
Read food labels and measure foods is
essential.
Teach client how to read a restaurant
menu, plan for box lunches, and eating
away from home.
Goal of MNT for CRF
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Slow the decline in
renal function, which
will decrease longterm health care cost
and prolong an
independent quality
of life.
What is Diabetes
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Problem with fuel delivery in body
Body cells need glucose
Glucose cannot get into the cells without
insulin
“Diabetes is a group of diseases marked
by high levels of blood glucose resulting
from defects in insulin production or
insulin action or both”
Carbohydrate food – digests to
glucose which enters the blood
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Starches, bread,
pasta, rice, cereal,
snacks, potatoes,
peas, corn
Fruit, juice
Milk, yogurt
Desserts, candy
Sugar Beverages
Glucose requires insulin to move
into the cells.
Insulin Resistance
http://www.hivandhepatitis.com/0_images_2008/insualin2..jpg
Liver produces glucose
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Liver maintains glucose balance in the
blood
Controlled by 2 hormones insulin and
glucagon
Important during sleep, between meals,
illness when we cannot eat.
Imbalance with diabetes in that the liver
also produces extra insulin when it is not
needed.
Types of Diabetes
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Type 1 – Insulin dependent, juvenile onset
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Type 2 – Insulin Resistance
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Gestational Diabetes
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Pre Diabetes
Type I Diabetes
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Auto immune disorder resulting in the
bodies immune system destroying the
beta cells of the pancreas that produce
insulin.
Insulin is needed to regulate blood
glucose
Requires insulin injections to live
Affects children and young adults
5-10% of diagnosed cases of Diabetes
Type 2 Diabetes
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In adults accounts for 90-95% of cases
Insulin resistance results in the pancreas
being over worked to produce extra insulin
and over time wearing out the Beta cells
resulting in decreased insulin production
and elevated blood sugars.
Associated with adults, obesity,
gestational diabetes, impaired glucose
metabolism, physical inactivity, race and
Gestational Diabetes
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Hormones produced during pregnancy
results in insulin resistance.
Elevated blood sugars can lead to birth
defects for baby, spontaneous abortions,
large size babies and complications during
delivery
Most common in
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African/Hispanic/Latino/American Indians
Obese women with family history of DM
5-10% of women with GDM found to have
DM 2
Pre Diabetes
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Also can be referred to as
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Impaired Glucose Tolerance
Impaired Fasting glucose
Prevalence 2003-2006 data ~26% of
adults >20
2007 National Diabetes Fact Sheet
Pre Diabetes
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Most people have pre diabetes before
progressing to Type 2 Diabetes.
Most people will progress to Type 2
Diabetes within 10 years.
Lifestyle intervention to lose weight,
increase activity can prevent or delay the
onset of diabetes
Sheet
2007 National Diabetes Fact
Risk Factors for
Diabetes
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Age 45 and older
Overweight (BMI ≥ 25)
Hypertension
Abnormal lipid levels
Family history of diabetes
Race/ethnicity
History of gestational diabetes
• History of vascular disease
• Signs of insulin resistance
(such as PCOS or
acanthosis nigricans)
• Impaired glucose tolerance or
• Impaired fasting glucose on
previous test
• Inactive lifestyle
American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.
Diagnostic Criteria for
Pre-diabetes and Diabetes
Fasting Plasma Glucose
Test (FPG)
2-Hour Glucose
Challenge Test
Below 100 mg/dl
Below 140 mg/dl
Pre-diabetes
100-125 mg/dl (IFG)
140-199 mg/dl (IGT)
Diabetes
126 mg/dl or above
200 mg/dl or above
Acceptable
American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.
.
Complications
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Heart Disease and Stroke
High Blood Pressure
Blindness
Kidney Disease
Nervous System Diseases
Amputations
Dental Disease
Complications in
pregnancy
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Other
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Biochemical imbalances
that can be life threatening
including: Ketosis, Coma
More susceptible to
illnesses, and often have
worse prognosis
Persons >60 are 2-3 times
more likely to be have
shortness of breath with
climbing stairs, walking,
housework than persons
without diabetes at same
age
Controlling Diabetes
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By managing the ABCs of diabetes, people
with diabetes can reduce their risk for
heart disease and stroke.
A stands for A1C
B stands for Blood pressure
C stands for Cholesterol
A1C
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A1C measures average blood glucose over
the last three months.
The higher the blood glucose the more
sugar attaches to Red Blood Cells
A1C should be checked at least twice a
year.
A1C goal is < 7
To control A1C
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Follow modified Carbohydrate meal plan
Don’t skip meals
Eat the right kind of carbohydrates &
distribute evenly in day
Regular activity ~ 150 minutes per week
Weight loss
Take medications as prescribed
Blood Pressure
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High blood pressure increases risk for
heart attack, stroke, eye problems and
kidney disease.
Check blood pressure at every medical
every visit.
Target BP = less than 130/80
To control blood pressure
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DASH diet – fruits, vegetables, whole
grains
1500-2300 mg sodium
Limit caffeine and alcohol
Exercise 30 minutes most days of week
Weight loss
Eliminate first and second hand smoke
Take blood pressure medications
Cholesterol
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Blood Lipids
 LDL (“louseyl”) cholesterol - can
narrow or block blood vessels
 HDL (“happy”) cholesterol - helps
remove cholesterol deposits
 Triglycerides - can raise your risk for
heart attacks/stroke
Cholesterol Targets
Target LDL = less than 100
Target HDL = above 40 (men)
above 50 (women)
Target triglycerides = less than 150
To control cholesterol
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Therapeutic Lifestyle Change “TLC”
(modified sodium and saturated fat)
Physical activity 30 minutes most
days/week
10-20 pounds weight loss
Increase soluble fiber
Add Omega 3 fatty acid
Smoking cessation
Goal:
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Goal is to normalize blood glucose
1.
2.
3.
Diet - limit carbohydrate (CHO) – thus
reducing blood glucose
Exercise (improves insulin efficiency)
Medication
Stimulate pancreas to make insulin
 Increase insulin efficiency & reduce liver output of
glucose
 Insulin injections
 Preserve pancreas function in prediabetes
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How the body uses CHO
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Carbohydrate foods (grains, starches,
fruit, sweets) break down to GLUCOSE
Protein foods (meats, nuts, beans) break
down to AMINO ACIDS
Fat foods (oils, butter, margarine,
avocado, bacon) break down to FATTY
ACIDS.
CHO foods have greatest immediate
Individualized Meal Plan
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Calorie & CHO goal (typically high fiber)
Exercise recommendations
Coaching & support for behavior change
Weight loss
Additional factors for other health
concerns
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Sodium
Fats
Calcium/Magnesium/Potassium
1 serving carbohydrate (15
grams) Examples:
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1 small piece of fresh fruit (4 oz)
1/2 cup of canned or frozen fruit
1 slice of bread (1 oz) or 1 (6 inch) tortilla
1/2 cup of oatmeal
1/3 cup of pasta or rice
4-6 crackers
1/2 English muffin or hamburger bun
1/2 cup of black beans or starchy vegetable
1/4 of a large baked potato (3 oz)
1 serving carbohydrate (15
grams) Examples:
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2/3 cup of plain fat-free yogurt or sweetened with sugar
substitutes
2 small cookies
2 inch square brownie or cake without frosting
1/2 cup ice cream or sherbet
1 Tbsp syrup, jam, jelly, sugar or honey
2 Tbsp light syrup
6 chicken nuggets
1/2 cup of casserole
1 cup of soup
1/4 serving of a medium french fry
Diabetes Meal Planning – 1st Step:
Determine Calorie Level
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You can use any of these methods:
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Indirect calorimetry
REE Mifflin St Jeor
TEE using activity factor
For weight loss
3500 calories/pounds divide 7 days (week) = 500
= 1 pound/week
 7000 calories/pound divide 7 days (week) = 1000
or 2 pound per week.
 Subtract 500 or 1000 calories from TEE for weight
loss
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Diabetes Meal Planning – 2nd Step:
Determine Calorie Level
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Determine Calorie Level - 1800 calories
example
Determine Nutrition Standards – ADA
example
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40% CHO, 30-35% Fat, <10% Saturated Fat
1800 calories x 40% = 720 calories
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4 calories/gram CHO
720 divided by 4 = 180 grams CHO for the
day
Diabetes Meal Planning – 3rd Step:
Carbohydrate Distribution
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3 meals, and snacks as needed –
depending on medications.
Meals:
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Women/weight loss : 30-45 grams
carbohydrate per meal (2-3 servings of
carbohydrate)
Men/weight loss : 45 – 60 grams
carbohydrate per meal (3-4 servings of
carbohydrate)
Snacks
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Women/weight loss: 0-15 grams
Sample Meal Plan
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1800 calories/180 g CHO
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Breakfast 500 calories/45 g CHO
choice
Lunch
500 calories/45 g CHO
choice
PM Snack 100 calories/30 g CHO
choice
Supper
500 calories/45 g CHO
choice
HS Snack 200 calories/15 g CHO
or 3 CHO
or 3 CHO
or 2 CHO
or 3 CHO
or 1 CHO
Case Study #1
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J.R., a 16 year old female is present with her mother to discuss elevated blood sugars. Her
mother tells you her daughter has had diabetes since the age of 8 and has always done really
well with it- monitoring, taking the correct amount of insulin and eating about 45-60 gm of total
carbohydrates at breakfast, lunch and dinner and about 30 gm of carbohydrates for an afternoon
and possibly an evening snack. Her mother is concerned because for the past 6 months, or since
she has started her junior year of high school and started to date a boy, her blood sugars have
been erratic and more or less in the 300-500s. She reports she does not believe her daughter is
checking her blood sugars like she needs to be or eating correctly or even taking the right
amount of insulin. She also indicates her daughter has lost about 30 lbs within these past 6
months and she does not know what to do. The daughter or client was very quiet during this
time, so you had asked both the client and her mother if it would be alright for the mom to wait
outside. The client eagerly agreed. When you had the client alone she tells you all her friends
are super skinny and because of all this insulin she has to take she got fat (however when you
look at her, she looks emaciated.). So she heard that if you keep your blood sugars really high
you can lose weight very quickly. She also tells you she eats 2 meals a day and does not even
count carbohydrates any longer. She informs you she takes half of the insulin amount she needs
to and does not even do the correction factor.
Height: 5’4” Weight: 110 lbs Weight history: 140 lbs (4 months ago per MD chart)
Labs: Blood sugar monitor for past 3 days only 4 numbers on there: 350-high
Is this a form of an eating disorder and if so which type?
How would you counsel this client?
Would you tell the mom your conversation?
Case Study #2
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A 42 year old woman, R.S., is present and very distraught that she will
have to be on dialysis in another year if she does not start taking care
of herself. When asked, the client told you the doctor told her this
would happen. She informed you she does have a past medical history
of diabetes, hypertension, renal failure and high cholesterol. She
reports she is eating very little protein, not that much salt and just does
not know what else to do. She brought in her most current labs- BUN
24, Creatinine 2.3, Sodium 135, Potassium 4.1, Phosphorus 5.0,
Glucose 105. Height: 5’5” Weight: 130 pounds
Medications: Multivitamins, Omega 3s, Lipitor, Lasix, Atenolol
What stage of change do you believe the patient is in?
What is her BMI and what do her labs indicate to you?
What nutrition information would you provide to her?
What goals would you establish with her?
Would you follow up with her?
Case Study #3
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A 20 year old female, E.D., is present with type 1 diabetes and is coming to you
because her blood sugars have been high for the past month. She currently is in her
3rd year of undergraduate studying engineering. She reports she has had diabetes
since the age of 5 and knows how to carbohydrate count and administer the correct
amount of insulin to the amount of carbohydrates consumed, she also checks her
blood sugars at least 4 times per day and when she feels bad or is sick. She admits
she has been staying up later at night and eating more because of her difficult
classes. She also goes out on Friday nights and will drink 2-3 bottles of beer. She
has not been exercising as much and has gained at least 10 pounds within the past 6
months. She would like to know how many calories and carbohydrates she needs to
consume per day and how to stop the late night eating.
Height: 5’9” Weight: 170 pounds Weight history: 160 pounds (6 months ago)
Labs for the past 24 hours: fasting 150, before lunch 200, before dinner 180, before
bed 300
Medications: Rapid acting insulin (Novolog), Long acting insulin (Lantus)
What is her BMI?
What do her labs mean to you and what about the medications?
What stage of change is the client in?
How many calories and carbohydrates would you provide to her?
Would you provide her with anymore nutrition information?
What goals would you establish with her?
Would you follow up with her?