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HANA- Dietary Education DM-Final 1

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HANA- Dietary Education DM-Final 1

  1. 1. Dietary Education for People with Diabetes Bsc. Nutrition & Food ProcessingBsc. Nutrition & Food Processing Colonel Hana Khasrouf MudabberColonel Hana Khasrouf Mudabber
  2. 2. Outline Aims of Nutritional Advice The goals of dietary advice Role of the dietician Dietary Education Tools: Stage1 Healthy Eating The food pyramid The signal system The hand jive The plate model  Stage 2  Food Exchanges  Carbohydrate Counting 1. Portion Estimation 2. Food Package Labels 3. Carb factors  Advanced carb counting carb: insulin ratio Methods: #1 #2 & #3  Glycemic Index
  3. 3. Aims of Nutritional Advice  The aim is to provide those who need advice with the information requirement to make appropriate choices on the type and quantity of food which they eat.  It must take into account the individuals: - Specific needs - Personal and cultural preferences - Beliefs and lifestyle - Wishes and willingness to change
  4. 4. The Goals of Dietary Advice Are: To maintain or improve health through the use of appropriate and healthy food choices To achieve and maintain optimal metabolic and physiological outcome
  5. 5. Role of the dietician The role of the dietitian is to translate nutritional objectives into practice in a way which is realistic and practical for the diabetic. Focussing on modifying the patient’s existing eating habits, food choice and timing of meals.
  6. 6. Role of the dietician The dietitian needs to assess diet for: Food choices Meal plan Nutritional adequacy and overall dietary balance Beliefs or misconceptions held about diet and diabetes Physical activity, occupation, literacy, economic circumstances , etc Body weight Other medical conditions – Coeliacs, visual handicap, nephropathy, etc Alcohol consumption
  7. 7. Avoid looking like a school teacher!Avoid looking like a school teacher! • Simple words • Open-ended questions • Encouragement • Positive feedback • Active listening • Repetition Role of the Dietician Implementing Good Communication Skills
  8. 8. Role of the dietician Example: Open-ended question  At what time do you take your meals? Closed question  Do you take your meals on time?
  9. 9. Patients can be overwhelmed, the dietician must not cram all teaching points into one session Adult learners have an attention span of about 20 minutes Scheduling follow-up Role of the dietician How to educate DM patient?
  10. 10. Role of the dietician Utilizing Interactive Tools and Educational Materials for Teaching Diabetes dietary education color books or educational stories for kids. Diabetes dietary education games for teens and adults (softwares or CDs)
  11. 11. ‫لصحتي‬ ‫المفيد‬ ‫الجيد‬ ‫الطعام‬ ‫أتناول‬ ‫أنا‬ ‫ا‬ً ‫وخصوص‬ ‫ال‬ً ‫قلي‬ ‫وأرتاح‬ ‫أجلس‬ ‫أن‬ ‫الى‬ ‫أحتاج‬ ‫ا‬ً ‫أحيان‬ .‫ا‬ً ‫كثير‬ ‫لعبت‬ ‫إذا‬ ‫ا‬ً ‫منخفض‬ ‫الدم‬ ‫سكر‬ ‫كان‬ ‫إذا‬ ‫خفيفة‬ ‫وجبة‬ ‫وأتناول‬
  12. 12. ‫تساعدني‬ ‫الفطور‬ ‫أتناول‬ ‫أن‬ ‫قبل‬ .‫النسولين‬ ‫أخذ‬ ‫في‬ ‫والدتي‬ .‫ا‬ً ‫تمام‬ ‫مثلك‬ ‫سكري‬ ‫لدي‬ ‫أنا‬ ‫أخذ‬ ‫قبل‬ ‫بالدم‬ ‫السكر‬ ‫فحص‬ ‫على‬ ‫نعمل‬ .‫الطعام‬ ‫تناول‬ ‫وبعد‬ ‫النسولين‬ .‫بذلك‬ ‫ا‬ً ‫أحيان‬ ‫أبي‬ ‫يساعدني‬ ‫الدم؟‬ ‫سكر‬ ‫تفحص‬ ‫هل‬ ‫ا‬ً ‫أيض‬ ‫وأنت‬
  13. 13. Diabetes Dietary Education Books & Stories for Kids
  14. 14. Diabetes Software for Teens & Adults
  15. 15. Approach to meal planning A uniform approach to meal planning does not work for everyone A flexible plan or a variety of approaches is required to deal with differing needs
  16. 16. Background Historically advice given on carbohydrate exchanges or portions In 1980s carbohydrate restriction found to be unnecessary – advice changed to healthy eating : plate model New DAFNE trial / Carbohydrate Counting
  17. 17. Dietary Education Tools
  18. 18. Dietary education Stage 1 (simple education methods)  Awareness of the basics of healthy eating/ balance of good health  The food pyramid The signal system (healthy food choices) The hand jive The plate model
  19. 19. Dietary education Stage 2 (advanced & require teaching skills) Food Exchange System Carbohydrate Counting Glycemic Index
  20. 20. Healthy Eating Australian Food Guide
  21. 21. Healthy Eating Grain products Vegetables and fruits Milk products Meat and alternatives Canadian Food Guide
  22. 22. Balance of Good Health Bread, cereals & potatoes Milk & dairy products Foods rich in sugars and fat Meat, fish & protein alternatives Fruits & vegetables UK Food Guide
  23. 23. My Food Pyramid (USDA(
  24. 24. Utilizing Interactive Activities for Teaching My Pyramid for Kids
  25. 25. Diabetes Dietary Education Games for Teaching My Pyramid
  26. 26. Signal System The signal system is based on a traffic lights concept:  Red foods (to be taken in small amounts)  those rich in fat  sugars (refined carbohydrate)  high glycemic index foods  low fiber content  Yellow foodsYellow foods (to be taken in moderation)  Moderate glycemic index foods  low fiber content  Green foods (healthy choice)  low glycemic index  high fiber content  low in fat
  27. 27. Healthy versus unhealthy food choices? Food groups Green zone Yellow zone Red zone Rice Steamed or boiled rice Fried rice/biryani Bread Whole wheat bread White bread Croissants and cakes Noodles Steamed or boiled noodles Deep fried noodles Potatoes Baked potato French fries Vegetables Steamed vegetable Sauteed vegetable Deep fried vegetable Salad Green salad Salad with mayonnaise Sauce Tomato based Cream based Chicken, fish & red meat Grilled Pan fried Deep fried
  28. 28. Hand Jive (starch): choose an amount equivalent to the size of 2 Carbohydrates fists.  Fruit: choose an amount equivalent to the size of 1 fist .  Protein: choose an amount equivalent to the size of the palm of your hand and the thickness of your little finger.  Vegetables: choose as much as you can hold in both hands. These should be low carbohydrate vegetables – green or yellow beans, cabbage or lettuce.  Fat: limit fat to an amount the size of the tip of your thumb. Drink no more than 250 ml of low-fat milk with a meal
  29. 29. Plate Model Protein Starch/cereal Vegetable Vegetable Fruit Fat Milk/yoghurt
  30. 30. Advanced Education Tools – Stage 2 Food Exchanges Carbohydrate Counting Glycemic Index
  31. 31. The “Exchange” System Foods with common nutrient values are grouped together. 1 Fat 1 Meat 1 Vegetable 1 Milk 1 Fruit 1 Starch 0 5 10 15
  32. 32. Food exchanges Within groups, a single food based on weight/ measure/ size has the same carbohydrate or Calorie value as another and can be interchanged Cereal exchanges: 1 slice of bread can be exchanged for 1/3 cup rice Foods from different groups cannot be interchanged – 1 slice of bread cannot be exchanged for 1½ tsp of butter
  33. 33. The Exchange Lists1 Groups/ Lists Carb. Protein Fat Calories Carbohydrate Group Starch 15 3 1 or less 80 Fruit 15 ___ ___ 60 Milk Skim Low-fat Whole 12 12 12 8 8 8 0-3 5 8 90 120 150 Other carbohydrates 15 varies varies varies Vegetables 5 2 ___ 25 Meat and Substitute Group Very lean Lean Medium-fat High-fat ___ ___ ___ ___ 7 7 7 7 0-1 3 5 8 35 55 75 100 Fat Group ___ ___ 5 45 1. Exchange Lists for Meal Planning, The American Diabetes Association, The American Dietetic Association, 1995
  34. 34. Counting Carbs Using the Exchange system Breakfast Exchange/# Carb Grams 1 pita bread (4 oz) starch (4) x 15 60g 1 tsp. olive oil fat (1)x0 0g 1 hard boiled egg protein (1)x0 0g 1/2 cup orange juice fruit (1) 15g 6 oz skim milk (3/4) x 12 9g Total Carbs 84g One oz. pita bread 15g carbExample :
  35. 35. Carbohydrate Choices One oz. slice bread Small piece of fruit One cup unsweetened cereal 1 small ear of corn ½ cup of juice One small potato 1 cup of milk 1/3cup rice One oz. pita bread
  36. 36. Carbohydrate Counting
  37. 37. Carbohydrate Counting Defined  A meal-planning approach based on the following ideas  Carbohydrate is the main nutrient affecting postprandial glycemic response  Total amount of carbohydrates consumed is more important than the source of carbohydrates
  38. 38. Meal 1 Hr 2 Hrs 3 Hrs 4 Hrs 5 Hrs 6 Hrs 7 Hrs 8 Hrs Timed Effect on Blood Sugar Levels * In absence of dietary carbs ** may cause insulin resistance in large qty CarbohydrateCarbohydrate: rapid digestion, total absorption/conversion to glucose (100%) Sugar AlcoholsSugar Alcohols: moderate digestion, partial absorption as glucose (50%) Protein…………..Protein…………..slow digestion, partial conversion to glucose* (~40%) Fat………………..Fat………………..slow digestion, little conversion to glucose** (<20%) Bloodglucoselevel
  39. 39. Why Count Carbohydrate? Keeping carb intake consistent at meals from day to day Base for rapid-acting insulin dosing with meals/snacks Allow more flexibility with eating for people with type 1 diabetes Result in reduced post-prandial hyper- and hypoglycemia
  40. 40. Prerequisites The ability & willingness of the diabetics to : Perform basic carb counting Do simple math Use nutrient analysis information, measuring cups, spoons and scales Keep accurate, detailed records: Blood glucose results Carbohydrate eaten Insulin or other meds Physical activity/exercise
  41. 41. Methods for Basic Carb Counting 1. Portion Estimation 2. Food Package Labels 3. Carb factors
  42. 42. Portion Estimation Using Food Models
  43. 43. 1. Portion Estimation Method Examples of 1-cup Carb Estimates: Potato: 40g Pasta: 40g Rice: 50g Rolls: 25g Cereal: 25gCereal: 25g Fruit: 20gFruit: 20g Cooked Vegetables: 10g Salad Vegetables: 5g Milk: 12g Corn: 30g Peas: 30g Beans: 40g Pretzels: 25g Chips: 15g Popcorn: 5gPopcorn: 5g Ice Cream: 35g Cake: 45g
  44. 44. Portion Estimation Method Example: 1 1cup fruit ⇒ 20g carb X 1 ¼ cups ≅ 25g carb
  45. 45. 1cup popcorn ⇒ 5g carb X 4 cups ≅ 20g carb Portion Estimation Method Example: 2
  46. 46. Portion Estimation Method Long Sandwiches 8g carb per inch (2.5 cm) Pizza 30g carb per adult hand-sized piece (fingers together) Cookies 20g carb per adult-sized palm Breaded meat/veg/cheese 4g carb per small (“thumb/nugget sized”) 10g carb large (“patty/palm-sized”)  
  47. 47. 1hand pizza ⇒ 30g carb X 1 1/3 hands ≅ 40g carb Portion Estimation Method Example: 4
  48. 48. 2. Nutrition Facts Label Method Labels are the best resource for carb counting but considering Serving Size Total Carbohydrate Fiber & Sugar Alcohol (if any)
  49. 49. Sugar Alcohols and Carb Counting Artificial Sweeteners Found in sugar free products e.g. chewing gum, mints, jam, ice cream, cookies and candy Digest slowly and partially (∼ 50%) Requires little or no insulin to be metabolized. Can have laxative effect (bloating, gas, diarrhea) if consumed in large amounts.
  50. 50. Comparison of Sweeteners Sweetener Cal per gram Artificial (Aspartame, Saccharin, Splenda) 0 Sugar Alcohols: Erythritol Mannitol Isomalt Lactitol Maltitol Xylitol Sorbitol Hydrogenated starch hydrolysates 0.2 1.6 2.0 2.0 2.1 2.4 2.6 3.0 Glycerine, sucrose, fructose, lactose 4.0
  51. 51. Example: 1 Nutrition FactsNutrition Facts Serving size: 2 piecesServing size: 2 pieces Amount Per ServingAmount Per Serving CaloriesCalories 3.83.8 Calories from Fat 0 Total Fat 0g (0%) Cholesterol 0g (0%) Sodium 0g (0%) Total Carbohydrate 1.6g (1%) Sugars 0g Sugar Alcohol (Xylitol) 1.6g Protein 0g If all carb is from sugar alcohols < 10 grams: FREE food
  52. 52. Example: 2 Nutrition FactsNutrition Facts Serving size: 5 piecesServing size: 5 pieces ( about 16 grams)( about 16 grams) Amount Per ServingAmount Per Serving CaloriesCalories 4040 Calories from Fat 10 Total Fat 1g (2%) Saturated Fat 0.5 g (3%) Trans Fat 0 (0)% Cholesterol 0g (0%) Sodium 70mg (3%) Total Carbohydrate 14g (5%) Sugars 0g Sugar Alcohol (lactitol) 14g Protein 0g (0%) If all carb is from sugar alcohols >10 grams: count ½ of the total carb If serving size = 5 pieces sugar alcohol: 14 g = 7g 2
  53. 53. Nutrition FactsNutrition Facts Serving Size: 1 Tbsp (17g).Serving Size: 1 Tbsp (17g). Servings per Container: 20.Servings per Container: 20. Calories per serv.: 10.Calories per serv.: 10. AMOUNT PER SERVING % DAILY VALUE* Total Fat: 0g 0% Sodium: 20mg 1% Total Carbohydrate: 3g 1% Sugars: 0g Sugar Alcohol: 3g Sorbitol Protein: 0g  If all carb is from number of sources, including sugar alcohols  Subtract ½ of the sugar alcohol grams from the total carb  If 2 servings used = 2Tbsp 6g Carb + 6g sorbitol = 9 g Carb 2 Example: 3
  54. 54. 3. Carbohydrate Factor Method Getting total carb count by: Weighing the portion of food Multiplying the weight by its carb factor* A carb factor is the percentage of the food’s weight that is carbohydrate. The rest is water, protein, fat and minerals.
  55. 55. Apple: 0.13 Apple Pie: 0.32 Carrot (raw): 0.06 Chocolate Cake: 0.51 mixed grain bread: 0.46 White bread: 0.50 Pancake: 0.28 Pizza (cheese): 0.32 Potato, baked: 0.22 Potato Salad: 0 .09 Rice: 0.27 Spaghetti: 0.26 Vanilla Ice Cream: 0.23 Watermelon: 0.06 Carb Factor Examples:
  56. 56. Carbohydrate Factor Method How much carb? is in a baked potato weighing exactly 300 grams? 300 x 0.22g = 66g carb Example: Calculating grams of Carb content
  57. 57. Impact of Fiber in Carbohydrate Counting Included in total carbohydrate Does not convert to glucose Subtract fiber from the Total Carbohydrate
  58. 58. Impact of Fiber Example: 1 Serving size: 13 g Total Carb - 3 g dietary fiber Count as 10 g carb
  59. 59. How Much Carbohydrate is Needed1 Calorie level ~ 1200 ~1400 ~1600 ~1800 ~2400 ~2800 Calorie range 1200-1500 1300- 1600 1400- 1700 1600- 1900 1800- 2300 2200- 2800 Carb grams 180 180 195 210 240 300 Carb choices 12 12 12-13 13-14 15-16 18-20 Grains, beans, & starchy vegetables 6 6 6 7 9 11 Vegetables 3 3 3 4 4 5 Fruits 3 3 3 3 3 4 Milk 2 2 2-3 2-3 2-3 2-3 Meats 2 (4oz) 2 (4oz) 2 (5oz) 2 (5oz) 2 (6oz) 3 (70z) Fats g/servings 40/4 47/5 54/6 60/7 74/9 93/12 1. Practical Carbohydrate Counting, American Diabetes Association, 2001. Calculated as 60% CHO from total calories.
  60. 60. Determining Amount of Carbs per meal Population Carb choices per meal Smaller, older, inactive women 2-4 Older, inactive men 3-5 Smaller, older, inactive men Large, active women trying to lose weight 4-6 Most older men Active women Larger men desiring to lose weight 5-7 Active, younger men 6-8
  61. 61. Advanced Carb Counting For those on insulin (MDI/ Insulin Pump) Adjusts rapid-acting insulin based on carb consumed and physical activity Carb: Insulin Ratio Calculates insulin dose for a specific amount of carbohydrate
  62. 62. The Actions of Insulins1 Insulin Onset Peak Duration  Rapid acting Lispro (Humalog) Aspart (Novolog) <15 min <15 min 0.5-1.5 hrs 0.5-1.0 hr 2-4 hrs 1-3 hrs  Short acting Regular 0.5- 1 hr 2-3 hrs 3-6 hrs  Intermediate NPH lente 2-4 hrs 3-4 hrs 4-10 hrs 4-12 hrs 10-16 hrs 12-18 hrs  Long acting Ultralente Glargine (Lantus) 6-10 hrs 2-4 hrs 10-16 hrs peakless 18-20 hrs 24 hrs 1. Practical Carbohydrate Counting, American Diabetes Association, 2001
  63. 63. Basal insulin Lantus Or Levemir Peak: 0.5-1.0 hour Onset: 15 minOnset: 15 min Duration: 1-3 hrsDuration: 1-3 hrs Peakless 24 hrs Glargine (Novolog) (Novolog) (Novolog)
  64. 64. Example of Carb Counting DAFNE Dose adjustment for normal eating 5 day structured teaching programme Improve diabetes control by matching insulin to carbohydrate. Evidence shows improved HbA1c, reduced severe hypo’s and less hospital admissions from DKA
  65. 65. DAFNE Timetable Monday Tuesday Wednesday Thursday Friday 09.15-09.45 INTRODUCTION 09.15-10.30 Group Discussion: Individual blood glucose levels ` 09.15-10.30 Group Discussion: Individual blood glucose levels 09.15-10.30 Group Discussion: Individual blood glucose levels 09.15-10.30 Group Discussion: Individual blood glucose levels09.45-10.45 WHAT IS DIABETES? 10.45-11.00 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 11.00-12.30 NUTRITION 1 •Identify carbohydrates 10.45-12.30 NUTRITION 2 Putting carbohydrate estimation into practice 10.45-12.30 NUTRITION 3 •Food Packaging •Recipes 10.45-12.30 NUTRITION 4 •Alcohol •Eating out •Healthy eating/ weight control THEORY OF GOAL SETTING 10.45-12.00 ANNUAL REVIEW AND SCREENING 12.00-13.00 QUESTIONS FOR THE DOCTOR GOAL SETTING 12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 13.00 – 14.30 Lunch 13.30-15.00 SELF MONITORING 13.30-15.00 DAFNE INSULIN ADJUSTMENT 13.30-15.00 HYPOGLYCAEMIA (Relatives/partners welcome) 13.30-15.00 PHYSICAL ACTIVITY Walk – weather depending. 14.30-15.00 QUIZ 15.00-15.15 Coffee 15.00-15.15 Coffee 15.00-15.15 Coffee 15.00 – 15.15 Coffee 15.15-16.15 ALL ABOUT INSULIN 15.15-16.15 INSULIN INJECTION TECHNIQUE 15.15-16.15 SICK DAY RULES 15.15-16.15 SOCIAL ASPECTS (Contraception and pregnancy – optional) 15.00-15.30 EVALUATION AND FOLLOW UP 16.15-17.00 Group Discussion: Individual blood glucose levels 16.15-17.00 Group Discussion: Individual blood glucose levels 16.15-17.00 Group Discussion: Individual blood glucose levels 16.15-17.00 Group Discussion: Individual blood glucose levels
  66. 66. Insulin: Carbohydrate Ratio Method # 1: Food dairy, insulin dose, and SMBG information Method # 2: Insulin: Carbohydrate ratio The rule of 500 or 450 Method # 3: Using the insulin sensitivity factor (ISF)
  67. 67. Carb to Insulin Ratio’s Starting point (if new to carb/insulin ratio’s) 1:15 ratio (1 unit rapid acting insulin for every 15 g carb eaten) May need different ratio’s for different meals Example: If 65 g carb for lunch Would need 4 units fast acting insulin coverage at lunch (65 ÷ 15 =4)
  68. 68. Method #1 Food dairy, insulin dose, and SMBG information1,2  Insulin: Carb ratio = Grams of carb at a given meal ÷ number of units of insulin taken at that meal Example  patient needs 4 units of insulin to cover 45g of carbs  Insulin: Carb ratio = 45 ÷ 4 = 11 ⇒ Ratio = 1:11 1. Carbohydrate Counting: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995 2. Practical Carbohydrate Counting, American Diabetes Association, 2001
  69. 69. Method #2 (The 500/450 Rule( The rule of 450 or 5001 keeps post meal readings normal  The 500 rule estimates accurately grams of carb per unit of rapid acting insulin (Humalog or Novolog)  The 450 Rule is used with Regular insulin. Insulin: Carb ratio = 450 or 500 ÷ total daily insulin dose (TDD) Example  TDD = 36 units (Bolus + Basal) Glucose levels are within target range  Insulin: Carb ratio = 500 ÷ 36 = 14 ⇒ Ratio = 1:14 1. Practical Carbohydrate Counting, American Diabetes Association, 2001
  70. 70. Method #3 (The 1800 OR 1600 Rule( Method # 3: Using the insulin sensitivity factor (ISF)1 can be used to bring down high blood sugars  ISF = 1800 or 1600 ÷ TDD  Insulin: Carb ratio = ISF× 0.33 Example  TDD = 25 units (Bolus + Basal)  ISF = 1800 ÷ 25 = 72 (meaning that 1 unit of rapid-acting insulin Hum. or Novolog would drop BG approx. 72 mg/dL)  Insulin: Carb ratio = 72 × 0.33= 24 ⇒ Ratio = 1:24 1. Practical Carbohydrate Counting, American Diabetes Association, 2001
  71. 71. Example  TDD= 34 units  Target BG = 100 mg/dl  Pre-meal BG = 226 mg/dl  60g of carb are to be consumed Answer  ISF = 1800 ÷34 = 53  Difference between target and actual BG = 226 – 100 =126 mg/dl  Units of insulin to decrease high pre-prandial BGUnits of insulin to decrease high pre-prandial BG =126 ÷ 53 = 2.3 units  Insulin: carb ratio • 500 ÷ 34 TDD = 15 • Ratio= 1:15  Units of insulin to cover carb consumed = 60 ÷ 15 = 4 units ⇒ Premeal insulin = 2.3 units + 4 units = 6.3 units (rounded to 6) 1. Practical Carbohydrate Counting, American Diabetes Association, 2001 Correcting Pre-meal Hyperglycemia1
  72. 72. Correcting Pre-meal Hypoglycemia1 Example  Insulin: carb ratio = 1:13 ISF = 35  Carbs to be consumed: 40g Actual BG level = 57 mg/dl  Target BG level = 110 mg/dl Answer # 1: Increase amount of carbohydrate  13g of carbs will raise BG by 35 mg/dl Answer # 2: Decrease pre-meal insulin dose  Amount of insulin to cover carbs= 40 ÷ 13 = 3 units of insulin  Amount of insulin to be subtracted= Difference between target and actual BG levels(110-57) ÷ ISF = 53 mg/dl ÷ 35 = 1.5 units insulin  Pre-meal insulin = 3 units – 1.5 units = 1.5 units Answer # 3: Delay pre-meal insulin 1. Practical Carbohydrate Counting, American Diabetes Association, 2001
  73. 73. Treating Hypoglycemia1 Amount of Carbs BGBG Apple or Orange Juice Grape juice Milk Cola/ Sprite 15 g 51-70 mg/dl51-70 mg/dl 120 ml 90 ml 300 ml 125 ml 20 g 41-50 mg/dl41-50 mg/dl 180 ml 120 ml 420 ml 190 ml 30 g <40 mg/dl<40 mg/dl 240 ml 180 ml 600 ml 250 ml 1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987
  74. 74. Exercise Guidelines Type of Exercise If BG Is: ↑ Carb. Intake by: Suggested Food Short Duration 80-100 mg/dl 10-15 g. 1 fruit Or 1 bread ≥ 100 mg/dl Not necessary ------- Moderate intensity 80-100 mg/dl 25-50 g before exercise then 10-15 g/hr, if necessary ½ meat sandwich + milk Or fruit 80-170 mg/dl 10-15 grams 1 fruit Or 1 bread 180-300 mg/dl Not necessary --------- ≥ 300 mg/dl Don’t exercise -------- Strenuous activity or exercise 80-100 mg/dl 50 g 1 meat sandwich + milk Or fruit 180-300 mg/dl 10-15 g/hr 1 fruit Or 1 bread ≥ 300 mg/dl Don’t exercise -----------
  75. 75. Carbohydrate Counting  Disadvantages  Takes time and practice  Increase in BG testing and need to keep detailed records of blood sugars/foods consumed  Possible weight gain if high calorie foods are eaten  Diet may become unbalanced
  76. 76. Glycemic Index and Load
  77. 77. Gylcemic Index – GI GI value is a ranking (on a 100 point scale) of how quickly 50g of CHO from foods elevates blood sugar levels The higher the number the quicker the CHO enters the bloodstream.
  78. 78. High GI eg: White bread Low GI eg: legumes Time Bloodglucoselevel
  79. 79. Glycemic Index Classification Classification GI Range Examples Low GI 55 or less Most fruits and vegetables (except potatoes, melons & pineapple), grainy bread, brown rice, freekeh, fish, egg, fructose. Medium GI 56-69 Pita bread, Whole wheat products, maftool, quick oats, basmati rice, sweet potato, honey & table sugar High GI 70 or more Flakes, rice krispies, instant oats, popcorn, baked potatoes, short grain white rice, rice noodles, white bread, straight glucose (100) (healthy choice) (to be taken in moderation) (to be taken in small amounts)
  80. 80. GI ExampleExample:: SpaghettiSpaghetti GI = 37GI = 37 Only 37% of spaghetti’s carbs turn into BG in the first 2 hrs. The rest will convert to BG over the next several hrs.
  81. 81. Glycemic Response A measure of the increase in blood sugar after a combination of foods is eaten
  82. 82. Glycemic Load Represent the glycemic impact of more typical portions of foods
  83. 83. High GI foods can be appropriate to treat hypos and for exercise It allows for knowing the proper timing for injecting rapid insulin for quick or slow meals It allows for occasional sweet food after a low GI meal How to use the GI in Practical advice
  84. 84. Quick & Slow Acting Carbs Game for Kids
  85. 85. Which Way to Go Treating Hypoglycemi a educational game for kids
  86. 86. Timing of Rapid Insulin for Quick or Slow Meals 1. Quick acting carb e.g. White roll bread, mashed potato ⇒ inject insulin before meal 2. Slow acting carb High fat &/or high protein slows up rise in BG so for meals such as pizza, pasta, (Freekeh), curry, fish & chips, Large Steak ⇒ inject after eating 3. Combined foods (Slow+ Quick) carb ⇒ inject during meal
  87. 87. How to increase consumption of low GI foods Eat high-fiber breakfast cereals (oats, bran, barley) Add berries, nuts, flaxseed and cinnamon to high GI cereals. OR GI = 60 GI = 42
  88. 88. How to increase consumption of low GI foods GI = 85 GI = 39 Replace white bread with whole grain breads, Watermelons & pineapples with pears & cherries OR Include 5-9 servings of fruits and vegetables every day.
  89. 89. Replace white potatoes with yams or sweet potatoes. OR Just eat smaller portion of high GI potatoes. How to increase consumption of low GI foods GI = 80 GI = 61
  90. 90. How to increase consumption of low GI snacks GI = 83 GI = 14 Replace crackers, Pretzels, Chips, Doughnuts with Fruit, Nuts, Ice Cream & Chocolates Add nuts to high GI breads and crackers. OR
  91. 91. Eat less refined sugars and convenience foods (soda, sweets, desserts, etc.) Combine nuts, fruit, yogurt, dark chocolates, ice cream with commercial sweets – just watch portion sizes. OR GI = 57 GI = 32 How to increase consumption of low GI snacks
  92. 92. Promotes healthy eating Increases fiber intake Helps control appetite Helps control BG levels Helps lower blood lipid levels Assists weight loss Offers a more comprehensive approach for type 2 DM Reduces risk of type 2 DM and heart disease Low glycemic Index Diet – Advantages
  93. 93. Standards of Medical Care in Diabetes  2010 Monitoring carbohydrate intake, whether by carbohydrate counting, exchanges, or experienced- based estimation, remains a key strategy in achieving glycemic control. For individuals with diabetes, use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone. Summery
  94. 94. “Helping others is good, teaching them to help themselves is better.” Thank You George Orwell

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