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

3. Nutrition Objectives To provide nutrition guidelines for the school nurse working with children with diabetes To describe the most popular methods of diabetes medical nutrition therapy To describe and educate on the use of carbohydrate counting

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

5. Goals of Medical Nutrition Therapy To provide adequate energy to ensure normal growth & development To facilitate changes in eating & physical activity habits to reduce insulin resistance Attain & maintain optimal metabolic outcomes Prevent & treat the chronic complications of diabetes

6. Goals of Medical Nutrition Therapy Improve health through healthy food choices & physical activity Address individual nutritional needs To provide self-management education for treatment of acute complications To decrease diabetes risk by encouraging physical activity & promoting healthy food choices

7. Medical Nutrition Therapy Goal to achieve blood glucose goals without excessive hypoglycemia Based on requirements for all healthy children & adolescents Ensure adequate intake of essential vitamins & minerals

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

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

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

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

12. Medical Treatment of Diabetes Target blood sugar range Use of insulin Subcutaneous (SQ) injections Continuous SQ insulin infusion Use of oral hypoglycemic agents Weight management Exercise Medical nutrition therapy

13. Weight Management for Type 2 Diabetes Exercise can decrease insulin resistance & help with weight management Weight loss can also improve lipid levels Decrease risk for more immediate health risks Slow rate of weight gain

14. Weight Management for Type 2 Diabetes 3 meals + 2-3 snacks a day should be encouraged Consumption of more fruits & vegetables, whole grain products, lowfat dairy products Facilitate behavior change Identify barriers to success & help eliminate them

15. ADA Exchange List Developed in 1950, revised by ADA in 1995 Lists of groups of measured foods that equal an “exchange” Can be used for Type 1 & Type 2 Alerts patient to fiber & sodium Divides foods into 3 food groups Carbohydrate Meat & Meat Substitutes Fat

16. ADA Exchange List Advantages Provides a framework for grouping foods Emphasizes important nutritional management concepts Can use nutrient values from food labels Not appropriate for use if the family cannot understand “exchanging”

17. Carbohydrate Counting Been around since 1920’s Specifically focused on techniques to optimize blood glucose control Used to match pre-meal insulin doses to the demand created by food Other nutrition aspects must be addressed separately

18. Carbohydrate Counting Easier to learn than exchanges Offers more variety in food choices Provides a more accurate prediction of rises in blood sugar following a meal or snack Allows utilization of food labels to make meal planning easier

19. Carbohydrate Counting Three Levels Basic - learn carbohydrate exchanges & consistent intake Intermediate - learn to identify patterns in blood glucose levels that are related to food eaten, diabetes medications used, &/or physical activity and how to make adjustments

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

21. SO HOW DO YOU COUNT CARBOHYDRATES?

22. IDENTIFY CARBOHYDRATE FOOD SOURCES

24. FRUITS STARCHES & STARCHY VEGETABLES MILK

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

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

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

28. WHAT TO CONSIDER WITH CARBOHYDRATE Used terms: sugars, starch, fiber Factors that influence glycemic responses to foods: Amount of Carbohydrate Type of sugar Nature of the starch Cooking & food processing Food form

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

30. 1 CARBOHYDRATE SERVING = 15 GRAMS CARBOHYDRATE

31. The Fruit Group Fresh fruit 1 cup, 1/2 banana, 15 grapes, 1/8 cantaloupe, tennis-ball size piece Canned fruit 1/2 cup 100% fruit juice 4 ounces Dried fruit 2 Tablespoons

32. The Starch Group Starches 1 slice bread, 1/3 cup rice, 1/2 cup pasta, 1/2 cup cereal, 1 small roll, 1/2 bun Starchy vegetables 1/2 cup corn, potatoes, dried beans, peas

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

34. READ THE NUTRITION FACTS LABELS!

35. 3 THINGS TO READ ON A LABEL Serving Size Total Carbohydrate Total Fat

37. How Meal Plan Developed for Each Child Based on age & ideal body weight in kilograms Pattern of growth & weight gain Typical food intake at home Food history & activity patterns Time & place of all meals & snacks Home & school schedule during week

38. Carbohydrate Counting: Suggested Education Progression Initial session Diet goals and rationale Healthy nutrition Balanced meals Timing/consistency of meals Carbohydrate, protein, fat sources & effects on blood sugar levels Concentrated sweets/free foods Basic level of carbohydrate counting

39. Carbohydrate Counting: Suggested Education Progression Follow-up (initial 1 to 2 months, at 6 months, yearly full nutrition assessment) Individualized meal plan based on clinical goals and patient/family readiness & motivation

40. Meal Plans at School Prescribed carbohydrate grams for meals and snacks Not every child with diabetes will have a meal plan Usually prescribed at diagnosis or clinic visit, cannot be prescribed over the phone Sent to nutritionist of Child Nutrition Program, who sends it to the school

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

42. Exercise Guidelines for Type 1 Diabetes Carry adequate ID & a source of fast- acting carbohydrate May require a decrease in insulin Continue monitoring blood glucose after exercise is completed

43. General Guidelines For Making Food Adjustments

44. Parties at School Can still participate and eat food at parties! Communicate with parent ahead of time –Can plan to change insulin dose to cover party food –Plan to have party around time of snack Encourage teacher or parents to provide healthy snacks at parties, sugar-free hard candy and lollipops Use fat-free whipped topping as icing on cakes or cookies

45. Questions