Practical Dietary Prescription for Ambulatory Diabetic Patient

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Practical Dietary Prescription for Ambulatory Diabetic Patient

  1. 1. 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
  2. 2. 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
  3. 3. How do I effectively set nutrition goals with a person who has diabetes? Issue 1
  4. 4. 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.
  5. 5. Behavioral Goal Setting • Less clinically focused but individualized • Purpose: establish realistic target behaviors → evaluate patient success in making lifestyle changes Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  6. 6. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  7. 7. 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? Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  8. 8. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  9. 9. 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 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. M T W T F S S M T W T F S S M T W T F S S M T W T F S S Notes:______________________________________________________ ____________________________________________________________ Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  10. 10. What should my priorities be when I’m providing initial MNT to a newly-diagnosed person with type 2 Issue 2 diabetes?
  11. 11. 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) Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  12. 12. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  13. 13. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  14. 14. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  15. 15. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  16. 16. 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?
  17. 17. What are the available meal Issue 3 planning approaches?
  18. 18. Idaho Plate Method Milk or or yogurt Empty Starch Breakfast Brown et al Diabetes Spectrum 2001
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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)
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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)
  29. 29. 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)
  30. 30. 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) Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  31. 31. 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
  32. 32. What are some indicators that carbohydrate counting will be helpful? Issue 4
  33. 33. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  34. 34. Choose CHO counting if the patient 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  35. 35. Choose CHO counting if the patient 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.” Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  36. 36. Choose CHO counting if the patient 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! Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  37. 37. Choose CHO counting if the patient 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  38. 38. Choose CHO counting if the patient 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  39. 39. Choose CHO counting if the patient 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. Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  40. 40. Choose CHO counting if the patient reports unexplained problems with hypoglycemia, hyperglycemia or both Meal plan should match the medication schedule Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  41. 41. Choose CHO counting if the patient is unable to correctly identify single portion sizes of CHO foods that they use regularly Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  42. 42. Choose CHO counting if the patient uses insulin, but makes no adjustments for hyperglycemia and/or hypoglycemia Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  43. 43. Choose CHO counting if the patient is looking for a fresh approach to diabetes meal planning Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  44. 44. Choose CHO counting if the patient has poor diabetes control (HbA1c >8%) Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  45. 45. What are the most important skills to teach people for eating away from home? Issue 5
  46. 46. 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. Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  47. 47. Teaching point about restaurant food Ask if they can decrease the number of times per week they eat away from home Dok, araw araw ako sa Jollibee! Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  48. 48. Teaching point about restaurant food 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. Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  49. 49. Why is portion control important and what are the concepts and skills to convey to Issue 6 patients about it?
  50. 50. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  51. 51. Teaching point for portion control at home When purchasing produce (fruits, vegetables, starches), buy the smallest ones Look for small apples, bananas and potatoes. Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  52. 52. Teaching point for portion control at home Use smaller plates, such as a lunch-size plate Large dinner plates promote overfilling and overeating. Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  53. 53. Teaching point for portion control at home 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! Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  54. 54. Teaching point for portion control at home 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. Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  55. 55. Teaching point for portion control at home If the habit of eating seconds is difficult to break, consider splitting the portions into two servings - firsts and seconds Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  56. 56. Teaching point for portion control at home Weighing and measuring foods at home trains the eyes to estimate portions when eating restaurant food Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  57. 57. 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  58. 58. Teaching point for portion control at the restaurant Order small menu items junior single queen regular petite kiddie Do not upsize portions; do not go for deals or bargains that promote overeating! Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  59. 59. Teaching point for portion control at the restaurant 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 Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  60. 60. Teaching point for portion control at the restaurant 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. Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
  61. 61. 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
  62. 62. What are the most important elements of the food label and what concepts should we teach the patients about it? Issue 7
  63. 63. 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, at least 25% less than Salt <5 mg Na/serving very low regular version 35 mg or less at least 25% less than 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
  64. 64. Orient patient to the elements of the food label
  65. 65. 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
  66. 66. Dok, ilang pieces ba ng Oreo ang 34 g?
  67. 67. 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

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