MSEM114.pdf

11/20/23, 5:26 PM Realizeit for Student Nutritional Therapy Nutrition, meal planning, weight control, and increased activity are the foundation of diabetes management (ADA, 2020; Evert, Dennison, Gardner, et al., 2019; Franz, MacLeod, Evert, et al., 2017). The most important objectives in the diet...

11/20/23, 5:26 PM Realizeit for Student Nutritional Therapy Nutrition, meal planning, weight control, and increased activity are the foundation of diabetes management (ADA, 2020; Evert, Dennison, Gardner, et al., 2019; Franz, MacLeod, Evert, et al., 2017). The most important objectives in the dietary and nutritional management of diabetes are control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and blood pressure to prevent heart disease. Success in this area alone is often associated with reversal of hyperglycemia in type 2 diabetes. However, achieving these goals is not easy. Because medical nutrition therapy (MNT)—nutritional therapy prescribed for management of diabetes usually given by a registered dietitian—is complex, a registered dietitian who understands the therapy has the major responsibility for designing and educating about this aspect of the therapeutic plan. Nurses and all other members of the health care team must be knowledgeable about nutritional therapy and supportive of patients who need to implement nutritional and lifestyle changes. Nutritional management of diabetes includes the following goals: 1.To achieve and maintain: a. Blood glucose levels in the normal range or as close to normal as is safely possible b. A lipid and lipoprotein profile that reduces the risk for vascular disease c. Blood pressure levels in the normal range or as close to normal as is safely possible 2.To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle 3.To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change 4.To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence For patients who have obesity and diabetes (especially those with type 2 diabetes), weight loss is the key to treatment. (It is also a major factor in preventing diabetes.) In general, overweight is considered to be a BMI of 25 kg/m2 to 29 kg/m2; obesity is defined as 20% above ideal body weight or a BMI equal to or greater than 30 kg/m2 (ADA, 2020; WHO, 2018). Patients who have obesity, type 2 diabetes, and require insulin or oral agents to control blood glucose levels may be able to reduce or eliminate the need for medication through weight loss. A weight loss of 5% to 10% of total weight may significantly improve blood glucose levels. For patients who have obesity and diabetes but do not take insulin or an oral antidiabetic medication, consistent meal content or timing is important but https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 1/6 11/20/23, 5:26 PM Realizeit for Student not as critical. Rather, decreasing the overall caloric intake is of greater importance. Meals should not be skipped. Pacing food intake throughout the day decreases demands on the pancreas. The actions of several oral antidiabetic medications include weight loss. For example, the glucagonlike peptide-1 (GLP-1) agonists are associated with delayed gastric emptying and weight loss. The dipeptidyl peptidase-4 (DPP4) and sodium-glucose cotransporter-2 (SGLT2) inhibitors improve glucose control assisting with weight loss (Keresztes & Peacock-Johnson, 2019). See discussion later in the module about oral antidiabetic medications. Consistently following a meal plan is one of the most challenging aspects of diabetes management. It may be more realistic to restrict calories only moderately. For patients who have lost weight incorporating new dietary habits into their lifestyles, diet education, behavioral therapy, group support, and ongoing nutrition counseling are encouraged to maintain weight loss. Meal Planning and Related Education The meal plan must consider the patient’s food preferences, lifestyle, usual eating times, and ethnic and cultural background. For patients who require insulin to help control blood glucose levels, maintaining as much consistency as possible in the amount of calories and carbohydrates ingested at each meal is essential. In addition, consistency in the approximate time intervals between meals, with the addition of snacks if necessary, helps prevent hypoglycemic reactions and maintain overall blood glucose control. For patients who can master the insulin-to-carbohydrate calculations, lifestyle can be more flexible and diabetes control more predictable. For those using intensive insulin therapy, there may be greater flexibility in the timing and content of meals by allowing adjustments in insulin dosage for changes in eating and exercise habits. Newer insulin analogues, insulin algorithms, and insulin pumps permit greater flexibility of schedules than was previously possible. This contrasts with the concept of maintaining a constant dose of insulin, requiring strict scheduling of meals to match the onset and duration of the insulin. The first step in preparing a meal plan is a thorough review of the patient’s diet history to identify eating habits and lifestyle and cultural eating patterns (ADA, 2020; Evert et al., 2019; Franz et al., 2017). This includes a thorough assessment of the patient’s need for weight loss, gain, or maintenance. In most instances, people with type 2 diabetes require weight reduction. In educating about meal planning, clinical dietitians use various tools, materials, and approaches. Initial education addresses the importance of consistent eating habits, the relationship of food and insulin, and the provision of an individualized meal plan. In-depth follow-up education then focuses on management skills, such as eating at restaurants; reading food labels; and adjusting the meal plan for exercise, illness, and special occasions. The nurse plays an important role in communicating https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 2/6 11/20/23, 5:26 PM Realizeit for Student pertinent information to the dietitian and reinforcing the patient’s understanding. Communication between the team is important. Certain aspects of meal planning, such as the food exchange system, may be difficult to learn. This may be related to limitations in the patient’s intellectual level or to emotional issues, such as difficulty accepting the diagnosis of diabetes or feelings of deprivation and undue restriction in eating. In any case, it helps to emphasize that using the exchange system (or any food classification system) provides a new way of thinking about food rather than a new way of eating. It is also important to simplify information as much as possible and to provide opportunities for the patient to practice and repeat activities and information. Caloric Requirements Calorie-controlled diets are planned by first calculating a person’s energy needs and caloric requirements based on age, gender, height, and weight. An activity element is then factored in to provide the actual number of calories required for weight maintenance. To promote a 1- to 2-lb weight loss per week, 500 to 1000 calories are subtracted from the daily total. The calories are distributed into carbohydrates, proteins, and fats, and a meal plan is then developed, taking into account the patient’s lifestyle and food preferences. Food Classification Systems To educate about diet principles and help in meal planning, several systems have been developed in which foods are organized into groups with common characteristics, such as number of calories, composition of foods (i.e., amount of protein, fat, carbohydrate in the food), or effect on blood glucose levels. Several of these are listed next. Exchange Lists. A commonly used tool for nutritional management is the exchange lists for meal planning (ADA, 2020). There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. Table 46-2 presents three sample lunch menus that are interchangeable in terms of carbohydrate, protein, and fat content. Exchange list information on combination foods such as pizza, chili, and casseroles, as well as convenience foods, desserts, snack foods, and fast foods, is available from the ADA (see the Resources section). Some food manufacturers and restaurants publish exchange lists that describe their products. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 3/6 11/20/23, 5:26 PM Realizeit for Student Nutrition Labels. Food manufacturers are required to have the nutrition content of foods listed on their packaging, and reading food labels is an important skill for patients to learn and use when food shopping. The label includes information about how many grams of carbohydrate are in a serving of food. This information can be used to determine how much medication is needed. For example, a patient who takes premeal insulin may use the algorithm of 1 unit of insulin for 15 g of carbohydrate. Patients can also be educated to have a “carbohydrate budget” per meal (e.g., 45 to 60 g). Carbohydrate counting is a nutritional tool used for blood glucose management because carbohydrates are the main nutrients in food that influence blood glucose levels. This method provides flexibility in food choices, can be less complicated to understand than the diabetic food exchange list, and allows more accurate management with multiple daily injections (insulin before each meal). However, if carbohydrate counting is not used with other meal-planning techniques, weight gain can result. A variety of methods are used to count carbohydrates. When developing a diabetic meal plan using carbohydrate counting, all food sources should be considered. Once digested, 100% of carbohydrates are converted to glucose. Approximately 50% of protein foods (meat, fish, and poultry) are also converted to glucose, and this has minimal effect on blood glucose levels. While carbohydrate counting is commonly used for blood glucose management with type 1 and type 2 diabetes, it is not a perfect system. All carbohydrates affect the blood glucose level to different degrees, regardless of equivalent serving size (i.e., the glycemic index—see later discussion). When carbohydrate counting is used, reading labels on food items is the key to success. Knowing what the “carbohydrate budget” for the meal is and knowing how many grams of carbohydrate are in a serving of a food, the patient can calculate the amount in one serving. Healthy Food Choices. An alternative to counting grams of carbohydrate is measuring servings or choices. This method is used more often by people with type 2 diabetes. It is similar to the food exchange list and emphasizes portion control of total servings of carbohydrate at meals and snacks. One carbohydrate serving is equivalent to 15 g of carbohydrate. Examples of one serving are an apple 2 inches in diameter and one slice of bread. Vegetables and meat are counted as one third of a carbohydrate serving. This system works well for those who have difficulty with more complicated systems. MyPlate Food Guide. The Food Guide (i.e., MyPlate) is another tool used to develop meal plans. It is commonly used for patients with type 2 diabetes who have a difficult time following a caloriecontrolled diet. Foods are categorized into five major groups (grains, vegetables, fruits, dairy, and protein), plus fats and oils. Foods (grains, fruits, and vegetables) that are lowest in calories and fat and highest in fiber should make up the basis of the diet. For those with diabetes, as well as for the https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 4/6 11/20/23, 5:26 PM Realizeit for Student general population, 50% to 60% of the daily caloric intake should be from these three groups. Foods higher in fat (particularly saturated fat) should account for a smaller percentage of the daily caloric intake. Fats, oils, and sweets should be used sparingly to obtain weight and blood glucose control and to reduce the risk for cardiovascular disease. Reliance on MyPlate may result in fluctuations in blood glucose levels, however, because high-carbohydrate foods may be grouped with lowcarbohydrate foods. The guide is appropriately used only as a first-step educational tool for patients who are learning how to control food portions and how to identify which foods contain carbohydrate, protein, and fat. Glycemic Index. One of the main goals of diet therapy in diabetes is to avoid sharp, rapid increases in blood glucose levels after food is eaten. The term glycemic index is used to describe how much a given food increases the blood glucose level compared with an equivalent amount of glucose. The effects of the use of the glycemic index on blood glucose levels and on long-term patient outcomes are unclear, but it may be beneficial (ADA, 2020; Evert et al., 2019). Although more research is necessary, the following guidelines may be helpful when making dietary recommendations: Combining starchy foods with protein- and fat-containing foods tends to slow their absorption and lower the glycemic index. In general, eating foods that are raw and whole results in a lower glycemic index than eating chopped, puréed, or cooked foods (except meat). Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption. Adding foods with sugars to the diet may result in a lower glycemic index if these foods are eaten with foods that are more slowly absorbed. Patients can create their own glycemic index by monitoring their blood glucose level after ingestion of a particular food. This can help improve blood glucose control through individualized manipulation of the diet. Many patients who use frequent monitoring of blood glucose levels can use this information to adjust their insulin doses in accordance with variations in food intake. LE 51-2 Selected Sample Menus From Exchange Lists https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 5/6 11/20/23, 5:26 PM Realizeit for Student Other Dietary Concerns Alcohol Consumption Patients with diabetes do not need to give up alcoholic beverages entirely, but patients and primary providers must be aware of the potential adverse effects of alcohol specific to diabetes. Alcohol is absorbed before other nutrients and does not require insulin for absorption. Large amounts can be converted to fats, increasing the risk for DKA. In general, the same precautions regarding the use of alcohol by people without diabetes should be applied to patients with diabetes. Moderation is recommended. A major danger of alcohol consumption by the patient with diabetes is hypoglycemia, especially for patients who take insulin or insulin secretagogues (medications that increase the secretion of insulin by the pancreas). Alcohol may decrease the normal physiologic reactions in the body that produce glucose (gluconeogenesis). Therefore, if a patient with diabetes consumes alcohol on an empty stomach, there is an increased likelihood of hypoglycemia. In addition, excessive alcohol intake may impair the patient’s ability to recognize and treat hypoglycemia or to follow a prescribed meal plan to prevent hypoglycemia. To reduce the risk of hypoglycemia, the patient should be cautioned to consume food along with the alcohol; however, carbohydrate consumed with alcohol may raise blood glucose. Alcohol consumption may lead to excessive weight gain (from the high caloric content of alcohol), hyperlipidemia, and elevated glucose levels (especially with mixed drinks and liqueurs). Patient education regarding alcohol intake must emphasize moderation in the amount of alcohol consumed. Moderate intake is considered to be one alcoholic beverage per day for women and two per day for men. Lower-calorie or less-sweet drinks (e.g., light beer, wine) and food intake along with alcohol consumption are advised (ADA, 2020; Evert et al., 2019). Patients with type 2 diabetes who wish to control their weight should incorporate the calories from alcohol into the overall meal plan. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX2deLl%2f4FdfKSHmHSZ7peJYyAcbNSqCsVXJC0jIBoVz… 6/6