MNT 2 - Exam #2 (Part 1) Flashcards Preview

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Flashcards in MNT 2 - Exam #2 (Part 1) Deck (110)
1

What is the prevalence of DM i the United States?

-25.8 million Americans have Diabetes;
-8.3% of population ;
-Type 1 = 5% of all patients with DM;
-Type 2 = 90-95%;
-GDM: (Gestational Diabetes);
-Occurs in 2-10% of pregnancies;
-Have 35-60% chance of developing type 2;
-7 million undiagnosed;
-Risk for death – DOUBLE → vs. no Diabetes

2

What is the average cost of DM?

Average. Cost – nearly double due to cost of treatment complications

3

Who is at risk for developing for DM?

-Age: > 45l
- > 120% IBW; BMI > 25 (especially those with abdominal obesity);
-Have 1st degree relative with dm;
-High risk ethnic group (African-American, Native American, Asian, Pacific Islander..);
-Delivered a baby > 9 lb or dx of GDM;
-HTN (> 140/90 mm Hg);
-HDL < 35 or TG > 250 mg/dl;
-IGT or IFG on previous testing ;
-Habitual physical inactivity

4

How is DM a diverse group of disorders?

-Differ in origin and severity;
-All share hyperglycemia /glucose intolerance from:
1. defect in insulin production
2. defect in insulin action
3. OR both

5

What are the 3 types of DM?

-Type 1 DM → Beta cells are destroyed and NO insulin production
-Type 2 DM → Insulin resistance; Cell do NOT RESPOND to insulin and thus glucose builds up and is not taken into cells
-Gestational DM (GDM)
→ IGT and IFG (pre diabetes) = increased risk of DM

6

What drugs are known to cause DM?

-Diabetes due to other causes (drugs, diseases);
-Corticosteroids put people at a high-risk for development of DM

7

What are the criteria for Diagnosis of DM?

1. Symptoms of DM plus casual blood glucose of > 200 mg/dL
OR
2. Fasting plasma glucose > 126 mg/dL
OR
3. 2-hour post-load glucose > 200 mg/dL during an OGTT
OR
4. HgbA1c > 6.5

8

What are the diagnostic criteria for IFG and IGT?

-IGT – Impaired Glucose Tolerance
-IFG – Impaired Fasting Glucose

— IFG = FPG > 110 and < 126 mg/dL
— IGT = 2 hPG > 140 and < 200 mg/dL

9

Who are the members of the medical treatment teams for patients with DM?

-Physicians, Nurse Practitioners, PA’s;
-RD/ DTR;
-CDE (Nurse &/or RD);
-Pharmacists;
-Mental Health Professionals;
-Other “allied health professionals”

10

What is the key to treatment with DM and preventing complications?

Diabetes Care, the EARLIER, the BETTER = Early Screening → Early Diagnosis → Early Care → Delay/Prevent Complications

11

What is included in the Lifetime Management of DM?

Includes “4 M’s”:
-MNT
-Physical activity
-Blood glucose monitoring
-Medications
-Self-management education (DSME)

12

What are the goals of MNT for DM?

**An overall good and healthful diet it applicable to DM and CVD and Renal Disease! All are one in the same with small variations;
1. Achieve and maintain optimal BG (blood glucose), BP (blood pressure), and lipid levels
2. Improve overall health (diet and exercise)
3. Address individual energy and nutrients needs while considering personal/cultural preferences, lifestyle, and patient’s readiness to change → Plan should be practical!
4. Prevent or delay, and treat long-term complications of DM:

13

What is included in the Education on Complication of DM?

1. Long term = Myopathy, Neuropathy, Retinopathy, Nephropathy, CVD
— Retinopathy is one of the most prevalent FIRST signs
2. Acute = Hyper- and Hypoglycemia

14

What does the AND says about Macronutrient recommendation for DM?

-“RD’s should encourage consumption of macronutrients based on the DRI’s for healthy eating as research does not support any ideal percentage of energy from macronutrients for persons with diabetes.” JADA. 2010:119:1852-1899.;
-No ONE diabetic diet → There is a lot of variation depending upon the patient ;
-Focus is NOT on the TYPE of CHO, but on the distribution and timing of the CHOs throughout the day

15

What are the recommendations for CHO?

-Total CHO vs Source of CHO
-Sucrose vs other CHO’s
-Dietary fiber: per dietary guidelines
-Emphasis on balanced diet
-Non-nutritive sweeteners are safe → Do produce a lower postprandial response and have lower energy values

16

What are the recommendations of Protein?

-Usual protein intake of approximately 15-20% energy can be maintained
-Exceptions for CHANGE =
•Individuals with excessive protein choices that are high in saturated fat content
•Individuals with protein intake < RDI’s
•Patients with diabetic nephropathy

17

What are the recommendations for fat?

-Cardio-protective nutrition interventions;
-If LDL level is > 100, use TLC
1. DM = risk equivalent=previous CVD/no DM
2. <7% saturated fat and 200 mg/d cholesterol
3. Limit intake of trans- fatty acids

18

What are the recommendations for Micronutrients?

-NO CLEAR evidence of benefit from vitamin or mineral supplementation
-EXCEPTIONS:
- Folate (prevent of birth defects) → Follow standard recommendations;
-Calcium (prevent bone disease) → Follow standard recommendations;
-Routine supplementation with antioxidants is NOT advised;
-Due to the uncertainties related to long-term safety

19

What are the Acute Complications or “Sick Days” with DM?

-Hypoglycemia
-Hyperglycemia
-DKA
-HHNS → Hyperosmolar Hyperglycemic Non-Ketotic Syndrome

20

What is Hypoglycemia?

Signs and symptoms = Initial S/S
— Neuroglycopenic S/S (inadequate glu to brain: confusion, irrational bx, seizure, coma);
— Test BG if possible/ if not – treat → CHECK

21

What is the treatment for Hypoglycemia?

— Treatment: → TREAT = initial 15-20 g of glucose
— Best thing is glucose tablets → Straight dextrose (w/o any extra calories)
— Re check in 15 minutes/ re treat if necessary → RE-CHECK
— Glucose levels will begin to fall after ~ 60 minutes of the glucose consumption
— Reevaluate/ additional tx if needed / consider a snack with CHO & protein
— IF next meal is more than about an hour away recommended a snack

22

What are ways to prevent and some of the causes?

Prevention/ causes?
-Too much meds
- Skipping or delayed meals → Recommend packing snacks or meals if busy!

23

What is Hyperglycemia?

ELEVATED blood glucose
- Increase thirst – Polydipsia
- Frequent urination – POLYURIA
→ Increased fluid loss
- Weight Loss → Particularly with Type 1
- Blurry Vision
- Delayed wound healing
- Irritability and hunger
- Fatigue

24

What are the causes of Hyperglycemia?

1. Excessive food/ CHO intake
2. Over-treatment of hypoglycemia
-Wrong timing of DM medications
— Insulin must be injected so that it peaks at the SAME time the blood glucose peaks from the meal that is consumed
— Some are taken at meals, some at bedtime → All depends on patient and medication
3. Illness → Sometimes meds have to be increased during illness due to increased stress and elevated blood glucose during sickness
-Stress → Raises blood glucose
4. Gastroparesis/other affecting digestion or absorption
5. Physical Activity
6. Other medications

25

What are the treatments and prevention methods of HYPERglycemia?

-Insulin Injections
-Oral-medications → Can take up to 3 different oral meds
-Diet
-Exercise
-Stress Management
-Treating subsequent illnesses

26

What are Acute Illness/Sick day management?

-Medications = continued/ may be increase;
-Monitor BG(before meals and snacks);
-Monitor Ketones (especially for T1DM);
-Adequate fluids;
-Adequate CHO;
-Watch for DKA;

27

Adequate CHO for Sick Day Management

-Prevent starvation ketosis!
-Adults= 150-200 g/CHO daily Or 45-50gm CHO every 3-4 hrs. Or 10-15gm CHO every 1-2 hrs. (may use liquids/ provide list of easy to tolerate CHO food/ beverages)
— 4oz. Regular Ginger-Ale
— 4oz. Apple Juice

28

What are the symptoms of DKA?

-Moderate to large amount of urine ketones, severe N/V diarrhea/ abdominal pain, rapid breathing, fruity breath;
-Kussmal Respirations = Rapid Breathing

29

What are the differences in HHS and DKA?

**DKA and HHNS are the most ACUTE and short-term complications of DM;
-Blood glucose does NOT get as high with DKA, as HHNS → BOTH are caused by HIGH glucose (lack of insulin causing alternate pathway of ketone formation)

30

What are the long term MICRO and MACROVASCULAR complications of DM?

1. Microvascular complications → “opathies”
— Nephropathy
— Retinopathy
— Neuropathy (Peripheral and Autonomic)
2. Macrovascular complications → CVD

31

What is Nephropathy?

(Microvascular);
- Single leading cause of CKD
- Marker for nephropathy and CVD: microalbuminuria 30-299 mg/24hr;
-Progress to macroalbuminuria
-Protein “restriction” and ACE inhibitors
-Need to monitor for long-term damage
-Optimal glycemic control
-BP guidelines per JNC8:
—JNC8 = 140/90
— American Diabetes Association = 130/80

32

What is Retinopathy?

(Microvascular);
-Most frequent cause of new blindness;
-Associated with duration of DM, though often dx with retinopathy first;
-Likely if nephropathy present;
-Macular edema: hypertension contributes;
-Glaucoma & cataracts- occur earlier in patients with DM;
-Cataracts can occur substantially earlier in life with DM;
-Progression slowed with glycemic and BP control

33

What is Neuropathy?

(Microvascular);
-Neuropathy = 60-70% of patients with DM;

34

What is Peripheral Neuropathy?

-Peripheral neuropathy → Loss of nerve function; Begins as tingling in the hands and mostly in the feet and eventually turns to significant pain and total loss of feeling;
-Prevention – Have patients were supportive, well-fitting shoes and socks at all times;

35

What is Autonomic Neuropathy?

→ Autonomic Nervous System;
1. GI tract: gastroparesis (slow gastric emptying and peristalsis) → from damage to VAGUS nerve;
— Constipation/diarrhea, anorexia, N/V, early satiety, persistent bloating = Slow emptying can lead to increased appetite but lack of absorption and utilization;

2. Dietary treatment = Low fiber, Low fat, Small meals throughout the day;

3.Genitourinary tract
Sexual dysfunction = Recurrent UTI’s, injury to kidneys, incontinence;

4. Cardiovascular system
— Resting tachycardia (>100bpm)
— Orthostatic hypotension – decreased blood pressure upon standing up or extreme changes of position
— Increased risk silent heart disease

36

What are the CVD Macrovascular complications?

-65% of deaths;
-Elevated glucose = endothelial damage to blood vessel (causes the initial injury to the blood vessels) ;
-Thickening and changes in composition of sub-endothelial layer;
-Decreased flexibility of vessels;
-Coexistence of hypertension & dyslipidemia = Very linked and must all be managed;
-Underlying metabolic syndrome;
-Treat hypertension and lipids → Start with the blood glucose – start with 3-4 initial visits and then recommend RD visits every 6 months

37

What do damages to the large blood vessels lead to…..

1. Increased risk of stroke;
2. High blood pressure and increased risk of heart attack;
3. Blocked arteties in legs;
4. Reduced blood flow to the feet causing sores that heal slowly or not at all — Infections are common due to high blood glucose levels that favor microbial growth — can cause amputations of the feet and toes

38

What do damages to the small blood vessels lead to….

1. Bleeding in the retina leading to blindness;
2. Damage to kidney cells; Excretion of protein in the urine and eventually kidney failure;
3. Nerve damage that causes numbness and pain;
4. Nerve damage causing numbness and tingling in the feet that affects balance and increase risk of accidental injury

39

How are long-term complications prevented?

-INTENSIVE THERAPY reduced risk of retinopathy by 77% =
— Slowed progression by 54%
— Reduced the occurrence of microalbuminuria by 32%
— Reduced the occurrence of micraalbuminuria by 47%
*Major focus on managing BG

40

What studies contributed to the benefit of intensive therapy?

-Studies in early 1990’s
1. DCCT
2. UKPDS
-Dramatically changed how we approach treatment of Diabetes

41

What are the group goals for specific groups?

-Children and adolescents → Normal growth and development rates
-Pregnancy → Provide adequate needs and nutrients for positive outcomes
-Elderly → Provide adequate needs and nutrients for aging

42

What are the Food Composition Databases?

1. Nutrient Database for Standard Reference developed by the USDA Agricultural Research Service;
2. International Nutrient Databank Directory (July 5, 2013) = The source for this databank is the USDA Nutrient Database for Standard Reference
3. Food and Nutrition Database for Dietary Studies = Describes the dietary information collected in US studies

43

What are other databases that might be utilized in nutrition research?

1. Special-interest databases = Agricultural Research Service has databases for added sugars, choline, flavonoids, fluoride, isoflavones, oxalic acid and proanthocyanidins
2. Dietary supplements databases
= Developed by the National Center for Health Statistics;
3. Food contaminants databases = Still in the development phase

44

What are the features of these databases?

“Give an accurate and appropriate name for each food item and provide sufficiently descriptive terms to distinguish each food from all other foods in the database”
- Food Grouping
- Unit or weight

45

What must be considered when using databases?

Important considerations =
- Wet weight vs Dry weight
- As purchased vs Edible portion
- Serving sizes and Unit conversions (weight vs volume)
- Don’t assume missing values are Zero’s

46

What are the limitations of databases?

-Metabolic studies
-Diet plans for patients with restricted diets
-Single day assessment for adequacy or deficiency for an individual = Good for multiple days and/or groups

47

What are the DRIs?

-DRIs for macronutrients and micronutrients include;
1. EARs
2. RDAs
3. AIs;
4. ULs;

-DRIs make two types of energy intake recommendations:
1. EERs
2. AMDRs

48

What are the EARs?

Estimated Average Requirements (EARs) are used to evaluate nutrient intakes of populations;
-Average amount a nutrient required for good health;
If everyone consumed this amount only 50% of the population would obtain their nutrient needs

49

What are the RDAs?

Recommended Dietary Allowances (RDAs) recommend specific amounts of nutrients for individuals.

50

What are the AIs?

Adequate Intakes (AIs) recommend specific amounts of nutrients for individuals.

51

What are the ULs?

Tolerable Upper Intake Levels (ULs) help with the prevention of nutrient toxicities;
-Set well above needs of everyone and represents the highest amount that will Not cause toxicity in most healthy people

52

What are the EERs?

Estimated Energy Requirements (EERs) can be used to calculate kilocalories needed to ensure a stable weight in a healthy individual.;
-Estimated Energy Requirement (EER) is calculated knowing: age, weight, height, and level of physical activity.

53

What are the AMDRs?

Acceptable Macronutrient Distribution Ranges (AMDRs) are expressed as ranges of percent of energy-yielding nutrients associated with reduced risk of chronic diseases while providing adequate intakes of essential nutrients.

54

How do you assess intakes of populations?

-Goal is to estimate the prevalence of inadequate intake (i.e. the percentage of people in the group who have usual intakes that do not meet their requirements);
-Calculate as the percentage of the group with intake below the EAR.;
-Thus the EAR rather than the RDA is the DRI used to assess the intake of populations.

55

What is included in the Nutr Assessment for DM?

1. Review medical record: PMHx, current co-morbidities, Labs, Meds;
2. Current ht, wt (BMI), WC or WHR
3. Previous diet instruction
4. Assess degree of glycemic control
5. Obtain nutrition hx (food record, 24 hr recall,FFQ )
— Assess nutritional adequacy/excesses of current intake → Focus on CHO count and distribution!
— Identify current DM regimen (or not)
6. Psychosocial, educational, lifestyle hx
7. Feelings and beliefs about food
8. Readiness to change/ barriers to change

56

What is a “Diabetic Diet”?

-No one “Diabetic diet” or “ADA diet”;
-Quantity vs. Type of CHO/ CHO distribution;
-Many approaches → Exchanges are NOT for everyone!
— CHO counting (basic and advanced)
— Exchange Lists
— MyPlate Guide
— TLC / DASH

57

What are the tests of Glycemia for DM?

1. SMBG – Self-Monitoring Blood Glucose
2. Urine/blood ketone testing
— Sick Day Management
— Regularly with T1DM
3. Glycosylated hemoglobin

58

SMBG: Self-Monitoring Blood Glucose

-Outpatient, Initially diagnosed with DM;
-When changing therapy, both types should monitor more often
-Most meters automatically convert the whole-blood results to plasma glucose values
-Plasma glucose levels are 10-15% higher than whole blood
-SMBG helps to determine if changes are needed in MNT, Exercise, Medications
-Typically have patient test twice a day

59

How often if SMBG used with Type 1?

-Type 1 may have to test more often = 3-4 or more; May be before and after meals

60

How often if SMBG used with Type 2?

-Sufficient to reach glucose goals
-1-4 x day
-Before breakfast and 2 hr after largest meal (post-prandial)
-Low blood glucose causing Gluconeogenesis is NORMAL for everyone early in the morning due to long time period without eating
-Patients with DM will ALWAYS have elevated blood glucose even upon waking and without eating = FASTING HIGH

61

What are barriers with SMBG?

-Cost of testing
-Psychological and physical discomfort with blood sampling
-Time, inconvenience
-Physical surroundings

62

What does SMBG indicate needs to be changed?

-MNT
-Exercise
-Medications

63

What are the target goals for Glycemic Control?

-Fasting = 90-130;
-2hr postprandial = < 180;
-Bedtime = 110-150;
-HbA1c = < 7

64

Why is the 2hr PP goal set at 180?

Body starts to react to the high blood glucose and initiates increased glucose loss through increased urination → Flow of glucose through the kidneys lead to damage of the nephrons in the kidneys

65

What is Glycated Hemoglobin?

-HbA1c;
-Indexes risk of complications for patient;
-Cannot be manipulated by patients in the short-term;
-Not affected by meals or acute changes in glucose;
-Very precise measurement = associated with LONG-TERM complications;
**Does NOT tell WHEN in relationship to eating levels are elevated

66

What does HbA1c test?

-Average blood glucose level over 2-3 months! → Serves as a marker for average blood glucose levels over the previous 3 months prior to the measurement as this is the half life of red blood cells.;
-Assesses how long glucose is attached to the hemoglobin molecules in circulation

67

What does Urine Ketone Testing indicate?

**Mostly T1DM and during pregnancy =
-Impending or established ketoacidosis;
-Type 1 patients should test:
•During acute illness
•Acute stress
•When blood glucose is consistently high
•During pregnancy (also GDM)
•Experiencing symptoms of ketoacidosis
•Nausea, vomiting, abdominal pain

68

What are the LIPID goals for Diabetics?

-Cholesterol: < 200
-LDL: < 100
-HDL: Men > 45, Women >55
-Triglycerides < 150

69

What are the blood pressure goals for diabetics?

-Systolic < 140
-Diastolic < 90

70

What are the benefits of physical activity with DM?

-Improved glycemic control/Increased insulin sensitivity
-Improved blood lipids, BP à decreased CV risk/mortality
-With pre Diabetes, prevention/delay onset DM
-Stress management
-Improved Fitness level

71

What are the general guidelines for exercise?

Monitor glucose before and after exercise (note acute decrease in BG- can be delayed)

72

AVOID exercise if….

-Fasting glucose levels are > 250 mg/dl and ketosis is present Avoid exercise ;
-Glucose levels are > 300 and no ketosis is present

73

What are the food intake recommendations with exercise for DM?

-Ingest added CHO if glucose levels are < 100;
-Ingest CHO if before breakfast or poss. Later afternoon;
-Have CHO foods readily available during and after

— Type 1: add 15 g CHO for every 30-60 minutes of activity (depends on intensity- higher intensity may require 30gCHO/hr) over above normal;
— Type 1: may need to decrease insulin dose with extra exercise

74

What is the occurrence of Type 2 DM?

-90-95% of cases of DM
-Adults, children & adolescents;
-Heredity (MODY) autosomal dominant pattern

75

What are the results of T2DM?

-Insulin resistance;
-Increased insulin production;
-Insulin deficiency

76

What is Insulin Resistance?

-CELL RECEPTOR DEFECT = Glucose transporters cannot translocate to cell outer membrane from cytoplasm;
-Body is making insulin but glucose transporters are not stimulated to the surface of the cell to allow glucose from the cytoplasm into the cells;
-Therefore body believes it is deprived, and makes more glucose, increasing levels even more
— (“key that doesn’t work” )

77

Who is at risk for T2DM?

-Age: > 45
-> 120% IBW; BMI > 25 (especially those with abdominal obesity)
-Heredity: have 1st degree relative with DM
-High risk ethnic group (African-American, Native American, Asian, Pacific Islander..)
-High or low birth weight (poor placental growth)
-HTN (> 140/90 mm Hg)
-HDL < 35 or TG > 250 mg/dl
-IGT or IFG on previous testing
-Habitual physical inactivity

78

What is the mechanism of Oral DM meds in the PANCREAS?

In the PANCREAS: insulin secretion is stimulated

79

What is the mechanism of Oral DM meds in the CELLS?

CELLULAR level (muscle and adipose): decreased insulin resistance/ enhanced glucose utilization

80

What is the mechanism of Oral DM meds in the LIVER?

In the LIVER: decreased hepatic glucose output (Especially overnight- improves fasting blood glucose)

81

What is the mechanism of Oral DM meds in the INTESTINE?

In the INTESTINE: glucose absorption is slowed (Improves postprandial levels of glucose)

82

What are other possible treatments/managements for T2DM?

-Insulin;
-“New” Injectable Meds;
-Incretin Mimetics (Exanitide/ Byetta)

83

How will a T2DM use INSULIN?

-Combination: Long acting Insulin & oral agents
-Pre mixed insulins
-Combination of basal long acting & rapid acting insulin before meals

84

What are “New” Injectable Meds for T2DM?

*Amylin Analogs (Pramlintide/ Symlin)- use w/insulin- DM1 or 2 =
1. Delays gastric emptying,
2. Decreases postprandial glucagon release
3. Suppresses appetite

85

What are Incretin Mimetics (Exanitide/ Byetta)?

-Mimics glucose dependent insulin secretion
-Suppresses elevated glucagon secretion
-Delays gastric emptying

86

What are the indicators for HYPRGLYCEMIC HYPEROSMOLAR SYNDROME (HHS)?

Labs =
1. Blood glucose > 600 mg/dL,
2. Arterial ph> 7.3
3. Serum bicarb. > 15mEq/L
4. Serum osmolality > 320 mOsm/kg,
5. Absence of urine or serum ketones

87

What causes HHS and who is usually affected?

Causes: Infection, Dehydration, prolonged hyperglycemia;

Population: type 2 DM, elderly

88

What are the symptoms and treatment of HHS?

Symptoms: polyuria, polydipsia, cognitive decline

Treatment: slow rehydration, treat underlying conditions

89

Physical Activity for T2DM

-Prescribed for all
-Enhances blood glucose uptake and improves insulin sensitivity
-Enhances weight loss efforts
-30-45 min. 3-5 days/week, no more than 2 consecutive days of rest
-Adjust CHO and insulin
-Consider CHO snack pre & post exercise

90

What diagnosis are important in T2Dm Assessment?

-CVD, HTN, High cholesterol
-Retinopathy
-Neuropathy
-Renal problems

91

What is included in the assessment for T2DM?

-Diagnosis;
-Reason for referral;
-Diabetes therapy/duration/control level
-Medical history
-Medication regimen (After about 2 weeks any discomfort subsides)
-Lab data;
-Med clearance for exercise

92

What are the labs for T2DM?

Lab data (HbA1c, lipids, other)
— HbA1c – every 2-3 months
— Lipids – every 3-4 months
— Renal Panel

93

What should be included in the Patient Interview?

-Relevant medical history
-Client goals
-Knowledge, skills, attitudes, and motivation
-Support systems
-Readiness to learn/Barriers to learning
-Psychosocial and economic issues
-Cultural influences

94

What data should be included in assessment?

-Height and weight (BMI)
-Usual food intake (times and amounts)
-Physical activity level
-BG monitoring skills — Might need to ask them to do more than the doctor did

95

How should CHOs be spread throughout the day?

-Spread carbohydrate foods throughout the day (starches, fruits, milk, sweets);
-Be aware of portion size and the number of carb portions included at each meal & snack;
-When in doubt, consider ½ cup as 1 serving;
-Beware of starchy entrees (pasta, beans & rice): limit entrée size & fill plate with veggies

96

What are lifestyles changes meant to improves with Prevention/ Pre Diabetes/Insulin Resistance?

**Lifestyle is the FIRST treatment plan to prevent T2DM =
-Glycemia
-Dyslipidemia- tx based on lipid panel
-HTN- tx to decrease risk of microvascular complications

97

What are the general lifestyle interventions?

-Decrease energy intake / promote wt. reduction → Greater benefit of weight reduction during pre-diabetes!!
-Increase physical activity
-Decrease sat. fat, trans fat & cholesterol
-Decrease sodium

98

What is the treatment plan for diagnoses T2DM?

-Blood glucose management becomes primary goal!!
-Progression from insulin resistance to insulin deficiency (wt. loss -> less benefit)
-Continue with:
— Healthy food choices
— Increased physical activity
— Moderate energy restriction
— Add SMBG/ focus on CHO distribution

99

What are the specific treatments for children and teens with T2DM?

1. Treatment Goals:
- Stop excessive weight gain
- Promote normal growth & development
- BG management

2. Medications: may require metformin or insulin
3. Family Involvement
4. Patient Goals (often behavioral)
- Consistent CHO intake
- SMBG (self-monitoring blood glucose)
- Increased physical activity

100

What are the possible food planning approaches with T2DM?

-“The first step in Diabetes Meal Planning” = (Uses MyPlate, ADA/ AND)
-Exchange lists for Meal Planning
-Plate method (picture)
-Basic Carbohydrate Counting → Counts the carbs per meal by combing them in the NSV, CHOs, meats, and fats
{1 CHO serving = 15grams of CHOs}
-Advanced Carbohydrate Counting → Related to insulin dosing
-Month of Meals books (supplements other education)

101

What are the steps for Exchange List planning?

1. Assess current intake / pattern
2. Categorize usual food intake into exchange amounts based on portions and food consumed
3. Calculate total kcal intake

102

Making the Meal Plan

1. Determine the energy prescription
2. Determine % of nutrients from kcal= as close to usual intake as possible (“Typically” 50%, 20%, 30 %)
3. Calculate grams of CHO, protein and fat and convert to exchanges
4. Determine meal plan (w/ patient for compliance) and distribute exchanges throughout the day.

103

What are the calculation for exchanges?

1. Determine energy prescription per assessed goals (and any other macronutrient goals per PES)
2. Determine % energy from CHO, Protein, Fat
3. Calculate energy from CHO, Protein and Fat
4. Calculate gms CHO, Protein and Fat (calculated energy divided by kcal/gm) and list across top of page subtract CHO (5g) and protein (2g) for NS Veg exchanges (3)
5. For remaining macronutrients,
— Calculate # of CHO servings (and subtract pro & fat)
— Calculate # meat servings (and subtract fat)
— Calculate # fat servings

104

What is the FIRST intervention for DM meal planning?

**Teach CHO (extent of this step per assessment of patient abilities, needs, goals)
1. Role of CHO in BG mgt
2. CHO containing foods (lists, food models)
3. Portion sizes (exchanges)
4. Use of starches, fruit and milk as CHO choices
5. 15gm CHO = 1 serving (discuss grams vs. servings)

105

What is the SECOND intervention for DM meal planning?

1. DEPENDS on type of meal planning selected;
2. With “straight” exchanges or exchanges for CHO counting, next step is:
— Role of non-starchy vegetables, meats and fats
— Use of exchanges
— Emphasis on lean meat choices and unsaturated fat choices
3. Develop meal pattern and sample menu

106

What are other interventions that should be included in the FIRST VISIT for T2DM nutrition?

1. Education/ Counseling SMBG
- Schedule to follow
- Record keeping
- How this information will be used at f/u
2. Hypoglycemia: S/S, prevention and tx
3. Sick day management
4. Role of exercise

107

What are the alcohol recommendations for T2DM?

- One drink = 15 grams of alcohol:
— 12 oz beer
— 5 oz wine
— 1.5 oz of distilled spirits

- Alcohol has HYPOGLYCEMIC effects;
- Determined by amount ingested, if consumed w/ or w/o food and if use is chronic or excessive
- To REDUCE risk consume with FOOD

108

What is included in T2Dm initial care plan documentation?

1. Nutrition prescription
2. Short and long term goals
3. Education:
— Food/meal plan
— Educational topics covered
4. Patient acceptance and understanding
5. Additional needed skill or information
6. Additional recommendations, plans for monitoring and evaluation, and ongoing care

109

What are the follow up interventions for T2DM?

1. Assess achievement of initial goals
2. Answer questions/concerns
3. Teach/fine tune self-management skills/ provide additional educational tools
4. Negotiate new short-term goals (glucose, eating, activity, weight)
5. Review or initiate long-term goals (BG, A1C, lipids, BP and weight)
6. Promote problem solving skills
7. Develop/schedule f/u plans (DOCUMENT!)

110

How do you assess the initial goal?

1. Weight, (ht), A1C, BP, lipids)
2. review food, exercise, BG records
3. Behavior changes
4. Assess current understanding of initial topics of education
5. Assess nutrition care plan and revise as needed