NUTRITION AND PHYSICAL ACTIVITY 12/2008

Goal: Optimal Student Health and Learning Managing nutrition and physical activity are vital pieces of a comprehensive plan. This training component is one of thirteen components created specifically for school nurses and non-medical school personnel who perform diabetes care tasks at school. These components are: • Diabetes Basics • Diabetes Medical Management Plan • Hypoglycemia • Hyperglycemia • Blood Glucose Monitoring • Glucagon Administration • Insulin Basics • Insulin by Syringe and Vial • Insulin by Pen • Insulin by Pump • Ketones • Nutrition and Physical Activity • Legal Considerations This unit is Nutrition and Physical Activity.

Learning Objectives Participants will be able to understand: Basic meal plans for students with diabetes Nutrition calculation methods Physical activity benefits for students with diabetes Physical activity guidelines for students with diabetes Participants will be able to understand: Basic meal plans for students with diabetes Nutrition calculation methods Physical activity benefits for students with diabetes Physical activity guidelines for students with diabetes

Nutrition: Why be concerned? Good nutrition is important for everyone for optimal health Nutrition planning is essential for good diabetes control: maintain blood glucose within target range to prevent or delay complications to help children and teens grow and develop properly to achieve healthy weight promote optimal learning Why be concerned about nutrition? Good nutrition is important for everyone for optimal health. Nutrition is essential for growth and development, health, and well being of all students and staff. Dietary factors are associated with 5 of the 10 leading causes of death including coronary heart disease, some types of cancer, stroke, type 2 diabetes, and osteoporosis. Nationwide, we are facing an epidemic of overweight and obesity, among children and adults. For people with diabetes, following a carefully designed meal plan is necessary to prevent both short and long-term complications by regulating blood glucose levels. Students who follow meal plan guidelines will be less apt to experience hyperglycemia or hypoglycemia and should have better attendance and participation. From a long-term perspective, following meal plan guidelines means that students can help to prevent or delay the onset of serious complications of diabetes, such as kidney disease, high blood pressure, heart disease, and blindness.* *While it is important for school personnel to be aware of the potential for these serious life-limiting or life threatening complications, it is not appropriate for school personnel to discuss risks for complications with individual students. Good nutrition will help children and teens grow and develop properly and help to make them ready to learn.

School Nutrition Management Student’s parent/guardian and health care team determine an individualized meal plan A diagnosis of diabetes does NOT always limit which foods a student can eat Meals & snacks need to be carefully timed to balance physical activity and insulin/medications Encourage healthy eating for all students The student’s parent/guardian and health care team determine an individualized meal plan. A diagnosis of diabetes does NOT completely limit which foods a student can eat. Foods that were previously thought to be off limits can now be incorporated into a meal plan for kids with diabetes. We now know that the same foods that are healthy for everyone are healthy for the person with diabetes. However, meals and snacks need to be carefully balanced with physical activity and medications (insulin or other diabetes medications). Eating consistent amounts of carbohydrate at scheduled times is important for children using a traditional insulin plan to match the effects of the peaking insulin. Children following a multiple daily insulin injection plan or using a pump have a bit more flexibility in the types of foods and timing than a child following a more traditional insulin plan. Students whose snacks and/or meals are delayed or skipped are at risk for a hypoglycemia if they are using a traditional insulin plan. Children taking multiple daily injections or using an insulin pump do not usually require planned snacks, but would need to give insulin if unplanned snacks are consumed. “Extra” or ill-timed snacks and/or meals can lead to high blood glucose unless the child has a diabetes Medical Management (DMMP) that specifies “coverage” with these extra foods. Timing is everything. One meal plan does not fit all; each student’s plan will vary according to family culture, individual needs and preferences. While establishing optimal blood glucose control is important, allowing students to have control over food choices and portions, within the scope of their meal plans, is important as well. The goal is to avoid creating any food conflicts or control issues and to allow for enjoyable meals and snacks.

School Nutrition Management Students with type 2 diabetes may need additional accommodations to help manage lipids, blood pressure and weight: May need support at meals and snacks to achieve calorie level targets and consistent carb amounts Assure that healthy foods such as whole grains, low-fat protein and dairy, fruits, and vegetables are available Students with type 2 diabetes may need additional accommodations to help manage lipids, blood pressure and weight. Many children with type 2 diabetes are on a nutrition plan designed to help them achieve a healthy weight. These students may be prescribed a calorie level target for the day as well as consistent carb amounts to aim for at each meal and snack to help control their weight and blood glucose. Assuring that healthy foods such as whole grains, low-fat protein and dairy, fruits, and vegetables are available is critical to their diabetes management.

Basic Meal Plans Key: Balance insulin/medications with carb intake Most students have flexibility in WHAT to eat Basic Carbohydrate Counting Advanced Carbohydrate Counting Many students have flexibility in WHEN to eat More precise insulin delivery (pumps, pens) Rapid-acting insulins Time dosing of insulin according to DMMP The management of type 1 diabetes has changed dramatically in the last 6-7 years, but the basic idea of balancing insulin or medications with carbohydrate intake has remained the same. More children than ever benefit from the flexibility in meal planning using the exchange or carbohydrate counting methods. These meal planning approaches are used successfully with traditional insulin plans, multiple daily insulin injections, or insulin pumps. The increased use of pen-devices and pumps to deliver insulin has made “on-the-spot” insulin delivery easier and more precise. Additionally, the introduction of newer insulins has cut down on the need to snack just to avoid low blood glucose. Most students will dose their insulin before a meal or substantial snack. However, some, who are picky or unpredictable eaters, may dose after eating, based on the actual amount of carbohydrate eaten. The timing of insulin dosing with respect to meals and snacks should be specified in the DMMP.

Basic Carbohydrate Counting Calories from: carbohydrate protein fat Each nutrient type affects blood glucose differently Carbohydrate has the biggest effect on blood glucose TOTAL carbohydrate matters more than the source (sugar or starch) Carbohydrate counting is based on the following from nutritional science: Calories in food come from three nutrient types: Carbohydrate Protein Fat Each nutrient type affects blood glucose differently. Carbohydrate, which includes both sugar and starch, has the biggest effect on blood sugar. Approximately 90-100% of carbohydrates are converted into glucose in 1-2 hours. Proteins and fats do not effect the blood glucose level much, therefore they are not usually “counted”. Carbohydrates are found in several types of sources: Natural sugar: like fruit, milk Starches with fiber like raw vegetables, legumes, whole grains Starches without fiber like white flour products, refined grain products Concentrated sugar like cake, candy, regular soft drinks TOTAL carbohydrate matters more than the source (sugar or starch). Eating equal amounts of sugar or starch will usually raise blood sugar about the same amount. The TOTAL amount of carbohydrate eaten (whether sugar or starch) will determine how high blood glucose level will be after a meal or snack.

Advanced Carbohydrate Counting USING THE INSULIN-TO-CARB RATIO The insulin-to-carb ratio: Varies from student to student Is determined by the student’s health care team Should be included in the DMMP Usually stated as a ratio of 1 unit of insulin to x grams carbohydrate May vary from meal to meal for a student The most advanced carbohydrate counting method allows the student to adjust his/her insulin depending on the amount of carbohydrate eaten at each meal or snack. The insulin-to-carb ratio: Insulin-to-carb ratio can be defined as the amount of rapid or short acting insulin that is needed to “cover” the blood glucose raising effect of a carbohydrates that are consumed at the meal or snack. Varies from student to student. Is determined by the student’s health care team Should be included in the DMMP. Usually stated as a ratio of 1 unit of insulin to x grams carbohydrate. The insulin-to carb ratio method is used more often by: Students who are trying to maintain tight control Students who use multiple daily injection insulin plan or insulin pumps Older or more independent students Students who are picky or unpredictable eaters Students who use this method may administer insulin before, during, or after the meal per their DMMP. If students are administering insulin before the meal, it is particularly important that they know the menu and the nutritional value of menu items, whether the lunch is purchased at school or prepared at home.

Using Insulin-to-Carb Ratio Example: 1:10 Ratio 1 unit of insulin to be given per 10 grams of carbohydrate eaten 60 gm meal / 10 gms = 6 units of insulin needed Here’s an example of how to calculate insulin dose based on a meal with 60 grams of carbohydrate. If a student’s insulin-to-carbohydrate ratio is 1 unit of insulin to 10 grams of carbohydrate, and the total amount of carbohydrate eaten is 60, then we take that carbohydrate amount of 60 and divide it by the number of grams per unit from the carb ratio, or 10. So 60 divided by 10 equals 6 units of insulin.

School Meals & Snacks Provide school menus and nutrition information to student/parent/guardian in advance. Provide sufficient time for eating. Monitor actual food intake per DMMP young or newly diagnosed picky eaters Respect, encourage independence. Some students will need assistance in the school lunchroom. Others will not. All students and their families should be provided with school menus and nutritional information in advance. If a staff member is assisting the student in making food choices she/he also needs to be provided with the menu and nutritional information. Students should be provided with sufficient time for eating. The actual food intake of some students may need direct monitoring per the DMMP. These students may include: younger or newly diagnosed students picky eaters Each student’s level of independence should be respected: Per the DMMP, students should be encouraged to make independent choices to the extent that they can do so responsibly. Students who are independent in making food selections should not be subject to “second-guessing” by staff or other students.

Nutrition Information at School The approximate carbohydrate content of school meals can be determined in advance by the school nutrition director and can be indicated on the school menu for each item. The approximate carbohydrate content of school meals can be determined in advance by the school nutrition director and can be indicated on the school menu for each item.

Beyond the Routine: School Parties Provide parent/guardian with advance notice of parties/special events Follow the student’s DMMP, 504 Plan or IEP Some may prefer to bring their own foods, but may eat what is available. Provide nutritious party snacks or non-food treats for all Limit use of food as reward Provide parent/guardian with advance notice of parties/special events. If no advance notice has been given, contact the parent/guardian once the event begins, if there are questions. Don’t restrict unnecessarily. Follow the student’s DMMP. Some students may prefer to bring their own foods, but may eat what is available. Many traditional party foods are high in sugar and fat, so consider providing a selection of healthful foods and snacks to encourage healthy eating habits for all. Limit use of food as reward

Beyond the Routine: Field Trips Notify school nurse as soon as trip is scheduled to allow for consultation with parent/guardian about food and/or insulin adjustments Bring plenty of quick-acting sugar sources to treat hypoglycemia Bring lunch as appropriate Bring diabetes equipment and supplies, including glucagon, if specified in DMMP Bring list of emergency contacts, copy of emergency care plan Students with diabetes should participate fully in field trips, even including fast food meals and strenuous outdoor adventure activities. Pre-planning is a necessity and should include the following: Notify school nurse as soon as trip is scheduled to allow for consultation with parent/guardian about food and/or insulin adjustments for extra activity level per DMMP. Advance planning will ensure that the student with diabetes can fully participate in all field trip activities. The student’s health care needs must be accommodated by the school district on a school sponsored field trip; the parent/guardian cannot be required to attend a field trip. Bring snacks to treat hypoglycemia in case of unforeseen schedule changes. Keep them with the student at all times. Bring lunch as appropriate. Bring diabetes equipment and supplies including glucagon, if specified in DMMP. Bring a list of emergency phone numbers for parent/guardian, caregivers, and student’s health care provider.

Activity & Diabetes Everyone benefits from physical activity. Students with diabetes should fully participate. In general, activity lowers blood glucose levels. If there is insufficient insulin, physical activity can raise blood glucose. May need to make adjustments to insulin/medications and food intake, per DMMP A quick-acting source of glucose, glucose meter, and water should always be available PE teachers and coaches must be familiar with symptoms of both high and low blood glucose Physical activity is a critical part of diabetes management. Everyone can benefit from regular activity, but it is especially important for a student with diabetes. Students with diabetes should participate fully in physical education classes and team sports, unless indicated by another health care condition, hypoglycemia, or high ketones as per DMMP. In general, activity lowers blood glucose levels. Students with diabetes may need to make adjustments to insulin/medications and food intake depending upon timing of activity to insulin peaks or meals and snacks. A quick-acting source of glucose, glucose meter, and water should always be available. PE teachers and coaches must be familiar with symptoms of both high and low blood glucose and know what action they should take including how to get help. If there is insufficient insulin, physical activity can raise blood glucose levels. Follow DMMP for activity restrictions when ketones are present.

Activity & Blood Glucose Monitoring Check before, during, and after physical activity per DMMP: Especially when trying a new activity or sport If blood glucose starts to fall, student should stop and have a snack or quick-acting source of sugar Students with pumps may disconnect or adjust the basal rate downward temporarily, prior to physical activity Guidelines for activity and blood glucose monitoring: Check before, during, and after physical activity per DMMP. Especially when trying a new activity or sport. If blood sugar starts to fall, student should stop and have a snack. Students with pumps may disconnect or adjust the basal rate downward temporarily, prior to physical activity (per DMMP). If students disconnect from the pump, they need to have a secure location to store the pump until reconnecting. The effects of activity can last up to 12 hours. Blood glucoses can trend downward for hours after physical activity.