Nutritional Management of Diabetes at School

1. Nutritional Management of Diabetes at School Betsy Smith, MS, RD Children’s Hospital January 11, 2007

2. 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

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

4. 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

5. 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

6. 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

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

8. Clinical Presentation Type 1 Diabetes • Hyperglycemia • Ketoacidosis • Dehydration • The “Polys” • Nausea & vomiting • Ill appearing • Weight loss

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

10. Clinical Presentation Type 2 Diabetes • Increased weight gain • Ketonuria • The “Polys” • Hyperglycemia • Elevated serum insulin • Acanthosis nigricans • Infections

11. 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

12. 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

13. 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

14. 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

15. 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”

16. 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

17. 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

18. 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

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

20. SO HOW DO YOU COUNT CARBOHYDRATES?

21. IDENTIFY CARBOHYDRATE FOOD SOURCES

23. MILK FRUITS STARCHES & STARCHY VEGETABLES

24. The Fruit Group • Fresh fruit • Canned fruit(packed in lite syrup, juice or water) • 100% fruit juice(Labeled on container) • Dried fruit (raisins)

25. The Starch Group • Starches (bread, pasta, rice, crackers, cereals, snack foods) • Starchy vegetables(corn, potatoes, dried beans, peas)

26. The Milk Group • Milk (whole, 2%, 1%, skim, buttermilk) • Yogurt • Pudding • Ice cream • NOT CHEESE !

27. 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

28. BE FAMILIAR WITH HOW MUCH FOOD COUNTS AS A SERVING

29. 1 CARBOHYDRATE SERVING = 15 GRAMS CARBOHYDRATE

30. 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

31. 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

32. The Milk Group • Milk 8 ounces • Yogurt 1 cup • Pudding & ice cream 1/3 -1/2 cup

33. READ THE NUTRITION FACTS LABELS!

34. 3 THINGS TO READ ON A LABEL • Serving Size • Total Carbohydrate • Total Fat

36. 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

37. 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

38. 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

39. 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

40. Exercise Guidelines for Type 1 Diabetes • Blood glucose monitoring • Precautions to avoid hypoglycemia • Food intake may need to be increased • Fluid intake is essential

41. 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

42. General Guidelines For Making Food Adjustments

43. 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

44. Questions