Kacy Aderhold, MSN, APRN-CNS, CMSRN

Promote and support healthy eating patterns ◦ Attain individualized glycemic, blood pressure, and lipid goals ◦ Achieve and maintain body weight goals ◦ Delay or prevent complications of diabetes

Emphasize a variety of nutrient dense foods in appropriate portion sizes

Address individual needs & barriers to change ◦ Culture ◦ Health literacy ◦ Access to healthy food ◦ Behavioral changes

Maintain pleasure of eating

Provide practical tools for day to day meal planning

(ADA, 2015)

“The goals of Medical Nutrition Therapy (MNT) in the hospital are to optimize glycemic control, to provide adequate calories to meet metabolic demands, and to create a discharge plan for follow-up care. The American Diabetes Association (ADA) does not endorse any single meal plan or specified percentages of macronutrients, and the term “ADA diet” should no longer be used. Current nutrition recommendations advise individualization based on treatment goals, physiologic parameters, and medication usage. Consistent carbohydrate meal plans are preferred by many hospitals since they facilitate matching the prandial insulin dose to the amount of carbohydrate consumed.” (ADA, 2011)

USDA, (2011) www.choosemyplate.gov

Balance calories Make ½ plate fruits &

vegetables Eat whole grains Switch to skim milk Avoid oversized portions Do not skip meals Eat about every 4 hours Choose food low in sodium Drink water instead of

sugary drinks

----------9 inches----------

Fruits: A serving of fruit is 1 small fresh fruit, 2 tbsp dried fruit, or ½ cup canned fruit or 4 oz unsweetened fruit juice

Vegetables: Choose nonstarchy vegetables, such as broccoli, carrots, cauliflower or green beans

Grains: Fill ¼ of the plate with a bread, cooked grain, or starchy vegetable such as corn, brown rice, or potatoes. Choose whole grains more often.

Dairy: Add 1 cup fat-free/low-fat milk or 2/3 cup fat-free/low-fat/light yogurt

Protein: Fill this ¼ of the plate with lean meat, poultry, or fish. If you choose a plant-based protein such as dried beans, consider the carbohydrate content as part of your total carbohydrate for the meal.

A healthy meal plan for patients with diabetes has foods from all major food groups (including carbs).

Carbohydrates raise blood glucose levels the most, but are an important part of a healthy meal plan.

Allows for variable intake and extra foods eaten between meals

Carbohydrates ◦ Have a significant effect on post-prandial blood glucose ◦ Equal amounts of carbs will have a similar impact on blood

glucose regardless of the source. ◦ Carbs are found in fruits, starchy vegetables, grains, milk,

yogurt, sweets, & sodas. ◦ Recommended carbs come from fruits, vegetables, whole

grains, legumes, and low-fat dairy

Fiber ◦ Adds bulk to meals and helps us feel fuller longer ◦ Beans, whole grains, brown rice, popcorn, nuts, baked

potato skin, berries, oatmeal, bran, vegetables ◦ If a food contains more than 5 gm of fiber, you can subtract

½ of the amount of fiber from the total grams of carbohydrate

15 grams of carbohydrate = 1 carb serving ◦ 1 cup milk (8oz) ◦ 1 small piece of fruit ◦ 1 slice of bread ◦ 1/3 cup cooked rice or pasta ◦ 4 oz. fruit juice or regular pop ◦ 2 small cookies

For most women, 45-60 grams of carbs (3-4 servings)

at each meal works well with 15 grams (1 serving) for snacks

For most men, 60-75 grams of carbs (4-5 servings) at each meal works well with 15-30 grams (1-2 servings) for snack

Carb Counting Video

Patients need to Look at 2 Things to Count Carbs

Serving Size or how many servings are in one bag/container

Total carbohydrates Remember you are teaching survival skills. The patient will need to follow up with a dietician after discharge.

If patients are carb counting, they need to know which foods to count. Typically, patients will need to count starchy carbs, fruits, milk, and sweets/desserts. Foods patients can consider “free” are proteins/meats, fats, and non-starchy vegetables like broccoli and spinach.

Remember you are teaching survival skills. The patient will need to follow up with a dietician after discharge.

Mealtime insulin is ordered as follows: 1 unit of Novolog (aspart) per 15 grams of carbohydrate with meals. The patient eats the following meal:

Ham Sandwich w/ mayo ____

Small banana ____

4 oz fruit juice ____

How much insulin would you give?

4 Units

Educate patient and family to report if anyone other than the patient ate anything on their tray.

Educate patient and family to report any extra food or beverages patient consumes.

When carb counting, don’t forget to include snacks and beverages.

Carb counting is not just for meal time.

Insulin must be given for these additional carbs in order to maintain euglycemia.

If only dosing for meals, BG fluctuations can occur.

Fat

◦ Limit saturated fat

◦ Fat has little effect on post prandial glucose

◦ Minimize trans fats to reduce risk of CV disease

◦ Two or more servings fish per week recommended

Cholesterol

◦ Limit cholesterol to less than 200 mg/day

Does not raise plasma glucose, but does stimulate insulin response

Should not be used to treat or prevent hypoglycemia

High protein diets generally not recommended

Chronic Kidney Disease ◦ Reduced protein diet may be beneficial for improving

kidney function in patients with kidney disease

Cardiovascular Disease ◦ Diets high in fruits, vegetables, whole grains, and nuts

may reduce risk.

Congestive Heart Failure ◦ Sodium less than 1500-2000 mg/day may reduce

symptoms

Hypertension ◦ 1500 mg/day sodium and a diet high in fruits,

vegetables, and low-fat dairy products lowers blood pressure

(Lustig, 2012)

Decreased appetite or no oral intake

Nausea/vomiting

Delayed meals/inconsistent meal timing

Inconsistent carbohydrate intake

Decreased activity level

Sudden interruption of either parenteral (TPN) or enteral (TF) nutrition.

Inadequate coordination of FSBS checks, meal tray delivery & insulin injections

NPO patients may still require basal insulin

Snacks are not mandatory for all patients-should be based on needs, preferences, medications

Provider who will manage DM after discharge

Assess need for HH or outpatient DM education ◦ Diagnosis

◦ SMBG & home goals

Information on consistent eating patterns

When & how to take BG lowering medications

Sick day management

Proper use & disposal of needles & syringes

(ADA, 2014)

ADA/ACC (2010). Choose to Live; Your Diabetes Survival Guide Ediba Diabetes Center of Excellence (2007). Diabetes Today: An update for health

care professionals. Moghissi, E., Korytkowski, M., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I.,

Inzucchi, S., Ismail-Beigi, F., Kirkman, S., & Ummpierrez, G., (2009). American association of clinical endocrinologists and american diabetes association consensus statement on inpatient glycemic control. Endocrine Practice, 15 (4). 1-17.

American Diabetes Association (2011). Clinical practice recommendations. Diabetes Care, 34 (1), S46

American Diabetes Association. Standards of Medical Care in Diabetes—2010 (Position Statement). Diabetes Care, 33(1), S11-S61

American Diabetes Association. Nutrition recommendations and interventions for diabetes. (Position Statement). (2008). Diabetes Care, 31(Suppl.1), S61-S78.

Gallagher Allred, C. R., Voss, A. C., Finn, S. C., & McCamish, M. A. (1996). Malnutrition and clinical outcomes: The case for medical nutrition therapy. Journal of the American Dietetic Association., 96(4), 361-369.

McKnight, K., and Carter, L. (2008). From trays to tube feedings: Overcoming the challenges of hospital nutrition and glycemic control. Diabetes Spectrum, 12(4), 233-240.