Transcript Improving Diabetes Care

Improving Diabetes Care:
The Role of Nutrition, Exercise,
and Education
Objectives:
• Describe the current standards of nutrition care
for patients with diabetes.
• Explain common meal planning approaches.
• Describe the role of exercise in blood sugar
management.
• Describe the value of a dietitian and/or diabetes
educator as a standard of care.
A little history…
“For forty-eight hours after admission to the hospital the
patient is kept on an ordinary diet, to determine the
severity of his diabetes.
Treatment:
“Then he is starved, and no food allowed save whiskey and
black coffee. The whiskey is given in the coffee: 1 ounce of
whiskey every two hours, from 7am until 7pm. The whiskey
is not an essential part of treatment; it merely furnishes a
few calories and keeps the patient more comfortable while
he is being starved.”
--Starvation (Allen) Treatment of Diabetes (1915).
Evolution of the “Diabetes Diet”……
1950: First ADA Exchange System Published
 Diabetes insulin-dependent and non insulin-dependent was just defined
 Diets based on total calories with set macronutrient % ranges
 Patients weighed all foods and followed rigid plans
1970’s: Exchange System updated to include CHO
 Research, but no way for consumers to determine carbohydrate content of foods
Early 90’s: Term “Carbohydrate Counting” introduced
 FDA food labeling for all US foods -Carbohydrate content now uniformly
regulated and easily accessible
 DCCT trial published documenting carbohydrate counting as a method of
effective dietary intervention
 Home glucose monitors become widely used and standard of care
Late 90’s-2000: Advances in insulin and oral med therapy
 First analog (Humalog), and peakless basal (Lantus) were approved by FDA
 Carbohydrate Counting gained scientific support and consumer popularity
2001 to current: Move to Evidence Based Nutrition Care
 ADA no longer endorses “ADA calorie diets” due to scientific evidence of no
benefit and potential harm
 Focus moves to consistent carbohydrate, individualized MNT
Clinical Goals of
“Modern” Diabetes Diet Plan
• Manage disease process: assist in achieving/maintaining blood
glucose levels within target range, lipid and lipoprotein profile that
reduces the risk for vascular disease, and blood pressure levels
• To prevent complications of diabetes, or at least slow the rate of
development, by modifying nutrient intake and lifestyle
• Address individual needs and strive to maintain the pleasure of
eating by only limiting choices when indicated by scientific evidence.
• Encourage ongoing healthy behaviors. Develop a plan for
continuing self management training and follow up care.
1.
Clement et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care, 2004;27:553-591.
2.
Franz et al. Nutrition Principles and recommendations in diabetes. Diabetes Care, 2004;27(Suppl 1):S36-S46.
3.
Nutrition Recommendations and Interventions for Diabetes. Diabetes Care, 2008;31 (Suppl 1):S61-S78.
Translating “Clinical Goals”
…into “Productive Change”
Diabetes Self-Management is NOT about RULES!!
It is about CHOICES!
Important choices that are made daily,
by the patient, not the care provider!
Providing written RULES, does not produce change in most patients.
Introducing relevant information and skills that allow patients to
better understand how their CHOICES impact their blood sugars,
risks, and ultimately quality of life does promote change.
Power of MNT?
• MNT has proven ability to lower A1c:
– ~1% in newly diagnosed Type 1
– ~2% in newly diagnosed Type 2
• Goes down to ~1% in Type 2 diagnosed >4 years
• Any time is a good time to refer to an RD, but
the BEST time is NEW diagnosis…don’t wait!!
Nutrition recommendations and interventions for diabetes. Diabetes Care 2007;30;S48-S65
Common Meal Planning Methods:
Plate Method
–
–
Can be used in addition to CHO counting
Can be used alone for patient with low literacy,
language barriers, etc.
Common Meal Planning Methods:
Consistent CHO or “CHO Counting”
–
–
–
Focused on BG control: carbohydrate
identification, moderation, and consistency – not
Can be adapted to a range of literacy levels
but requires higher level learner than plate
method
Works well with all treatment types
•
•
•
•
–
lifestyle controlled
oral meds
MDI
insulin pumps
Has proven higher long term compliance
than calorie based “ADA” type diet plans
• Moderation
– Eat total carbohydrate appropriate for
caloric needs, and spread evenly over
the course of the day.
• Consistency
– Eat consistent amounts of
carbohydrates each day.
• Maximums
– Avoid over eating carbohydrate at any
given sitting.
• Matching
– If patient is on MDI or insulin pump,
carbohydrate and insulin doses should
be matched as evenly as possible.
What is a moderate amount?
Ideally CHO intake should be individualized, but general
recommendations are as follows:
Male
Female
60-75g CHO per meal
45-60g CHO per meal
(4-5 CHO servings/meal)
15-30g CHO per snack
(1-2 CHO servings/snack)
(3-4 CHO servings/meal)
15g-30 CHO per snack
(1-2 CHO serving/snack)
Common Meal Planning Methods:
ADA Exchange System
•
There is no longer endorsed use of “ADA Calorie Based
Diets”. The American Diabetes Association does not endorse any
single meal plan or specified percentages of macronutrients.1
•
An individualized diet plan based on moderate and consistent
carbohydrate intake is recommended.
1
“Diabetes Nutrition Recommendations for Health Care Institutions.” American Diabetes Association. Diabetes Care 27.1 (2004)
2
Moghissi, ES, Hirsch, IB. “Hospital Management of Diabetes.” Endocrinology and Metabolism Clinics
of North America 34 (2005)
3
“Nutrition Care Manual”. American Dietetic Association. (2011)
A closer look….ADA Calorie Plans
are Consistent Carbohydrate Plans!
Calorie level
1200
1500
1800
2000
2200
2500
(calc. at ~50% total kcal)
150
195
225
240
270
315
Carbohydrate Servings*
(10)
(13)
(15)
(16-17)
(18)
(21)
Breakfast
Lunch
Dinner
HS
3
3
3
1
4
4
4
1
4
5
5
1
5
5
5
1-2
5
6
5
2
5
6
6
4
Target CHO grams
Specific fruit, starch, and milk choices will vary by patient preference.
Meats
2 (4oz)
2 (4oz)
2 (5oz)
3 (6oz)
3 (6oz)
4 (8oz)
Fats g/servings
40/4
47/5
54/6
60/7
74/9
83/12
What about protein?
Protein
• Usual daily protein intake has minimal effect on BG,
lipids, or insulin secretion
• For those with normal renal function, protein intake
recommendations are:
– 0.8-1 g/kg/day
– 15-20% total kcal/day
• Along with CHO counting, teach patients healthy
portion size, lean protein choices
• Protein is still important to overall health, but they
have much less impact on direct blood glucose
changes than carbohydrate ingestion.
1.
“Diabetes Nutrition Recommendations for Health Care Institutions.” American Diabetes Association. Diabetes Care 27.1 (2004)
2.
“Nutrition Care Manual”. American Dietetic Association. (2011)
3.
““Evidence for MNT in Type 1 and Type 2 Diabetes in Adults.” Journal of American Dietetic Association. 2010;110:1852-1889.
What about fat?
Fat
• Moderate fat intake has minimal effect on BG
– 30% kcal or less total fat
– 7% kcal or les total saturated fat
• Along with CHO counting, include cardio-protective
MNT
• Reduction of saturated, trans fat, and dietary
cholesterol
– Inclusion of healthy foods ie. Omega 3’s, poly and mono
unsaturated fats, more fiber
– Sodium and potassium adjustments for BP
• Fat is still important to overall health, but they have
much less impact on direct blood glucose changes
than carbohydrate ingestion.
1.
“Diabetes Nutrition Recommendations for Health Care Institutions.” American Diabetes Association. Diabetes Care 27.1 (2004)
2.
“Nutrition Care Manual”. American Dietetic Association. (2011)
3.
““Evidence for MNT in Type 1 and Type 2 Diabetes in Adults.” Journal of American Dietetic Association. 2010;110:1852-1889.
What about
Weight Management?
• Over 80% of patients with Type 2 Diabetes are overweight/obese
• It is estimated that only 1-5% of people who successfully lose weight
are able to the maintain loss
• During pre-diabetes, a weight loss of 5-7% of current body weight has
been shown effective to prevent or delay onset of overt DM
• Mild weight loss of 5-10% current body weight has been shown to
improve insulin sensitivity,especially in patient with new onset DM.
Obesity is a huge challenge, but is NOT an excuse for poor blood sugar
control!
Benefits of Physical Activity and Exercise
• Exercise can lower blood pressure and cholesterol levels
• Exercise strengthens your heart and circulatory system
• Exercise can decrease body fat and increase muscle tone
• Exercise can make you feel more relaxed, relieves tension and stress
How Does Exercise Effect Blood Glucose
• Activity will lower your blood glucose because the body cells take in
glucose more efficiently
•In Type 2 exercise may increase cells’ sensitivity to the effects of insulin
• Exercise helps reduce the amount of glucose released by the liver
• Regular exercise may reduce insulin requirements
Choosing an Exercise Program
• Choose something you enjoy and will do regularly
• ADA recommends 30 min a day/5 days a week
• Consult your health professional before starting and exercise program
• Start slow and gradually increase your activity
• Set realistic goals
Diabetes Self Management Education
(DSMT)
• ADA 7 Self-Care Behaviors
•Healthy Eating
•Being Active
•Monitoring
•Taking Medications
•Problem Solving
•Reducing Risks
•Healthy Coping
Are You In The Top 1%???
• 8.5 Million Medicare recipients are eligible for DSMT/MNT
• Only 58,000 – Less than 1% have utilized the covered benefit
Medicare Coverage
• Medicare patients are eligible for 10 hours of DSMT initial class and 2
hours for a refresher every year.
•Medicare patients are eligible for 3 hours of Medical Nutrition Therapy
(MNT) the first year and 2 hours every year
Role of a Diabetes Educator
• Integral to the multidisciplinary diabetes care team
• Facilitate behavior change by counseling patients and families on how to adopt
informed lifestyle decisions and incorporate healthier choices into their selfmanagement (7 Self-Care Behaviors)
• Assist the healthcare providers with Medication management, insulin titration
and instruction
• Insulin pump education/pre-pump, pump start and post-pump
Value of Outpatient Diabetes Self Management
Training (Case Study)
• Newly Diagnosed Type 2 – A1C 12.4 started on one oral medication
• Referred to outpatient education
• At completion of class his A1C was – ?????
Value of Outpatient Diabetes Self Management
Training
• A1C - 6.4 Because he came to class!
• Learned how to make better choices
• Incorporated lifestyle changes he could live with
Presented By:
• Cristin McKinley, R.D., C.D., C.D.E. – Johnson Memorial Hospital
• Carla Duncan, R.N. – Johnson Memorial Hospital