Nutritional Management of Diabetes at School

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Nutritional Management of Diabetes at School

• Betsy Smith, MS, RD
• Childrens Hospital
• January 11, 2007

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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

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Outline

• Professional guidelines
• 2 Main types of MNT with pediatrics
• Carbohydrate Counting
• Making adjustments for exercise
• Questions

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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

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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

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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

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Diabetes Classification

• Type 1 Diabetes
• Idiopathic
• Autoimmune
• Beta cell destruction
• Autoantibodies
• Insulin dependent

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Clinical Presentation

• Type 1 Diabetes
• Hyperglycemia
• Ketoacidosis
• Dehydration
• The Polys
• Nausea vomiting
• Ill appearing
• Weight loss

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Diabetes Classification

• Type 2 Diabetes
• Insulin resistance
• Deficient insulin secretion
• Obesity or increased body fat
• Elevated insulin levels
• Initially treated with diet, exercise, medications

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Clinical Presentation

• Type 2 Diabetes
• Increased weight gain
• Ketonuria
• The Polys
• Hyperglycemia
• Elevated serum insulin
• Acanthosis nigricans
• Infections

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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

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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

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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

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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

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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

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Carbohydrate Counting

• Been around since 1920s
• 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

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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

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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

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Carbohydrate Counting

• Advanced - learn how to adjust short-acting
  insulin to the carbohydrate content of meals
  (carbohydrate to insulin ratios)

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SO HOW DO YOU COUNT CARBOHYDRATES?
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IDENTIFY CARBOHYDRATE FOOD SOURCES
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MILK
FRUITS
STARCHES STARCHY VEGETABLES
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The Fruit Group

• Fresh fruit
• Canned fruit (packed in lite syrup, juice or
  water)
• 100 fruit juice (Labeled on container)
• Dried fruit (raisins)

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The Starch Group

• Starches (bread, pasta, rice, crackers, cereals,
  snack foods)
• Starchy vegetables (corn, potatoes, dried beans,
  peas)

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The Milk Group

• Milk
• (whole, 2, 1, skim, buttermilk)
• Yogurt
• Pudding
• Ice cream
• NOT CHEESE !

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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

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BE FAMILIAR WITH HOW MUCH FOOD COUNTS AS A SERVING
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1 CARBOHYDRATE SERVING 15 GRAMS CARBOHYDRATE
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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

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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

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The Milk Group

• Milk
• 8 ounces
• Yogurt
• 1 cup
• Pudding ice cream
• 1/3 - 1/2 cup

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READ THE NUTRITION FACTS LABELS!
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3 THINGS TO READ ON A LABEL

• Serving Size
• Total Carbohydrate
• Total Fat

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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

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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

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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

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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

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Exercise Guidelines for Type 1 Diabetes

• Blood glucose monitoring
• Precautions to avoid hypoglycemia
• Food intake may need to be increased
• Fluid intake is essential

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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

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General Guidelines For Making Food Adjustments
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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

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Questions