- Email: [email protected]
New interventions in diabetes with medical nutrition therapy
supplement
New Interventions in Diabetes with
Medical Nutrition Therapy Eileen Paul, RD, CD, CDE Nutrition therapy has been the focus of diabetes management since before insulin was discovered.1 Many theories and approaches have been recommended and reemerged over the years. Since the Diabetes Control and Complications Trial (DCCT) results were released in 1993, nutrition is considered the most critical and pivotal component of diabetes care in achieving blood glucose goals. We have seen increased emphases on individualized nutrition therapy and the dietitian as a true partner in diabetes care, research, and management.1 Advances in nutrition therapy now center on methods to improve behavioral change because it is the major challenge facing people with diabetes. Access to nutrition therapy and self-management training is critical to improve clinical outcomes and reduce health care costs otherwise spent on clinic visits, expensive medications, emergency room visits, and hospitalizations.1
The nutrition recommendations and principles for people with diabetes mellitus from the American Diabetes Association (ADA) outline optimal nutrition care. The goals for medical nutrition therapy (MNT) are to help individuals with diabetes make changes in nutrition and exercise habits that improve metabolic control. The more specific goals are to maintain normal or near normal glycemic control, achieve optimal lipid levels, provide adequate calories and nutrients for individuals’ needs, prevent complications, and improve overall health.2 Daily goals include: • 50% to 60% of calories from carbohydrates • 12% to 20% of calories from proteins • 30% or fewer calories from fats, with less than 10% from saturated fats • Less than 300 mg cholesterol • Moderate sodium intake (<300d mg) • Alcohol in moderation and with food • Fiber 20-35 g • A wide variety of foods for micronutrients In the course of educating a person with diabetes, it is necessary to assess his or her needs based on the type of diabetes. The needs and goals for a person with type 1 diabetes will be different from those of a person with type 2 or a woman with TCM 78
March/April 2002
gestational diabetes. The materials may be the same for all three types, but the approach to the education and the intensity of diabetes management to achieve blood glucose control will differ. Behavior change and readiness to change are also key factors in any education process. One thing is clear to most nutrition educators and dietitians: no one standard meal plan works for everyone. Meal planning requires flexibility to address different preferences, lifestyles, cultures, etc. Using a variety of approaches will maximize outcomes. This flexibility requires a variety of teaching tools and more than one approach when teaching from them. No more standardized, preprinted diet/meal plans! An individualized approach is critical for long-term success. Knowing why it is important to follow a particular plan helps a person with diabetes make the best decisions of how to change behavior that influence diabetes outcomes. Knowing how the body responds to certain foods and what to expect allows the patient to integrate new treatments, such as diet, and evaluate the results or benefits. Using analogies and word pictures are helpful because they demonstrate concepts. For example, describing a cell as having doorways that allow glucose to enter creates a picture that can
supplement be understood more easily. Discussing how medications work to open the doorways or how exercise increases the flow through the doorways can be useful in getting patients to dose their medications appropriately or add more exercise to their daily routines. Using analogies, such as doorways that overcrowd when the blood glucose rises too high after a meal, helps patients see that portion control and activity after meals can improve blood glucose levels. Understanding glucose as fuel can help a person see that activity will use glucose for energy and avoid overfueling the body. Ideally, nutrition intervention should be conducted in stages based on a comprehensive nutrition assessment and an individual’s goals and needs.1 Guideline approaches provide the foundation of basic nutrition information, underscore consistency in food, and emphasize healthier food choices. Some examples of this include a simple food guide pyramid, which provides a visual of dietary guidelines and the concept of food grouping. The American Dietetic Association and the ADA have worked together to develop a tool called First Steps in Meal Planning,3 a modified food guide pyramid that teaches basic diabetes meal-planning goals. It allows for adjustment in the number of servings but keeps a standard portion size similar to the food exchange list. Both of these visual tools are easy to read (First Steps is written at a 5th- to 7th-grade reading level). When using First Steps, the educator and patient need to set a target goal for daily nutrient intake. This approach targets carbohydrates and sets a “carb budget.” Carbohydrate is the focus in diabetes meal planning because it is the primary nutrient that raises blood glucose. Generally, a range in amount of carbohydrate per meal/per day is established. The patient then is able to mix and match the food groups in the pyramid to control total carbohydrate intake. Carbohydrates include such things as fruits, milk, starches, etc. As an example, meals may be set at 45-60 grams and snacks at 15-20 grams of carbohydrate each. Intake then can be made more specific, such as 45 grams for breakfast, 60 grams for lunch and dinner, 15 grams for each snack during the day, and 30 grams for a bedtime snack. Menu selections may vary from day to day, such as fruit, nonfat milk, and whole-grain toast on 1 day and fruit with an English muffin with light margarine on another day. The carbohydrate count is equal even though the type of food is different. This method gives people with diabetes more options to eat a wide variety of foods and allows for occasional substitutions of sweets into the budget without negative results. Consider Tom, who is 67 years old and has had type 2 diabetes for 4 years. His glycemic goals are less than 130 mg/dL fasting and before meals and less than 150 mg/dL 2 hours after meals. He has just visited a fast food restaurant, where he chose a grilled chicken sandwich, a garden salad with light dressing, and a diet soda. Tom’s budget for lunch is 60 grams
of carbohydrates. He consults a reference book, such as The Diabetes Carbohydrate and Fat Gram Guide,4 for the fast food restaurant in question. The sandwich is listed as having 38 grams, the salad 7 grams, and the fat-free vinaigrette 11 grams. The carbohydrate total is 56 grams. He is well within the acceptable carb budget for his meal. We could expect Tom to remain within his target range for blood glucose at the next meal and 2 hours afterward. The in-depth stage of the nutrition process provides more information about meal planning and approaches that offer greater variety and flexibility.1 These approaches include such things as the exchange list for meal planning, where foods are grouped into six lists and the foods within each group can be exchanged in the indicated amount. Other approaches include counting principles. One new innovative counting approach to diet education that has gained in popularity is carbohydrate counting. This approach can be individualized at varying levels of intensity, works to improve blood glucose goals, and allows the use of a variety of teaching tools. For more intensive insulin management for types 1 and 2 diabetes, it is possible to determine the amount of insulin needed for the amount of carbohydrates eaten. Whether the insulin delivery system is multiple daily injections (MDIs) or continuous subcutaneous insulin infusion (CSII) by an insulin pump, attention to the details of the diet and blood glucose is considered meal by meal. Creating a ratio of insulin to carbohydrates allows the individual more possibilities to eat varied amounts of food at meals and more flexibility in the timing of meals and snacks. The Rule of 500 may be applied: 500 total daily dose (TDD) of insulin equals the number of grams of carbohydrate that one unit of short-acting insulin will cover.5 For example, 500 (50 units TDD = 10 grams of carbohydrate per unit of insulin) or a ratio of 1:10. This type of calculation is essential for successful intensive insulin management, whether by MDI or CSII, because the insulin must match the food intake to manage the blood glucose levels. Using insulin pumps allows even more precise calculation because they may be set to deliver smaller doses than one unit. Insulin pumps also may be customized to a preprogrammed basal rate that delivers the background insulin (in place of longer acting insulin such as NPH, Lente, Ultralente, or Lantus) to meet the needs of each patient. A different delivery rate can be programmed for each hour. This customization offers improved blood glucose control with less hypoglycemia.6 More intensive insulin management requires more detailed information and recordkeeping when starting out. One excellent education tool for this approach is the “Carbohydrate Counting” booklet series available from the ADA: “Getting Started,” “Moving On,” and “Using Carbohydrate/Insulin Ratios.”7 These booklets provide a three-level approach to education. The patient begins with the basics using the first March/April 2002
TCM 79
supplement Figure 1
drates listed. Total fiber should be subtracted if the fiber is greater than 5 grams per serving because it is not digestible and will not affect blood glucose. In addition to the carbohydrate/insulin ratio, intensive insulin management involves taking a correction dose of insulin for blood glucose levels above the patient’s target range. A formula called the Rule of 1800 may be used to determine this dose: 1800 TDD of insulin (include all types) equals the number of mg/dL that one unit of insulin will lower the blood glucose.5 For example, if the TTD is 60 units, the correction factor would be 30 mg/dL lowered for every 1 unit of insulin. For example, Jo is 46-year-old woman who has had type 1 diabetes for 27 years. She is using an insulin pump with Humalog insulin. Her basal rates have been set to keep her blood glucose levels within target range while fasting. Her blood glucose goals are 80 to 140 mg/dL. Before lunch, her blood glucose is 156 mg/dL. She is planning to eat food that she brought from home, including a tuna sandwich, a large apple, and 8 ounces of light yogurt. Assuming a ratio of 1:15 or 1 unit per 15 grams of carbohydrate, Jo counts her bread as 30 grams, her apple as 40 grams, and her yogurt at 15 grams, totaling 85 grams. Jo then divides 85 by 15 and gets 5.6 units of insulin. She will take 5.6 units for the carbohydrate in her meal.
book and moves through the remaining two levels, intermediate and advanced, at a rate that matches his or her need and readiness for progress. The inexpensive books are easy to read and teach from. Some individuals may seek more information and even greater flexibility. They may prefer to use reference books that provide information on calories and fats in addition to carbohydrates. Information in the nutrition facts on food labels, such as the one shown in Figure 1, helps with this information. When reading a food label, important information to note includes: • Serving size listed • Servings per container • Total carbohydrate in grams (which includes all sugars and fiber) • Total fat grams Other concepts should be remembered when reading food labels. The number of servings eaten should be calculated to determine true total carbohydrates. Sugars do not need to be counted separately because they are part of the total carbohyTCM 80
March/April 2002
Because her blood glucose is also above target range (156 mg/dL with target of 140 mg/dL), she needs to take insulin to bring the reading down. This is referred to as a correction factor. Her correction factor is 1 unit for each 40 mg/dL of blood glucose, which means she will need one unit for her elevated premeal blood glucose plus the amount of insulin calculated for her carbohydrates. This figure equates to 5.6 units for carbohydrate + 1 unit as a correction factor, which totals 6.6 units of insulin. Because Jo is wearing an insulin pump, she can program the exact bolus amount in tenths of a unit and deliver 6.6 units easily. Her next reading should be less than 140mg/dL, assuming she continues her usual activity. The best approach to meal planning should be based on a comprehensive assessment and goals tailored to each patient. No one system or approach is correct. Offering a combination of resources can help build on each person’s nutrition knowledge one step at a time. Ongoing support for behavior change also is critical for long-term success. Patients often are asked to keep records of their eating habits, activities, and blood glucose values. This recordkeeping can be another very helpful tool if the health care team uses it. Having the diabetes team (physician, nurse, dietitian, and/or pharmacist) respond to this level of detail gives patients direction for improving and fine-tuning their diabetes management. Such records are useful to help patients see the whole picture, better understand relationships to blood glucose control, and use pattern recognition in their daily routines. Assessing and providing ongoing care and education, along with detailed
supplement records of food, insulin or medication, activity, and stress or illness are the best ways to empower patients with the information they need to manage their blood glucose. Daily diabetes management is in the hands of the patient, but this approach unites the patient and the provider as a team. The bottom line outcome for diabetes management is having the best glucose control possible to avoid acute and chronic complications. Reducing the costs of caring for people with diabetes creates a win-win situation for both managed health care plans and patients. MNT can help reduce these costs by giving people with diabetes tools and decision-making skills for lifestyle management.8 Whether a patient’s diabetes is controlled solely by diet and exercise or with a combination of oral agents and insulin, nutrition education is important. Referral to a certified diabetes educator dietitian as part of the expert team may be the turning point in cost savings for health care plans.8 Referrals to a dietitian are recommended at least once a year to review meal plans and provide reinforcement education. Case managers, as part of the team, can help identify the appropriate patients for referral and help assess patient needs and reinforce nutrition information. It is also important for case managers to stay abreast of new information and maintain access to nutrition experts to best assist patients with successful diabetes management. The Internet can be a powerful tool to accomplish this and stay in contact with the American Dietetic Association, ADA, and the American Association of Diabetes Educators for additional resources.
2. The American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care 2001;24(Supl 1):S44-S47. 3. The American Diabetes Association, American Dietetic Association. First steps in meal planning. 1997. 4. Holzmeister L. The diabetes carbohydrate and fat gram guide. 2nd ed. Chicago: The American Diabetes Association; 2001. 5. Walsh J, Robert R. Pumping insulin. 3rd ed. San Diego: Torrey Pines Press; 2000. 6. Bode B, Steed R, Davidson P. Reduction in severe hypoglycemia with long-term subcutaneous insulin infusion in type 1 diabetes. Diabetes Care 1996;19:324-7. 7. The American Diabetes Association. Carbohydrate counting: getting started, moving on and using carbohydrate/ insulin ratios. Chicago: The Association; 1995. 8. Sheils J, Stapleton D, Dietrich K, Scrivner S, The Lewin Group. The cost of MNT under Medicare: 1998-2004. Final Report, April 18, 1987. American Dietetic Association Courier 1997;36(5). Eileen Paul, RD, CD, CDE, is a diabetes educator and clinical dietitian for the Group Health Cooperative in Seattle, Wash. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/123065 doi:10.1067/mcm.2002.123065
References 1. Powers M. Handbook of medical nutrition therapy. Gaithersburg (MD): Aspen Publishers; 1996.
March/April 2002
TCM 81
supplement test This article has been approved for 1 hour of CCM, CRC, and CDMS education credit by The Foundation for Rehabilitation Education and Research. To obtain your education credit, please do the following: 1. Read the “Controlling Costs and Improving Diabetes Care” and “New Interventions in Diabetes with Medical Nutrition Therapy” articles. 2. Make copies of this page for each person applying for credit. 3. Answer the following questions by selecting one statement. Four questions must be answered correctly to receive the educational credit. 4. Mail this completed form with a check for $10 to: Foundation for Rehabilitation Education and Research 1835 Rohlwing Rd., Ste. E, Rolling Meadows, IL 60008 Questions: For which educational credit (1 hour) are you applying? CCM ID#___________ CRC ID#___________
CDMS ID#__________
1. Goals for medical nutrition therapy include: ___ A. Maintaining normal or near normal glycemic control ___ B. Achieving optimal lipid levels ___ C. Providing adequate calories and nutrients ___ D. Preventing complications and improving overall health ___ E. All of the above 2. Which of the following statements are true? ___ A. Most diabetes patients are seen by specialists. ___ B. Approximately 15% of total U.S. health care expenditures are spent on diabetes. ___ C. The incidence of diabetes is increasing. ___ D. A, B ___ E. B, C 3. The Diabetes Control and Complications Trial demonstrated which of the following: ___ A. Diabetes complications can be prevented in patients with type 1 diabetes through improved glycemic control. ___ B. Therapies proven to achieve improved glycemic control include frequent blood glucose monitoring, frequent insulin injections or pump therapy, and ongoing care by a team of diabetes specialists. ___ C. Standardized meal plans are an acceptable therapy for improving glycemic control. ___ D. A, C ___ E. A, B 4. Case managers can help improve diabetes care by doing which of the following? ___ A. Link the patient with the appropriate resources ___ B. Ensure providers are following practice guidelines ___ C. Discuss patient outcomes with other caregivers ___ D. Assess patient needs and intervene as appropriate ___ E. All of the above 5. Benefits of insulin pump therapy include: ___ A. Customized continuous insulin delivery to meet patient needs ___ B. Improved blood glucose control ___ C. Less hypoglycemia ___ D. A, C ___ E. All of the above Name ______________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ City ___________________________________________________ State __________________ ZIP ________________________ Signature ___________________________________________________________________________________________________ An individual application and $10 payment must accompany each request. Applicants who do not score 80% or higher may reapply with another application and additional $10 payment. No refunds will be issued for the $10 processing fee, regardless of the certification an applicant holds. Documentation of credit and an approval number will be mailed from the foundation in 3 to 4 weeks. Credit available from March 1 to September 30, 2002.
TCM 82
March/April 2002
New Interventions in Diabetes with
Medical Nutrition Therapy Eileen Paul, RD, CD, CDE Nutrition therapy has been the focus of diabetes management since before insulin was discovered.1 Many theories and approaches have been recommended and reemerged over the years. Since the Diabetes Control and Complications Trial (DCCT) results were released in 1993, nutrition is considered the most critical and pivotal component of diabetes care in achieving blood glucose goals. We have seen increased emphases on individualized nutrition therapy and the dietitian as a true partner in diabetes care, research, and management.1 Advances in nutrition therapy now center on methods to improve behavioral change because it is the major challenge facing people with diabetes. Access to nutrition therapy and self-management training is critical to improve clinical outcomes and reduce health care costs otherwise spent on clinic visits, expensive medications, emergency room visits, and hospitalizations.1
The nutrition recommendations and principles for people with diabetes mellitus from the American Diabetes Association (ADA) outline optimal nutrition care. The goals for medical nutrition therapy (MNT) are to help individuals with diabetes make changes in nutrition and exercise habits that improve metabolic control. The more specific goals are to maintain normal or near normal glycemic control, achieve optimal lipid levels, provide adequate calories and nutrients for individuals’ needs, prevent complications, and improve overall health.2 Daily goals include: • 50% to 60% of calories from carbohydrates • 12% to 20% of calories from proteins • 30% or fewer calories from fats, with less than 10% from saturated fats • Less than 300 mg cholesterol • Moderate sodium intake (<300d mg) • Alcohol in moderation and with food • Fiber 20-35 g • A wide variety of foods for micronutrients In the course of educating a person with diabetes, it is necessary to assess his or her needs based on the type of diabetes. The needs and goals for a person with type 1 diabetes will be different from those of a person with type 2 or a woman with TCM 78
March/April 2002
gestational diabetes. The materials may be the same for all three types, but the approach to the education and the intensity of diabetes management to achieve blood glucose control will differ. Behavior change and readiness to change are also key factors in any education process. One thing is clear to most nutrition educators and dietitians: no one standard meal plan works for everyone. Meal planning requires flexibility to address different preferences, lifestyles, cultures, etc. Using a variety of approaches will maximize outcomes. This flexibility requires a variety of teaching tools and more than one approach when teaching from them. No more standardized, preprinted diet/meal plans! An individualized approach is critical for long-term success. Knowing why it is important to follow a particular plan helps a person with diabetes make the best decisions of how to change behavior that influence diabetes outcomes. Knowing how the body responds to certain foods and what to expect allows the patient to integrate new treatments, such as diet, and evaluate the results or benefits. Using analogies and word pictures are helpful because they demonstrate concepts. For example, describing a cell as having doorways that allow glucose to enter creates a picture that can
supplement be understood more easily. Discussing how medications work to open the doorways or how exercise increases the flow through the doorways can be useful in getting patients to dose their medications appropriately or add more exercise to their daily routines. Using analogies, such as doorways that overcrowd when the blood glucose rises too high after a meal, helps patients see that portion control and activity after meals can improve blood glucose levels. Understanding glucose as fuel can help a person see that activity will use glucose for energy and avoid overfueling the body. Ideally, nutrition intervention should be conducted in stages based on a comprehensive nutrition assessment and an individual’s goals and needs.1 Guideline approaches provide the foundation of basic nutrition information, underscore consistency in food, and emphasize healthier food choices. Some examples of this include a simple food guide pyramid, which provides a visual of dietary guidelines and the concept of food grouping. The American Dietetic Association and the ADA have worked together to develop a tool called First Steps in Meal Planning,3 a modified food guide pyramid that teaches basic diabetes meal-planning goals. It allows for adjustment in the number of servings but keeps a standard portion size similar to the food exchange list. Both of these visual tools are easy to read (First Steps is written at a 5th- to 7th-grade reading level). When using First Steps, the educator and patient need to set a target goal for daily nutrient intake. This approach targets carbohydrates and sets a “carb budget.” Carbohydrate is the focus in diabetes meal planning because it is the primary nutrient that raises blood glucose. Generally, a range in amount of carbohydrate per meal/per day is established. The patient then is able to mix and match the food groups in the pyramid to control total carbohydrate intake. Carbohydrates include such things as fruits, milk, starches, etc. As an example, meals may be set at 45-60 grams and snacks at 15-20 grams of carbohydrate each. Intake then can be made more specific, such as 45 grams for breakfast, 60 grams for lunch and dinner, 15 grams for each snack during the day, and 30 grams for a bedtime snack. Menu selections may vary from day to day, such as fruit, nonfat milk, and whole-grain toast on 1 day and fruit with an English muffin with light margarine on another day. The carbohydrate count is equal even though the type of food is different. This method gives people with diabetes more options to eat a wide variety of foods and allows for occasional substitutions of sweets into the budget without negative results. Consider Tom, who is 67 years old and has had type 2 diabetes for 4 years. His glycemic goals are less than 130 mg/dL fasting and before meals and less than 150 mg/dL 2 hours after meals. He has just visited a fast food restaurant, where he chose a grilled chicken sandwich, a garden salad with light dressing, and a diet soda. Tom’s budget for lunch is 60 grams
of carbohydrates. He consults a reference book, such as The Diabetes Carbohydrate and Fat Gram Guide,4 for the fast food restaurant in question. The sandwich is listed as having 38 grams, the salad 7 grams, and the fat-free vinaigrette 11 grams. The carbohydrate total is 56 grams. He is well within the acceptable carb budget for his meal. We could expect Tom to remain within his target range for blood glucose at the next meal and 2 hours afterward. The in-depth stage of the nutrition process provides more information about meal planning and approaches that offer greater variety and flexibility.1 These approaches include such things as the exchange list for meal planning, where foods are grouped into six lists and the foods within each group can be exchanged in the indicated amount. Other approaches include counting principles. One new innovative counting approach to diet education that has gained in popularity is carbohydrate counting. This approach can be individualized at varying levels of intensity, works to improve blood glucose goals, and allows the use of a variety of teaching tools. For more intensive insulin management for types 1 and 2 diabetes, it is possible to determine the amount of insulin needed for the amount of carbohydrates eaten. Whether the insulin delivery system is multiple daily injections (MDIs) or continuous subcutaneous insulin infusion (CSII) by an insulin pump, attention to the details of the diet and blood glucose is considered meal by meal. Creating a ratio of insulin to carbohydrates allows the individual more possibilities to eat varied amounts of food at meals and more flexibility in the timing of meals and snacks. The Rule of 500 may be applied: 500 total daily dose (TDD) of insulin equals the number of grams of carbohydrate that one unit of short-acting insulin will cover.5 For example, 500 (50 units TDD = 10 grams of carbohydrate per unit of insulin) or a ratio of 1:10. This type of calculation is essential for successful intensive insulin management, whether by MDI or CSII, because the insulin must match the food intake to manage the blood glucose levels. Using insulin pumps allows even more precise calculation because they may be set to deliver smaller doses than one unit. Insulin pumps also may be customized to a preprogrammed basal rate that delivers the background insulin (in place of longer acting insulin such as NPH, Lente, Ultralente, or Lantus) to meet the needs of each patient. A different delivery rate can be programmed for each hour. This customization offers improved blood glucose control with less hypoglycemia.6 More intensive insulin management requires more detailed information and recordkeeping when starting out. One excellent education tool for this approach is the “Carbohydrate Counting” booklet series available from the ADA: “Getting Started,” “Moving On,” and “Using Carbohydrate/Insulin Ratios.”7 These booklets provide a three-level approach to education. The patient begins with the basics using the first March/April 2002
TCM 79
supplement Figure 1
drates listed. Total fiber should be subtracted if the fiber is greater than 5 grams per serving because it is not digestible and will not affect blood glucose. In addition to the carbohydrate/insulin ratio, intensive insulin management involves taking a correction dose of insulin for blood glucose levels above the patient’s target range. A formula called the Rule of 1800 may be used to determine this dose: 1800 TDD of insulin (include all types) equals the number of mg/dL that one unit of insulin will lower the blood glucose.5 For example, if the TTD is 60 units, the correction factor would be 30 mg/dL lowered for every 1 unit of insulin. For example, Jo is 46-year-old woman who has had type 1 diabetes for 27 years. She is using an insulin pump with Humalog insulin. Her basal rates have been set to keep her blood glucose levels within target range while fasting. Her blood glucose goals are 80 to 140 mg/dL. Before lunch, her blood glucose is 156 mg/dL. She is planning to eat food that she brought from home, including a tuna sandwich, a large apple, and 8 ounces of light yogurt. Assuming a ratio of 1:15 or 1 unit per 15 grams of carbohydrate, Jo counts her bread as 30 grams, her apple as 40 grams, and her yogurt at 15 grams, totaling 85 grams. Jo then divides 85 by 15 and gets 5.6 units of insulin. She will take 5.6 units for the carbohydrate in her meal.
book and moves through the remaining two levels, intermediate and advanced, at a rate that matches his or her need and readiness for progress. The inexpensive books are easy to read and teach from. Some individuals may seek more information and even greater flexibility. They may prefer to use reference books that provide information on calories and fats in addition to carbohydrates. Information in the nutrition facts on food labels, such as the one shown in Figure 1, helps with this information. When reading a food label, important information to note includes: • Serving size listed • Servings per container • Total carbohydrate in grams (which includes all sugars and fiber) • Total fat grams Other concepts should be remembered when reading food labels. The number of servings eaten should be calculated to determine true total carbohydrates. Sugars do not need to be counted separately because they are part of the total carbohyTCM 80
March/April 2002
Because her blood glucose is also above target range (156 mg/dL with target of 140 mg/dL), she needs to take insulin to bring the reading down. This is referred to as a correction factor. Her correction factor is 1 unit for each 40 mg/dL of blood glucose, which means she will need one unit for her elevated premeal blood glucose plus the amount of insulin calculated for her carbohydrates. This figure equates to 5.6 units for carbohydrate + 1 unit as a correction factor, which totals 6.6 units of insulin. Because Jo is wearing an insulin pump, she can program the exact bolus amount in tenths of a unit and deliver 6.6 units easily. Her next reading should be less than 140mg/dL, assuming she continues her usual activity. The best approach to meal planning should be based on a comprehensive assessment and goals tailored to each patient. No one system or approach is correct. Offering a combination of resources can help build on each person’s nutrition knowledge one step at a time. Ongoing support for behavior change also is critical for long-term success. Patients often are asked to keep records of their eating habits, activities, and blood glucose values. This recordkeeping can be another very helpful tool if the health care team uses it. Having the diabetes team (physician, nurse, dietitian, and/or pharmacist) respond to this level of detail gives patients direction for improving and fine-tuning their diabetes management. Such records are useful to help patients see the whole picture, better understand relationships to blood glucose control, and use pattern recognition in their daily routines. Assessing and providing ongoing care and education, along with detailed
supplement records of food, insulin or medication, activity, and stress or illness are the best ways to empower patients with the information they need to manage their blood glucose. Daily diabetes management is in the hands of the patient, but this approach unites the patient and the provider as a team. The bottom line outcome for diabetes management is having the best glucose control possible to avoid acute and chronic complications. Reducing the costs of caring for people with diabetes creates a win-win situation for both managed health care plans and patients. MNT can help reduce these costs by giving people with diabetes tools and decision-making skills for lifestyle management.8 Whether a patient’s diabetes is controlled solely by diet and exercise or with a combination of oral agents and insulin, nutrition education is important. Referral to a certified diabetes educator dietitian as part of the expert team may be the turning point in cost savings for health care plans.8 Referrals to a dietitian are recommended at least once a year to review meal plans and provide reinforcement education. Case managers, as part of the team, can help identify the appropriate patients for referral and help assess patient needs and reinforce nutrition information. It is also important for case managers to stay abreast of new information and maintain access to nutrition experts to best assist patients with successful diabetes management. The Internet can be a powerful tool to accomplish this and stay in contact with the American Dietetic Association, ADA, and the American Association of Diabetes Educators for additional resources.
2. The American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care 2001;24(Supl 1):S44-S47. 3. The American Diabetes Association, American Dietetic Association. First steps in meal planning. 1997. 4. Holzmeister L. The diabetes carbohydrate and fat gram guide. 2nd ed. Chicago: The American Diabetes Association; 2001. 5. Walsh J, Robert R. Pumping insulin. 3rd ed. San Diego: Torrey Pines Press; 2000. 6. Bode B, Steed R, Davidson P. Reduction in severe hypoglycemia with long-term subcutaneous insulin infusion in type 1 diabetes. Diabetes Care 1996;19:324-7. 7. The American Diabetes Association. Carbohydrate counting: getting started, moving on and using carbohydrate/ insulin ratios. Chicago: The Association; 1995. 8. Sheils J, Stapleton D, Dietrich K, Scrivner S, The Lewin Group. The cost of MNT under Medicare: 1998-2004. Final Report, April 18, 1987. American Dietetic Association Courier 1997;36(5). Eileen Paul, RD, CD, CDE, is a diabetes educator and clinical dietitian for the Group Health Cooperative in Seattle, Wash. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/123065 doi:10.1067/mcm.2002.123065
References 1. Powers M. Handbook of medical nutrition therapy. Gaithersburg (MD): Aspen Publishers; 1996.
March/April 2002
TCM 81
supplement test This article has been approved for 1 hour of CCM, CRC, and CDMS education credit by The Foundation for Rehabilitation Education and Research. To obtain your education credit, please do the following: 1. Read the “Controlling Costs and Improving Diabetes Care” and “New Interventions in Diabetes with Medical Nutrition Therapy” articles. 2. Make copies of this page for each person applying for credit. 3. Answer the following questions by selecting one statement. Four questions must be answered correctly to receive the educational credit. 4. Mail this completed form with a check for $10 to: Foundation for Rehabilitation Education and Research 1835 Rohlwing Rd., Ste. E, Rolling Meadows, IL 60008 Questions: For which educational credit (1 hour) are you applying? CCM ID#___________ CRC ID#___________
CDMS ID#__________
1. Goals for medical nutrition therapy include: ___ A. Maintaining normal or near normal glycemic control ___ B. Achieving optimal lipid levels ___ C. Providing adequate calories and nutrients ___ D. Preventing complications and improving overall health ___ E. All of the above 2. Which of the following statements are true? ___ A. Most diabetes patients are seen by specialists. ___ B. Approximately 15% of total U.S. health care expenditures are spent on diabetes. ___ C. The incidence of diabetes is increasing. ___ D. A, B ___ E. B, C 3. The Diabetes Control and Complications Trial demonstrated which of the following: ___ A. Diabetes complications can be prevented in patients with type 1 diabetes through improved glycemic control. ___ B. Therapies proven to achieve improved glycemic control include frequent blood glucose monitoring, frequent insulin injections or pump therapy, and ongoing care by a team of diabetes specialists. ___ C. Standardized meal plans are an acceptable therapy for improving glycemic control. ___ D. A, C ___ E. A, B 4. Case managers can help improve diabetes care by doing which of the following? ___ A. Link the patient with the appropriate resources ___ B. Ensure providers are following practice guidelines ___ C. Discuss patient outcomes with other caregivers ___ D. Assess patient needs and intervene as appropriate ___ E. All of the above 5. Benefits of insulin pump therapy include: ___ A. Customized continuous insulin delivery to meet patient needs ___ B. Improved blood glucose control ___ C. Less hypoglycemia ___ D. A, C ___ E. All of the above Name ______________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ City ___________________________________________________ State __________________ ZIP ________________________ Signature ___________________________________________________________________________________________________ An individual application and $10 payment must accompany each request. Applicants who do not score 80% or higher may reapply with another application and additional $10 payment. No refunds will be issued for the $10 processing fee, regardless of the certification an applicant holds. Documentation of credit and an approval number will be mailed from the foundation in 3 to 4 weeks. Credit available from March 1 to September 30, 2002.
TCM 82
March/April 2002