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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
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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 Type 1 Diabetes • Idiopathic • Autoimmune • 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)
MILK FRUITS STARCHES & STARCHY VEGETABLES
The Fruit Group • Fresh fruit • Canned fruit(packed in lite syrup, juice or water) • 100% fruit juice(Labeled on container) • Dried fruit (raisins)
The Starch Group • Starches (bread, pasta, rice, crackers, cereals, snack foods) • Starchy vegetables(corn, potatoes, dried beans, peas)
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: Amountof Carbohydrate Type of sugar Nature of the starch Cooking & food processing Food form
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
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
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