Transcript Nutrition Therapy in Diabetes Mellitus

Nutrition Therapy
in Diabetes
Mellitus
A Guide for the Nurse
Marion Technical College
NUR 1021
Spring 2016
Objectives of Nutritional
Therapy in DM
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Control of total caloric intake to attain or maintain
reasonable weight
Control of blood glucose to maintain health and prevent
complications
Address individual nutritional needs
Normalization of lipids and BP to reduce risk for
cardiovascular disease
Modify lifestyle as needed to treat obesity,
hyperlipidemia, CV disease, and nephropathy
For patients on insulin…
• Important to maintain consistency in amount of
calories and carbs at each meal,
AND
• Throughout the day
Nutritional Therapy in
Diabetes
• Cornerstone of care for the person with diabetes,
• Also the most challenging for many people.
• Nutritional therapy -greatest impact on the person
with diabetes if provided at the onset of diagnosis
• Registered dietician – responsible for design of diet &
education
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Nurses are supportive of diet plan & reinforce guidelines
Plan Nutrition Therapy to Achieve
Target Blood Glucose Level
• Emphasize to the patient and family members
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Diet is a balanced meal rather than eating a “diabetic
diet”
• If patient has type 2 diabetes mellitus and is obese
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Emphasize positive benefits of nutritional changes
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Helps lower blood glucose levels
Decrease lipid levels
Lower BP & will help in losing weight.
For Type 2 diabetics…
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Obesity is a major factor
80-90% are overweight
Obesity is also associated with increased insulin
resistance
Weight loss is the key to treatment
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Weight loss -increases insulin sensitivity & helps normalize
liver glucose production
Result is less need for medications to control blood glucose
What is overweight???
• A BMI of 25-29 (BMI is a height-to-weight ratio)
• Obesity is 20% or more over ideal body weight
For both types of diabetics…
• Skipping meals is undesirable
• For insulin-dependent persons, hypoglycemia may
result
• Even for Type 2 persons, pacing food more evenly
tends to equalize demands on pancreas
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WHAT DO YOU THINK IS OFTEN A CHALLENGE IN
MANAGING THE DIET FOR A PERSON WITH DIABETES ?
Consistency in eating habits
Considerations when
doing meal planning with
diabetics
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Food preferences
Lifestyle
Usual eating times
Ethnic and cultural practices
Who buys the food?
Who cooks the food?
Can they afford food?
Others in household?
Is transportation for food-buying an issue?
Caloric distribution
• Meal plan focus- Determining % of calories for CHO,
fats & protein
• Carbs (CHO) have the most impact on blood
glucose – they are digested and converted to
glucose quicker
• Per the American Dietetic Association (ADA):
CHO 50-60%
Fat 20-30%
Proteins (PRO) 10-20%
CHO, Fat & Protein
guidelines
• Recommended most of CHO come from whole
grains
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CHO should be eaten in moderation to avoid high
postprandial blood sugar
Concentrated sweets not totally eliminated but can be eaten
in moderation (up to 10% of total calories)
• Fat- should be less than 30% of total calories
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Limit of 10 % saturated fats; dietary cholesterol<300 mg/day
Benefit of ↓ coronary artery disease- leading cause of death
& disability among people with diabetes
• Protein – include non-animal sources of protein
(legumes & whole grains)
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Assists in reducing sat. fat & cholesterol intake
Protein may be reduced in people with early kidney
disease
• Fiber- increase in diet may improve blood glucose
level
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May reduce need for insulin- intake of 25 grams/day
Also helps in lowering total cholesterol & LDL’s
Soluble fiber (legumes, oats, some fruits) – better at
lowering blood glucose
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Results from slower rate of glucose absorption
Food Classification
Systems & Tools
• Exchange lists
• Nutrition labels
• Food Guide Pyramid
• Glycemic index – how much a given increases the
blood glucose compared to a given amount of
glucose
Exchange Lists
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Meal plans based on recommended number of choices
from each exchange
6 main exchanges
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Bread/starch
Vegetable
Milk
Meat
Fruit
Fat
Food exchanges on combination foods such as pizza –
available from the American Dietetic Association
Sample Menu from Exchange Lists
Exchanges
Sample Lunch #1
Sample Lunch # 2
Sample Lunch # 3
2 starch
2 slices bread
Hamburger bun
1 c. cooked pasta
3 meat
2 oz sliced turkey& 1 oz
low fat cheese
3 oz lean beef patty
3 oz boiled shrimp
1 vegetable
Lettuce, tomato, onion
Green salad
½ c. plum tomato
1 fat
1 tsp mayonnaise
1 TB salad dressing
1 tsp olive oil
1 fruit
1 med apple
1 ¼ c. watermelon
1 ¼ c. fresh
strawberries
“Free” items
(optional)
Unsweetened ice tea,
mustard, pickle, hot
pepper
Diet soda
1 TB catsup, pickle,
onions
Ice water with lemon
Garlic, basil
Let’s Plan a Meal:
Exchanges
2 starch
3 meat
1 vegetable
1 fat
1 fruit
“Free” items (optional)
Sample Lunch
Nutrition Labels
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Reading labels – very important
Note grams of CHO in serving
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1 unit of insulin for 15 g. CHO
Use as a guide for dose of
premeal insulin
Recommended budget of 40-60
g CHO /meal
CHO Counting- main influence
on blood glucose
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Less complicated than
exchange lists
Offers more flexibility
Glycemic Index –
Describes how much a given food increases the blood
glucose level compared to an equal amount of
glucose 2 hrs after ingestion(postprandial)
• Guidelines for dietary recommendations:
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Combine starchy foods with protein & fat-containing foodslows its absorption→ lowers glycemic index
• Whole fruit decreases the glycemic response as
opposed to fruit juice – fiber slows absorption
Benefits of glycemic index
• Foods with sugar should be eaten with more slowly
absorbed foods → lowers glycemic index
• Glycemic index helps avoid sharp increases in blood
sugar after meals are eaten
• If doing frequent monitoring of BS- can use GI to
adjust insulin doses with variations in food intake
Target Blood Glucose
Levels for People with
Diabetes
Before meals
90-130
1-2 hours after the start of a meal
Less than 180
Alcohol Consumption
• Moderate (usually defined as 1/day) is ok
• Must be calculated into meal plan
• Alcohol is absorbed before other nutrients and does
not require insulin for absorption
• Alcohol has an inhibitory effect on glucose
production by the liver
Sweeteners and SugarFree Food
• Examples of non-nutritive sweeteners include
Splenda, NutraSweet, and Sunnette
• Moderation in use- avoids potential complications
• Read all food labels carefully so you know what you
are getting- may still provide calories if made with
nutritive sweeteners (sorbitol)
Non-Nutritive Sweeteners
THINK LIKE A NURSE:
• If a patient has symptoms of a hypoglycemic reaction
what is the first action to take?
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Obtain a serum capillary blood glucose reading
• If a blood glucose
was below normal what should
the nurse do next?
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Provide a snack that includes CHO & protein- cheese &
crackers, half a sandwich or milk & crackers
EXERCISE
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Essential part of diabetes management
Recommended exercise 3 x/week
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Follow a consistent schedule
Usually after meals when BS ↑
Important to self-monitor BS before, during & after
If BS <100mg/dl eat a 10-15 g CHO snack before exercise
If BS>250mg/dl and ketones are present, DO NOT exercise
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May result in further elevated blood glucose
Important to monitor for hypoglycemia several hours after
exercise – eat a snack at end of exercise to avoid this
Remember - Sick Day Rules
• Most important guideline: NEVER eliminate insulin
when n/v occur
• Take usual dose of insulin
• Attempt to consume small frequent portions of CHO
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This includes foods “avoided”- soda, gelatin, juices
Blood glucose & urine ketones = assess @ 4-6 hr intervals
• Contact HCP if not able to retain
ketones persist
fluids or ↑BS &