Practical Dietary Prescription for Ambulatory Diabetic Patient

PSEM Updates
2 August 2009

Practical Dietary Prescription for the
Ambulatory Diabetic Patient
Gabriel Jasul Jr. MD, FPCP, FPSEM
Iris Thiele Isip Tan MD, FPCP, FPSEM

The Case

• 45 year-old seafarer
• Pre-employment clearance
• FBS 189 mg/dL
• 2h OGTT 255 mg/dL
• Ht 5’6” Wt 165 lbs
• Physically active if on sea duty
• Sedentary since 3 mos ago

How do I effectively set
nutrition goals with a person
who has diabetes?

Issue 1

Goal Setting in Diabetes

Diabetes
Education
Management
Self-management
Clinical parameters: training
HbA1c, lipids, BP, BMI

Behavioral goals
Assist in changing a person’s lifestyle

Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.

Behavioral Goal Setting
• Less clinically focused
but individualized
• Purpose: establish
realistic target behaviors
→ evaluate patient
success in making
lifestyle changes


Behavioral Goal Setting

• Be s e n s i t i ve t o
ne e d f o r • Goals are established by
ﬂ e x i bi li t y a n d mutual agreement
s t r uc t u re - Patient will “own” the goals
• G u ide , b u t and become committed
e n c o u r ag e
i n de p e n de n t
s e l f- c a re

What To Ask
• What behaviors would you like to
change?
• What changes do you want to make
to your current lifestyle?
• What are you willing to do right now?
• What obstacles do you see to making
these changes?
• What beneﬁts do you see as a result
of making these changes?


Goal setting is a continuous process ...

• Each goal should be speciﬁc
and measurable
• Set up the patient for success
- Start with 1 to 3 achievable
goals
• Use a form to track daily
progress


GOALS
Things I will do to improve my eating behavior
Check off each day you meet your goal.
Goal 1. Eat breakfast, lunch and dinner everyday.
M T W T F S S M T W T F S S


Notes:______________________________________________________
____________________________________________________________

Goal 2. Eat ﬁve servings of fruits and vegetables everyday.


Notes:______________________________________________________
____________________________________________________________

What should my
priorities be when I’m
providing initial MNT
to a newly-diagnosed
person with type 2

Issue 2
diabetes?

Bawal softdrinks!
Di ba juice puwede
basta unsweetened?
Bawal ang karne!
Di puwede ang kanin!
Okay lang ang tinapay.
Skyﬂakes at oatmeal na
lang kinakain ko, Dok.

Learn what the patient thinks about
food and diabetes (including
preconceptions or misconceptions)

Di na ba talaga
puwede ang kanin?
Diet coke, ok lang?
Eh, Milo?

Dok, ano ba talaga ang
bawal at puwedeng kainin?
Di naman nakakapili ng
pagkain sa barko, Dok!

Assess interest and willingness to
change eating habits; ask what they
would like to know about nutrition

Kape lang ako sa
almusal, bawi na
lang sa tanghalian.
Hindi ako nagme-
merienda sa umaga.
Sa hapon merienda ko
kanin, minsan noodles.
Malakas talaga ako sa
kanin, Dok!

Find out what the patient typically
eats and drinks for meals and
snacks each day

Start with what the patient is currently eating

• Eat s ome t h i ng i n • Set individualized goals for
th e ﬁrs t 2 h o f eating behavior change
t h e d ay
- As opposed to providing a
•E at 25% le s s
calculated calorie prescription
C H O at di n ne r
and giving a structured meal
•W a l k f o r 10 plan
mi nu te s af te r
e at i ng a me a l


Nutrition Education Priority in T2DM

• Eat regular meals at regular
times, spaced no more than
4 or 5 hours apart
• Establish a few,
individualized eating
behavior goals that make
gradual changes in current
lifestyle

Meal Planning
• Ht 5’6” Wt 165 lbs
Ideal weight for height: 112 lbs + (6 x 4) = 136 lbs or 62 kg
• Physically active if on sea duty
TCR = 62 kg x 40 kcal = 2480 - 500 = 1980 ... 2000 kcal/day
Activity: bedrest 25, sedentary to light 30, light 35, moderate 40, heavy 45

• Composition: CHO 50-60%, CHON 12-15% max 20%, Fat 30%
CHO (60%) 300 g, CHON (15%) 75 g, Fat (25%) 55 g

How do we convert these computations into a meal plan?

What are the
available meal

Issue 3
planning
approaches?

Idaho Plate Method
Milk or
or yogurt
Empty
Starch

Breakfast Brown et al Diabetes Spectrum 2001

Idaho Plate Method

*

*1/2 cup
pudding or
ice cream

9-inch plate
Lunch/Dinner
provides
1200-1500 calories Brown et al Diabetes Spectrum 2001

Plate method works
well for the following:

Eat 3 meals a Low literacy
day (move level or have ✓elderly
cognitive ✓need to lose
side items to weight
snack time) difﬁculties ✓hospitalized
Works well when Does not require needing
eating outside math skills or “survival”
the home high reading level information

Challenging for those whom rice is a staple and
those who enjoy only a limited variety of vegetables

Brown et al Diabetes Spectrum 2001

Diabetic Exchanges
Daily meal plan based on a set amount of servings from each category

Starch Meat/meat Non-starchy
substitutes vegetables

Fruit Milk Fats

Diabetic Exchanges
Starch Meat/meat Non-starchy
substitutes vegetables

Fruit Milk Fats

• Allows a person to measure rather than weigh food
• Any food may be substituted for another within the same
food category
• Free food contains <20 cal (can be eaten in any amount
spread throughout the day) i.e. catsup, soy sauce, spices

Meal Planning

• Composition: CHO 50-60%, CHON 12-15% max 20%, Fat 30%
CHO (60%) 300 g, CHON (15%) 75 g, Fat (25%) 55 g

• 16 CHO servings/day
10 rice exchanges + 4 fruit exchanges + 2 milk
exchanges

Vegetable Exchange List
Leafy vegetables Non-leafy vegetables
1 cup raw or 1/2 cup cooked 1/2 cup raw or cooked
alugbati chayote fruit onion bulb carrots pigeon pea pods
leaves chayote leaves pako coconut shoot rimas
ampalaya fruit cucumber papaya green cowpea pods singkamas pods
baguio beans eggplant patola jackfruit singkamas tuber
bamboo shoot gabi leaves pepper leaves lima bean pods squash fruit
banana heart kangkong petsay mungbeans sprout string beans pod
bataw pods katuray ﬂowers radish Non-leafy vegetables Processed
beets lettuce saluyot
asparagus tips 1 cup
cabbage malunggay leaves sigarilyas pods
baby corn 2 pcs (8 cm long, 5 1/2 cm
cauliﬂower mushroom fresh stringbeans
circumference each)
camote leaves mustard leaves tomato
green peas 1 tbsp
celery okra upo
golden sweet corn 2 tbsp
mushroom 1/3 cup
tomato juice 1/2 cup undiluted
water chestnut 3 pcs (2 cm dia each)

Fruit Exchange List
Fruits high in Vitamin C Other Fruits
Anonas 1/2 of 5x8 cm diameter Apple 1/2 of 8 cm diameter
Atis 1 pc (5 cm diameter) Banana 1 pc (9x3 cm)
Dalanghita 2 pcs (6 cm diameter each) Chico 1pc (4 cm diameter)
Datiles 1 cup Duhat 20 pcs (2 cm diameter each)
Guava 2 pcs (4 cm diameter each) Durian 1 segment of 6 1/2 x 4 1/2 cm or 1 1/2 tbsp)
Guyabano 1 slice (8x6x2 cm) or 1/2 cup Grapes 10 pcs (2 cm diameter each) or 4 pieces (3 cm dia)
Kamachile 7 pods Jackfruit, ripe 3 segments (6 cm diameter each)
Mango green 1 slice (11x6 cm) Lansones 7 pcs (4 x 2 cm each)
Mango ripe 1 slice (12 x 7 cm) or 1/2 cup Lychees 5 pcs (3 cm diameter each)
Papaya ripe 1 slice (10x5x2 cm) or 3/4 cup Macopa 3 pcs (4 cm diameter each)
Strawberry 1 1/4 cup Melon 1 slice (12x10x3 cm) or 1 1/3 cups
Suha 3 segments (8x4x3 cm) Pear 1 pc (6 cm diameter)
Tiesa 1/4 of 10 cm diameter Pineapple 1 slice (10x6x2 cm) or 1/2 cup
Rambutan 8 pcs (3 cm diameter each)
Prunes 3 pcs unsweetened Santol 1 pc (7 cm diameter)
Buko water 1 cup Sineguelas 5 pcs (3 cm diameter each)
Buko meat 1/2 cup Starapple 1/2 of 6 cm diameter
Mangosteen 3 pcs (6 cm diameter each) Watermelon 1 slice (12x6x3 cm) or 1 cup
Tamarind, ripe 2 of 6 segments each Juice 1/3 cup unsweetened

Milk Exchange List
Whole milk
Milk, evaporated 1/2 cup undiluted
Milk, fresh 1cup
Milk, powdered 4 level tbsp
Low fat milk
Powdered 1/4 cup or 4 level tbsp
Light low fat milk 1 tetra brick
Skimmed (nonfat)
Buttermilk:
Liquid 2/3 cup
Powdered 1/4 cup or 4 level tbsp
Longlife skimmed
Milk 1 cup
Yogurt 1/2 cup

Rice Exchange List
Rice 1/2 cup Noodles (bihon, macaroni, sotanghon,
Lugaw 1 cup spaghetti) 1 cup
Suman sa ibos 1 pc (8x4x2 cm) Sweet potato 1/2 of 11 cm long x 4 1/2 cm
Pan americano 2 slices (9x8x1 cm) diameter
Pan de sal 2 pcs (7x4 cm) Cassava 1 pc (5 cm long x 4 1/2 cm
Pan de limon 1 pc (6x5x4 cm) diameter)
Rolls 1 pc (11x4x3 cm) Potato 2 pcs (1/2 of 7 cm long x 4 cm
Wheat bread 2 pcs (11 1/2x8x1 cm each) diameter)
Galyetas de patatas 10 pcs (4x4x1/2 cm Chestnut 11 pcs large or 20 small
diameter each) Crackers 8 pcs (5x4x1/2 cm)
Binatog 1/2 cup French fries 1 cup
Corn, boiled 1 pc (12x4 cm) Oatmeal, cooked 1 cup, thick consistency
Corn ﬂakes 1 cup Popcorn plain 2 cups
Corn canned 1 cup Skyﬂakes 4 pcs

Meat Exchange List
Lean Meat Medium Fat Meat
Lean beef, carabeef, chicken 1 Halaan 1/3 cup shelled or 3 cups Beef (flank, brisket plate, chuck) 1
slice, matchbox size (5x 3 1/2 x with shell slice, matchbox size (5x 3 1/2x 1
1 1/2 cm) Kuhol 1/2 cup shelled or 2 cups 1/2 cm)
Lean pork 1 slice matchbox size with shell Pork, pata 1 slice (4 cm diameter x
(6 1/2 x 3x1 1/2 cm) Monggo 1/2 cup 2 cm thick)
Chicken leg small (13 1/2 cm Cottage cheese 1/3 cup Brain (beef, pork, carabeef), 3/4
long x3 cm diameter) Vegemeat 1 1/2 slices cup
Chicken breast 1/4 (6 cm long) Daing 1 pc medium Fish 1 slice
Liver, blood, gizzard, heart, Fishball 6 pcs Chicken egg 1 pc
lungs, small intestines, spleen, Tinapa, bangus 1/4 of 20 x 8 cm Quail’s egg 9 pcs
tripe 3/4 cup Tuyo (sapsap, tunsoy) 3 pcs (11 Cheddar cheese, 1 slice (6x3x2 cm)
Fish 1 slice (18x 4 1/2 cm) 1/2 x8 cm) Soybean (utaw) 1/2 cup
Alamang 1 1/4 tbsp Dried pusit 1 pc (8x1 cm) Sardines, canned in oil/tomato
Alimango, alimasag meat 1/4 Salmon, canned 1/3 cup flaked sauce, 1 pc
tbsp or 1/2 pc medium Tuna in brine/water 1/3 cup Tuna sardines 1 1/2 of 6x4x3 cm
Lobster 2 tbsps flaked Tofu 1/2 cup
Shrimps 5 pcs (12 cm each) Tocino lean w/o sugar 1 slice Tokwa 1 pc (6x6x2 cm)
Prawns 2 pcs (13 cm each) (11x4x 1/2 cm) Corned beef 3 tbsps
Squid 3 pcs (7x3 cm each)

Fat Exchange List
Saturated Polyunsaturated Monounsaturated

Bacon, 1 strip 10x3 cm Oil (corn, soybean, Avocado 1/2 of 12x7 cm
Butter, coconut oil, safﬂower, sesame, Peanut, olive oil,
margarine, mayonnaise rapeseed canola, shortening 1 tsp
1 tbsp sunﬂower) 1 tsp
Butong pakwan 1 tbsp
Coconut cream, cream
cheese, sandwich spread,
whipping cream 1 tbsp
Sitsaron 2 pcs (5x3 cm
each)

Carbohydrate Counting
• Count the grams of CHO in various foods and
adjust the amount of CHO consumed during the
day as a reﬂection of blood glucose levels
• Meal plan outlines the number of CHO choices a
person may select for meals and snacks
• 16 CHO servings/day
10 rice exchanges (230 g) + 4 fruit exchanges (40 g) +
2 milk exchanges (24 g)


Current Food Exchange
Categories and Values
Type of food Serving size Calories CHO g CHON g Fat g
Vegetables 1/2 cup - 1 cup 16 3 1 0
Fat-free or
3/4 - 1 cup 80 12 8 0
very low fat milk
Lean protein varies 41 0 8 1
Medium fat protein varies 86 0 8 6
High fat protein varies 122 0 8 10
Fruits varies 40 10 0 0
Rice varies 100 23 0 0
Fats 1 tsp - 1 tbsp 45 0 0 5

What are some indicators
that carbohydrate
counting will be helpful?

Issue 4

Assess existing knowledge

•What are the foods/food
groups that contain CHO?
•What are foods/food groups
that do not contain CHO?
•What is the impact of various
foods (macronutrients) on
blood glucose?

Choose CHO counting if the patient
has heard or read about
CHO counting and asks to learn about it

desires increased ﬂexibility
of food choices and timing of meals

CHO in foods is the
main contributor to
the rise in blood
glucose after eating


is frustrated with or confused by perceived
dietary restrictions on sweets and desserts
Bawal lahat ng matamis!

ADA Recommendation
“Sucrose-containing food can
be substituted for other CHO
Di ko mak ain in the meal plan or if added to
ang gusto ko! the meal plan, covered with
insulin or other glucose-
lowering medication. Care
should be taken to avoid
excess energy intake.”


is excessively focused on sugars per se,
without understanding that portions of
all CHO foods are equally important

“Equivalent amounts of CHO
from a variety of CHO-containing
foods raise blood glucose about
the same degree in about the
same amount of time” (ADA 2008)
Ok lang k ahit marami ang
mak ain, basta sugar free!

reads food labels for grams of
sugar instead of total grams of CHO

• Tendency to exclude
nutritious high-sugar foods
i.e. fruits and milk
• Overeating of cereals and
grains: no added or
natural sugars but do
contain a lot of CHO


has a nutrition history that shows
frequent use of/preference for pasta, rice,
potatoes, bread, sweets and desserts

It is easier to adjust
medications than to
change lifelong eating
habits


avoids plant-based foods such as bread,
potatoes, grains, fruits and some vegetables
because “they will turn into sugar”

Fruits, vegetables and grains
are always better choices
than foods that do not
contribute to health, i.e.
softdrinks, sweets, snack
chips, crackers, desserts etc.

reports unexplained problems with
hypoglycemia, hyperglycemia or both

Meal plan should
match the medication
schedule

is unable to correctly identify single portion
sizes of CHO foods that they use regularly


uses insulin, but makes no adjustments for
hyperglycemia and/or hypoglycemia


is looking for a fresh approach
to diabetes meal planning


has poor diabetes control (HbA1c >8%)


What are the most
important skills to teach
people for eating away
from home?

Issue 5

Teaching point about restaurant food
Acknowledge the pitfalls: portions, fat and
sodium content, large servings of meat.
Use the meals they typically eat to demonstrate.


Ask if they can decrease the number of
times per week they eat away from home

Dok, araw araw ako sa Jollibee!

Help them choose foods
with lower saturated fat,
cholesterol and sodium content
Choose restaurants that offer healthier choices.

Practice choosing healthier meals at their
favorite restaurants.

Practice estimating the CHO content of
restaurant meals from available nutrition
information.


Why is portion
control important
and what are the
concepts and
skills to convey to

Issue 6
patients about it?

Teaching point for portion control at home
Advise people to eat just the serving size of
foods given in Nutrition Facts on food labels

Food label serving sizes are not necessarily the
same as diabetes (exchange/choice) servings
Food Diabetes Serving Food Label Serving
Milk 1 cup / 8 oz 1 cup / 8 oz
Bread 1 slice / 1 oz 1 slice / 1 oz
Fruit juice 1/2 cup / 4 oz 1 cup / 8 oz
Margarine 1 tsp regular stick 1 tbsp regular stick


When purchasing produce (fruits,
vegetables, starches), buy the smallest ones

Look for small apples,
bananas and potatoes.


Use smaller plates, such as a lunch-size plate

Large dinner plates
promote overﬁlling
and overeating.


Do not prepare too much food

If you plan on
leftovers, put the
extra food away
before serving.

Dok, sayang ang tira,
kailangang ubusin!
Maraming nagugutom!

Do not place bowls, pots or casserole
pans on the table within easy reach.

Make people get up from the
table if they want seconds.

If the habit of eating seconds is difﬁcult
to break, consider splitting the portions
into two servings - ﬁrsts and seconds


Weighing and measuring foods at
home trains the eyes to estimate
portions when eating restaurant food


Teaching point for portion control at the restaurant
Do not order large servings
unless you plan to split them
giant
grande
supreme
extra large
jumbo
double
triple
double-decker
king-size
super

Order small menu items

junior
single
queen
regular
petite
kiddie
Do not upsize portions;
do not go for deals or bargains
that promote overeating!

Be creative with menus

Don’t automatically order a main course
✓ soup and salad
✓ salad and appetizer
✓ appetizer and soup
Order a half portion

Split, share, mix and match menu items to eat
in desirable portions


Use portion-estimating abilities
developed at home

If the portion served will
be too large, ask for a
take-home container.

Put away the extras
before starting the meal.


Hand Guides for Portion Control
Tight ﬁst = 1/2 cup Palm = 3 oz

Handful = 1 cup

Thumb =
2 tbsp or 1 oz Thumb tip = 1 tsp

What are the most
important elements
of the food label
and what concepts
should we teach the
patients about it?

Issue 7

Nutrient Claims and % Daily Value

Free Low Reduced
Calorie <5 cal/serving <40 cal/serving
<0.5 g fat or saturated 3 g or less of total
Fat fat/serving fat
<0.5 g saturated fat or at least 25% less than
Saturated fat trans fat
1 g or less
regular version
at least 25% less than
Sugar <0.5 g/serving
regular version
140 mg Na or less,
Salt <5 mg Na/serving very low
regular version
35 mg or less
Cholesterol <2 mg/serving 20 mg or less
regular version
High fiber: 5 g or more of fiber/serving;
Good source of fiber: 2.5 g to 4.9 g of fiber/serving

Orient patient to
the elements of the
food label

The nutrients in
the Nutrition Facts are
provided by ONE
serving of the food

Teach the patients to use
the food label to
estimate the amount of
CHO in the portion they
will actually eat

Dok, ilang pieces ba
ng Oreo ang 34 g?

One, Two ... Count my food.
Three, Four ... Exercise more.
Five, Six ... Small meals I ﬁx.
Seven, Eight ... Now how’s my weight?
Nine, Ten ... Start again.
Brown et al Diabetes Spectrum 2001

Thank You
www.endocrine-witch.info

Practical Dietary Prescription for Ambulatory Diabetic Patient

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