Transcript Effective Diabetes Management at School
Nutritional Management of Diabetes at School
Betsy Smith, MS, RD Children’s Hospital January 11, 2007
Nutrition Objectives
• To provide nutrition guidelines for the
school nurse working with children with diabetes
• To describe the most popular methods
of diabetes medical nutrition therapy
• To describe and educate on the use of
carbohydrate counting
Outline
• Professional guidelines • 2 Main types of MNT with pediatrics • Carbohydrate Counting • Making adjustments for exercise • Questions
Goals of Medical Nutrition Therapy
• To provide adequate energy to ensure
normal growth & development
• To facilitate changes in eating &
physical activity habits to reduce insulin resistance
• Attain & maintain optimal metabolic
outcomes
• Prevent & treat the chronic
complications of diabetes
Goals of Medical Nutrition Therapy
• Improve health through healthy food
choices & physical activity
• Address individual nutritional needs • To provide self-management education
for treatment of acute complications
• To decrease diabetes risk by
encouraging physical activity & promoting healthy food choices
Medical Nutrition Therapy
• Goal to achieve blood glucose goals
without excessive hypoglycemia
• Based on requirements for all healthy
children & adolescents
• Ensure adequate intake of essential
vitamins & minerals
Diabetes Classification
• Idiopathic • Autoimmune Type 1 Diabetes • Beta cell destruction • Autoantibodies • Insulin dependent
Clinical Presentation
Type 1 Diabetes • Hyperglycemia • Ketoacidosis • Dehydration • The “Polys” • Nausea & vomiting • Ill appearing • Weight loss
Diabetes Classification
Type 2 Diabetes • Insulin resistance • Deficient insulin secretion • Obesity or increased body fat • Elevated insulin levels • Initially treated with diet, exercise, medications
Clinical Presentation
Type 2 Diabetes • Increased weight gain • Ketonuria • The “Polys” • Hyperglycemia • Elevated serum insulin • Acanthosis nigricans • Infections
Medical Treatment of Diabetes
• Target blood sugar range • Use of insulin Subcutaneous (SQ) injections Continuous SQ insulin infusion • Use of oral hypoglycemic agents • Weight management • Exercise • Medical nutrition therapy
Weight Management for Type 2 Diabetes
• Exercise can decrease insulin resistance & help with weight management • Weight loss can also improve lipid levels • Decrease risk for more immediate health risks • Slow rate of weight gain
Weight Management for Type 2 Diabetes
• 3 meals + 2-3 snacks a day should be encouraged • Consumption of more fruits & vegetables, whole grain products, lowfat dairy products • Facilitate behavior change • Identify barriers to success & help eliminate them
ADA Exchange List
• Developed in 1950, revised by ADA in
1995
• Lists of groups of measured foods that
equal an “exchange”
• Can be used for Type 1 & Type 2 • Alerts patient to fiber & sodium • Divides foods into 3 food groups • Carbohydrate • Meat & Meat Substitutes • Fat
ADA Exchange List
Advantages
• Provides a framework for grouping foods • Emphasizes important nutritional
management concepts
• Can use nutrient values from food labels
Not appropriate for use if the family cannot understand “exchanging”
Carbohydrate Counting
• Been around since 1920’s • Specifically focused on techniques to
optimize blood glucose control
• Used to match pre-meal insulin doses to
the demand created by food
• Other nutrition aspects must be
addressed separately
Carbohydrate Counting
•
Easier to learn than exchanges
•
Offers more variety in food choices
•
Provides a more accurate prediction of rises in blood sugar following a meal or snack
•
Allows utilization of food labels to make meal planning easier
Carbohydrate Counting Three Levels
•Basic - learn carbohydrate
exchanges & consistent intake
•Intermediate - learn to identify
patterns in blood glucose levels that are related to food eaten, diabetes medications used, &/or physical activity and how to make adjustments
Carbohydrate Counting
• Advanced - learn how to adjust
short-acting insulin to the carbohydrate content of meals (carbohydrate to insulin ratios)
SO HOW DO YOU COUNT CARBOHYDRATES?
IDENTIFY CARBOHYDRATE FOOD SOURCES
FRUITS STARCHES & STARCHY VEGETABLES MILK
The Fruit Group
• Fresh fruit • Canned fruit in lite syrup, juice or water) (packed • 100% fruit juice (Labeled on container) • Dried fruit (raisins)
The Starch Group
• Starches (bread, pasta, rice, crackers, cereals, snack foods) • Starchy
vegetables
potatoes, dried beans, peas) (corn,
The Milk Group
• Milk (whole, 2%, 1%, skim, buttermilk) • Yogurt • Pudding • Ice cream • NOT CHEESE !
WHAT TO CONSIDER WITH CARBOHYDRATE
• Used terms: sugars, starch, fiber • Factors that influence glycemic
responses to foods:
Amount of Carbohydrate Type of sugar Nature of the starch Cooking & food processing Food form
BE FAMILIAR WITH HOW MUCH FOOD COUNTS AS A SERVING
1 CARBOHYDRATE SERVING = 15 GRAMS CARBOHYDRATE
The Fruit Group
• Fresh fruit 1 cup, 1/2 banana, 15 grapes, 1/8 cantaloupe, tennis-ball size piece • Canned fruit 1/2 cup • 100% fruit juice 4 ounces • Dried fruit 2 Tablespoons
The Starch Group
• Starches 1 slice bread, 1/3 cup rice, 1/2 cup pasta, 1/2 cup cereal, 1 small roll, 1/2 bun • Starchy
vegetables
1/2 cup corn, potatoes, dried beans, peas
The Milk Group
• Milk 8 ounces • Yogurt 1 cup • Pudding & ice
cream
1/3 - 1/2 cup
READ THE NUTRITION FACTS LABELS!
3 THINGS TO READ ON A LABEL
• Serving Size • Total Carbohydrate • Total Fat
How Meal Plan Developed for Each Child
• Based on age & ideal body weight in
kilograms
• Pattern of growth & weight gain • Typical food intake at home • Food history & activity patterns • Time & place of all meals & snacks • Home & school schedule during week
Carbohydrate Counting: Suggested Education Progression • Initial session Diet goals and rationale Healthy nutrition Balanced meals Timing/consistency of meals Carbohydrate, protein, fat sources & effects on blood sugar levels Concentrated sweets/free foods Basic level of carbohydrate counting
Carbohydrate Counting: Suggested Education Progression • Follow-up (initial 1 to 2 months, at 6 months, yearly full nutrition assessment) Individualized meal plan based on clinical goals and patient/family readiness & motivation
Meal Plans at School
• Prescribed carbohydrate grams for
meals and snacks
• Not every child with diabetes will have a
meal plan
• Usually prescribed at diagnosis or clinic
visit, cannot be prescribed over the phone
• Sent to nutritionist of Child Nutrition
Program, who sends it to the school
Exercise Guidelines for Type 1 Diabetes
• Blood glucose
monitoring
• Precautions to
avoid hypoglycemia
• Food intake may
need to be increased
• Fluid intake is
essential
Exercise Guidelines for Type 1 Diabetes
• Carry adequate ID & a source of fast-
acting carbohydrate
• May require a decrease in insulin • Continue monitoring blood glucose after
exercise is completed
General Guidelines For Making Food Adjustments Types of Exercise If Blood Sugar Is:
Walking, leisure bike Less than 80 Above 80
Increase Food Intake By:
10-15 g CHO/hour Not needed Jogging, swimming, golf Less than 80 25-50 g CHO/hour Football, soccer, basketball, cheerleading 80-170 Less than 80 10-15 g CHO/hour 45 g CHO/hour 80-170 20-45 g CHO/hour
Parties at School
• Can still participate and eat food at
parties!
• Communicate with parent ahead of time – Can plan to change insulin dose to
cover party food
– Plan to have party around time of
snack
• Encourage teacher or parents to provide
healthy snacks at parties, sugar-free hard candy and lollipops
• Use fat-free whipped topping as icing on
cakes or cookies