1. Setting Goals: Stages of Change
Pre-contemplation: unaware, unwilling or discouraged about making a change in behavior
Contemplation: thinking about change, but on “sometime in the future, ” generally in the next 6 months (people may stay in this stage for years!)
Planning: planning for how to make a change in behavior in the next 30 days- a good time to set specific short-term goals
Taking action: person has been making changes in habits or environment for less than 6 months- can be very stressful; self-efficacy is important here (confidence in one’s ability to make the changes needed)
Maintenance: person has maintained healthy behavior for 6 months; always be alert for triggers to slip into old behavior
Relapse: part of the learning process; learn from relapse, re-define plan and start again
Important: the change process is circular- a person can enter the cycle at any point and may relapse to an earlier stage.

2. Remember!
The goal is to move through the stages of change… not always to “take action.”

3. Practice Setting a Goal
Choose a healthy behavior that you have already been thinking about changing.
Some ideas: healthy eating, being more active physically, taking your medicine, checking your feet, checking your blood sugar.
What will you gain if you make this change?
What will you have to give up?
On a scale of 1-10, how much do you want to make this change?
What stage of change are we in when we are thinking about these things? Contemplation- we are thinking about changing, looking at the pros and cons and deciding if it is worth it or not. Remember the goal? The goal is to move through the states of change…not always to take action.

4. 1. Ride the exercise bike for 10 minutes daily
My Goal: to lose 5 pounds
My reason for this goal: so I can wear my favorite dress for my son’s wedding
Steps I’ll take:
1. Ride the exercise bike for 10 minutes daily
2. Eat a salad and fruit for lunch
3. Park my car as far from the door as I can
Who will help me: my best friend
With this step we moved one stage further on the stages of change wheel—from contemplation to planning.
It is important that goals be clear, simple, and short term. Find people who will encourage you along the way.

5. When I’ll start: this Thursday
When I’ll meet my goal: in 2 months
How I’ll reward myself for making progress toward my goal:
Buy an audio book to listen to on the way to work

6. Eating Healthy with Diabetes

7. What is diabetes? Having diabetes means… Diabetes is…
Too much glucose, a form of sugar, in your bloodstream
Not enough insulin OR
Your body has trouble using the insulin that you make
Let’s review…
Have 2 participants read each column

8. Healthy eating is important
Benefits include:
blood sugar as near normal as possible
maintain a healthier weight
improve cholesterol
improve blood pressure
improve overall health

9. Benefits of Healthy Weight
Reduces risk for high blood pressure, high cholesterol, diabetes, heart disease, and stroke
Helps us live longer
Protects our backs and joints
Helps us get well and stay well
Boosts our energy levels

10. Diet low in fat & cholesterol reduces risk of heart disease
People with diabetes have a higher risk of heart attack, stroke, and other heart problems
Low-fat foods
help prevent heart disease
maintain a healthy weight

11. Basic Nutrition Guidelines
Eat a variety of foods everyday
Try new foods
Eat high fiber foods: fruits, vegetables, whole grains, and beans
Use less added fat, sugar and salt
Be physically active every day
Eat meals and snacks at regular times every day

12. Basic Nutrition Guidelines
Eat about same amount of food each day.
Eat smaller portions
Try not to skip meals
Try to eat out no more than once a week When you do eat out, make low‐fat choices
Try to do 30 minutes of physical activity each day
Start slowly: take the stairs, walk more, do more yard work

13. Keeping & Using a Food Diary
An important tool in diabetes self-care
Excellent way to change your eating habits
Keep track at least three days in a row
Gives an idea of what your diet is usually like.
Studies have shown that simply keeping track of what you eat will help you lose weight!

14. Let’s Review! Diabetes is too much _____ in your bloodstream.
Insulin is like a _____ that allows glucose (sugar) to enter the cells.
How many of the “Basic Nutrition Guidelines” can you remember?
Diabetes is too much glucose
Insulin is like a key that allows glucose (sugar) to enter the cells
Review slides 6-8 for basic nutrition guidelines.

15. Food Affects Blood Sugar
Carbohydrate ––main energy source, raises blood sugar quickly
Protein ––building block for muscles and body organs
Fat ––stores calories as an energy supply
All the food you eat will affect your blood sugar! Carbohydrate raises your blood sugar more than protein or fat.

16. What Are Carbohydrates (carbs)?
Carbs are found in many foods.
Carbs provide glucose (sugar) for your body and brain.
Glucose: most important carbohydrate
Glucose used by cells for energy.

17. Carbs give energy to walk, climb stairs, and do other physical activities.
Brain must have glucose to work right.
Carbs = Energy

18. What foods have carbs?
Fruits, vegetables, milk, yogurt, rice, cereals, and bread
Snack foods, such as pretzels, chips and popcorn
Sweets, regular soda, cakes, candy, cookies, ice cream, pies, doughnuts

19. What about sugar? Sugars are carbohydrates
“Natural” sugars (honey) and table sugar are both carbs
All carbohydrates break down into sugar
Some foods contain a lot of sugar and have few nutrients (“empty calories”)

20. What about sugar substitutes?
Sugar alcohols
Xylitol
Sorbitol
Mannitol
Non-nutritive sweeteners
Aspartame (Equal)
Saccharin (Sweet and Low)
Sucralose (Splenda)
The FDA has approved five nonnutritive sweeteners for use in the U.S.: acesulfame potassium, aspartame, neotame, saccharin, and sucralose. Before being allowed on the market, all underwent rigorous scrutiny and were shown to be safe when consumed by the public, including people with diabetes and women during pregnancy. Reduced calorie sweeteners approved by the FDA include sugar alcohols (polyols) such as erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, tagatose, and hydrogenated starch hydrolysates. The use of sugar alcohols appears to be safe; however, they may cause diarrhea, especially in children.

21. Why Do I Need to Know about Carbs?
1. Your body turns carbs into glucose (sugar). 2. Insulin moves glucose into your cells. Diabetes means either you don’t make enough insulin or your body can’t use the insulin you make. 3. Eating the right amount of carbs at each meal and taking diabetes medications may help keep your blood glucose closer to target levels.

22. Let’s Review! “Carbs” is the short name for _____
Do carbs RAISE or LOWER blood sugar?
Another name for sugar is ________
True or False: “Natural” sugars (like honey) are not carbs.
True or False: Eating the right amount of carbs at each meal will NOT help keep your blood glucose at target levels.
Use “body parts” apron to review this material
Carbs is the short name for CARBOHYDRATES
Carbs RAISE blood sugar
Another name for sugar is GLUCOSE
FALSE: Natural sugars (like honey) are not carbs
FALSE: Eating the right amount of carbs at each meal will not help keep your blood glucose at target levels.

23. How do you count carbs? CARB COUNTING 1 carb choice = 15 grams carbs
Most WOMEN need 3-4 carb choices per meal OR
45 to 60 grams of carbs at each meal
1 carb choice or 15 grams of carbs for snacks (if needed)

24. How do you count carbs? 1 carb choice = 15 grams carbs
Most MEN need about 4-5 carb choices per meal OR
60 to 75 grams of carbs at each meal
1 to 2 carb choices or 15 to 30 grams of carbs for snacks (if needed)

25. Carbohydrate Counting
Means keeping track of the carbohydrates in a meal or snack
Means controlling the total amount of carbohydrate
Controls blood sugar levels
Count carbs and check your blood glucose

26. Carbs per serving size Breads: Fruits: Vegetables:
Muffin, bagel: 45g (3 carb choices)
6 saltine crackers: 15g (1 carb)
Oatmeal (1 package): 30g (2 carbs)
Whole grain bread (1 slice): 15g (1 carb)
Fruits:
Apple, orange (medium): 20g (1 1/3 carb)
Banana (medium): 25g (1 2/3 carb)
Vegetables:
Brocolli, zucchini (1/2 cup): 5g (1/3 carb)
Carrots, peas (1/2 cup): 10g (2/3 carb)
Squash, corn (1/2 cup): 15g (1 carb)

27. Carbs per serving size Meats: Milk: Oils:
Turkey burger (no bun): 0g (no carbs)
Chicken breast, roasted, no skin: 0 g (no carbs)
1 egg, hard-boiled: 0.1g (almost no carbs)
Milk:
Low fat cottage cheese (1/2 cup): 3g (<1/4 carb)
Low fat milk (1 cup): 12g (3/4 carb)
American cheese (1 slice): 0.3g (almost no carbs)
Oils:
Low fat Ranch dressing: 4 g (1/3 carb)
Butter, margarine: 0.1 g (almost no carbs)

28. Carbohydrate Counting
Means keeping track of the carbohydrates in a meal or snack
Means controlling the total amount of carbohydrate
Controls blood sugar levels
Count carbs and check your blood glucose

29. Carbs per serving size Meats: Milk: Oils:
Turkey burger (no bun): 0g (no carbs)
Chicken breast, roasted, no skin: 0 g (no carbs)
1 egg, hard-boiled: 0.1g (almost no carbs)
Milk:
Low fat cottage cheese (1/2 cup): 3g (<1/4 carb)
Low fat milk (1 cup): 12g (3/4 carb)
American cheese (1 slice): 0.3g (almost no carbs)
Oils:
Low fat Ranch dressing: 4 g (1/3 carb)
Butter, margarine: 0.1 g (almost no carbs)

30. Check the serving size. Is that how much you plan to eat?
Be a Carb Detective!
Check the serving size. Is that how much you plan to eat?
Count the total carbs
You do not need to count the sugars separately because it is already counted as part of the total carbs
TO CALCULATE CARB CHOICES:
Divide the number of grams of total carbs by 15
(because 1 carb choice = 15 grams of carb).
Total carb = 31g
31 divided by 15 = about 2

31. Sample of a 4-Carb Meal 1 slice of bread ½ cup mashed potatoes
½ cup peaches
1 cup skim milk
Use these foods to round out the meal:
Chicken (size of your hand)
Lettuce salad
1-2 tablespoons salad dressing

32. Let’s Review! 1 Carb choice = ____ grams carbs
Women need MORE or FEWER carb servings than men every day.
True or False: If you count carbs, you do not need to check your blood sugar.
To calculate carbs, divide the total carbohydrate grams by ____ because there are 15 grams in each carb choice.
1 carb choice = 15 g carbs
Women need fewer carb servings than men every day
False: If you count carbs, you do not need to check your blood sugar
To calculate carbs, divide the total carbohydrate grams by 15 because there are 15 g in each carb choice.

33. The Diabetes Food Guide Pyramid
Choose most foods from lowest levels:
Grains, starchy vegetables, & beans
Non-starchy vegetables
Fruits
Fewer choices from the milk, meats, and other protein groups
Very few choices from fats, oils, sweets and alcohol

34. What’s a Portion Size?
Portion size is the amount that you actually eat of a specific food. It can be different for each person. Your portion size may be larger than the serving size listed on the food package. Check the nutrition facts label to find the carbs you are actually eating.

35. Portion Size
Portion sizes keep getting bigger and bigger! The larger the portion, the more people tend to eat!

36. More About Portion Sizes
20 years ago:
333 calories
Today:
590 calories
Interactive slide
20 years ago:
210 calories
Today:
610 calories

37. “Rules of Thumb” Meat portion= deck of cards Cheese portion= domino
Butter portion= die
Salad dressing= golf ball
Rice, pasta, casseroles, potatoes= the size of your fist

38. More “Eating Out” Tips Select fruits and veggies
Avoid soups, sauces, gravies and broths
Avoid bread and rolls with salty, buttery crusts
Order salad dressing on the side- dip your fork into the dressing, then pick up the lettuce
Select grilled, broiled, or roasted meat, fish or poultry

39. Let’s Review!
The Food Guide Pyramid and understanding ________ sizes are the keys to making good choices when eating out.
What food are on the lower two levels of the Food Guide Pyramid? (eat more of these)
What foods are on the top level? (avoid these)
A meat serving is the size of a _______
A rice or casserole serving is the size of the _______ ____ ______ ________
The Food Guide Pyramid and understanding portion sizes are the keys to making good choices when eating out.
Whole grains, fruits, and veggies are on the lower two levels
Fats, oils, and sweets are on the top level
A meat serving is the size of a deck of cards
A rice or casserole serving is the size of the palm of your hand.

40. How to Use a Nutrition Facts Label
What is the serving size?
What are the servings per container?
How much carbohydrate is there in one serving?
If you eat the entire container, how much carbohydrate will you get?
How much dietary fiber is there in one serving?

41. How to Use a Nutrition Facts Label
How much Total Fat is there in one serving?
How much of that is Saturated Fat?
How much of that is Trans Fat?
How many Calories are in a serving?
How many Calories in each serving come from Fat
How much Cholesterol is in one serving?

42. Let’s Talk About… Fiber Fat
Interactive slide- talk about the emotional impact of being told to eat a diet low in fat and high in fiber
Diabetes is a very serious and scary chronic illness. It is totally life changing for those diagnosed. Eating becomes literally a matter of life and death. And the way a person is used to eating is usually changed drastically.
How did it make you feel when you were told you will need to make changes in the way you eat? What have you found to be the biggest obstacles to eating a high fiber, low fat, low carbohydrate diet?

43. Fiber= carbs that can’t be digested.
Role of Fiber
Fiber= carbs that can’t be digested.
High fiber diets make you feel “full” longer.
High fiber diets may help protect you from heart disease and diabetes.
High intake of dietary fiber has been linked to a lower risk of heart disease in a number of large studies that followed people for many years. In a Harvard study of over 40,000 male health professionals, researchers found that a high total dietary fiber intake was linked to a 40 percent lower risk of coronary heart disease, compared to a low fiber intake. Cereal fiber, which is found in grains, seemed particularly beneficial. A related Harvard study of female nurses produced quite similar findings.
Another meta-analysis of several large studies, including more than 700,000 men and women, found that eating an extra 2 servings of whole grains a day decreased the risk of type 2 diabetes by 21 percent. So to protect against heart disease and diabetes, perhaps the best advice is to choose whole grain, high-fiber foods at most meals.(Harvard School of Public Health, 2009)

44. Insoluble fiber Soluble fiber
Two Types of Fiber
Insoluble fiber
speeds up passage of food through the digestive tract
is found in whole grain bread, cereal, wheat bran, fresh fruit and vegetables
Soluble fiber
slows down the passage of food through the digestive system
is found in oat bran, rice bran, dried beans, peas, and lentils.
Insoluble fiber. This type of fiber promotes the movement of material through your digestive system and increases stool bulk, so it can be of benefit to those who struggle with constipation or irregular stools. Whole-wheat flour, wheat bran, nuts and many vegetables are good sources of insoluble fiber.
Soluble fiber. This type of fiber dissolves in water to form a gel-like material. It can help lower blood cholesterol and glucose levels. You can find generous quantities of soluble fiber in oats, peas, beans, apples, citrus fruits, carrots, barley and psyllium.

45. Eating For a Healthy Heart
Limit total fat to 30% or less of calories
Decrease total fat, saturated fat, and trans fat
Increase omega 3 fats found in fish oil, canola oil, and flax seed
Decrease omega 6 fats (vegetable oils)
Use “healthy fats” such as olive oil for sauces and dressings

46. The Dash Diet
Blood Pressure can be lowered by following the “Dietary Approaches to Stop Hypertension” (DASH) diet
DASH diet is rich in fruits and vegetables Fresh fruits and veggies have little or no salt DASH eating plan makes it easier to eat less salt.

47. Dash Eating Plan

48. Mediterranean Diet Key facts about Mediterranean Diet
Get plenty of exercise.
Eat meals with family or friends.
Eat at least 5 servings daily of fruits and vegetables.
Use olive oil and canola oil.
Use herbs and spices instead of salt to flavor food.
Eat small portions of nuts (20 unsalted nuts/day).
Eat fish at least twice a week
Eat very little beef or red meat.
Research indicates that a Mediterranean diet may work better than a standard low-fat diet for losing weight in people who have T2DM and are overweight.
The Mediterranean diet includes plenty of fruit, vegetables, fish, and chicken. The carbohydrate content should be less than 50% of the total calories and the main source of fat is olive oil. A standard low fat diet keeps fat intake to below 30% of the total calories, and the diet is rich in whole grains. A Mediterranean diet is helpful for weight loss, and the monosaturated fat in olive oil may also improve insulin sensitivity. This might help delay the onset of the use of anti-diabetes medications.

49. Making the Changes
Interactive slide- talk about the emotional impact of being told to eat a diet low in fat and carbs and high in fiber
Diabetes is a very serious and scary chronic illness. It is totally life changing for those diagnosed. Eating becomes literally a matter of life and death. And the way a person is used to eating is usually changed drastically.
How did it make you feel when you were told you will need to make changes in the way you eat? What have you found to be the biggest obstacles to eating a high fiber, low fat, low carbohydrate diet?
Being consistent is an important strategy for keeping blood sugar under good control. If you can eat more or less the same amount of food at the same time of day and spread out your carbs so that they are evenly distributed with each meal, your blood sugar most likely will stay in a health range.
Blood sugar control is controlled by more than just WHAT foods you eat. From these slides we have seen that how much you eat and when you eat are also important.
Physical activity also plays an important part in keeping your blood sugars in the target range. This is what we will talk about in the next section of the program.