Practical Dietary Prescription for Ambulatory Diabetic Patient

Practical Dietary Prescription for the Ambulatory Diabetic Patient

Gabriel Jasul Jr. MD, FPCP, FPSEMIris Thiele Isip Tan MD, FPCP, FPSEM

PSEM Updates2 August 2009

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?

Issu

e 1

Goal Setting in Diabetes

Behavioral goalsAssist in changing a person’s lifestyle

Diabetes Management

Clinical parameters: HbA1c, lipids, BP, BMI

Education

Self-management training

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


•Be sensitive to need for flexibility and structure

•Guide, but encourage independent self-care

Behavioral Goal Setting

• Goals are established by mutual agreement- Patient will “own” the goals

and become committed


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


GOALSThings I will do to improve my eating behaviorCheck off each day you meet your goal.

M T W T F S S M T W T F S S


Goal 1. Eat breakfast, lunch and dinner everyday.

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 diabetes?

Issu

e 2

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


Di puwede ang kanin!Okay lang ang tinapay.

Bawal softdrinks!Di ba juice puwede basta unsweetened?

Bawal ang karne!

Skyflakes at oatmeal na lang kinakain ko, Dok.

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


Dok, ano ba talaga ang bawal at puwedeng kainin?

Di na ba talaga puwede ang kanin?

Diet coke, ok lang? Eh, Milo?

Di naman nakakapili ng pagkain sa barko, Dok!

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


Sa hapon merienda ko kanin, minsan noodles.

Kape lang ako sa almusal, bawi na lang sa tanghalian.

Hindi ako nagme-merienda sa umaga.

Malakas talaga ako sa kanin, Dok!

• Set individualized goals for eating behavior change

- As opposed to providing a calculated calorie prescription and giving a structured meal plan

Start with what the patient is currently eating


•Eat something in

the first 2 h of the day

•Eat 25% less CHO at dinner

•Walk for 10 minutes after eating a meal

• 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

Nutrition Education Priority in T2DM


Meal Planning

• Ht 5’6” Wt 165 lbsIdeal weight for height: 112 lbs + (6 x 4) = 136 lbs or 62 kg

• Physically active if on sea dutyTCR = 62 kg x 40 kcal = 2480 - 500 = 1980 ... 2000 kcal/dayActivity: 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 planning approaches?

Issu

e 3

Idaho Plate Method

Breakfast

Starch

Milk or

or yogurtEmpty

Brown et al Diabetes Spectrum 2001

Idaho Plate Method

*1/2 cup pudding or ice cream

*

Lunch/Dinner9-inch plate


provides 1200-1500 calories

Plate method works well for the following:

Eat 3 meals a day (move

side items to snack time)

Low literacy level or have

cognitive difficulties

Works well when eating outside the home

Does not require math skills or high reading level

✓elderly✓need to lose

weight✓hospitalized

needing “survival” information

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


Diabetic Exchanges

Starch Meat/meat substitutes

Non-starchy vegetables

FatsFruit Milk

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

Diabetic ExchangesStarch Meat/meat

substitutesNon-starchy vegetables

FatsFruit Milk

• 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 ListLeafy vegetables

1 cup raw or 1/2 cup cookedNon-leafy vegetables

1/2 cup raw or cookedalugbati leaves ampalaya fruitbaguio beansbamboo shootbanana heartbataw podsbeetscabbagecauliflowercamote leavescelery

chayote fruitchayote leavescucumbereggplantgabi leaveskangkongkaturay flowers lettucemalunggay leavesmushroom freshmustard leavesokra

onion bulbpakopapaya greenpatolapepper leavespetsayradishsaluyotsigarilyas podsstringbeanstomatoupo

carrotscoconut shootcowpea podsjackfruitlima bean podsmungbeans sprout

pigeon pea podsrimassingkamas podssingkamas tubersquash fruitstring beans pod

Non-leafy vegetables Processed

asparagus tips 1 cupbaby corn 2 pcs (8 cm long, 5 1/2 cm circumference each)green peas 1 tbspgolden sweet corn 2 tbspmushroom 1/3 cuptomato juice 1/2 cup undilutedwater chestnut 3 pcs (2 cm dia each)

Fruit Exchange ListFruits high in Vitamin C Other Fruits

Anonas 1/2 of 5x8 cm diameterAtis 1 pc (5 cm diameter)Dalanghita 2 pcs (6 cm diameter each)Datiles 1 cupGuava 2 pcs (4 cm diameter each)Guyabano 1 slice (8x6x2 cm) or 1/2 cupKamachile 7 podsMango green 1 slice (11x6 cm) Mango ripe 1 slice (12 x 7 cm) or 1/2 cupPapaya ripe 1 slice (10x5x2 cm) or 3/4 cupStrawberry 1 1/4 cupSuha 3 segments (8x4x3 cm)Tiesa 1/4 of 10 cm diameter

Apple 1/2 of 8 cm diameterBanana 1 pc (9x3 cm)Chico 1pc (4 cm diameter)Duhat 20 pcs (2 cm diameter each)Durian 1 segment of 6 1/2 x 4 1/2 cm or 1 1/2 tbsp)Grapes 10 pcs (2 cm diameter each) or 4 pieces (3 cm dia)Jackfruit, ripe 3 segments (6 cm diameter each)Lansones 7 pcs (4 x 2 cm each)Lychees 5 pcs (3 cm diameter each)Macopa 3 pcs (4 cm diameter each)Melon 1 slice (12x10x3 cm) or 1 1/3 cupsPear 1 pc (6 cm diameter)Pineapple 1 slice (10x6x2 cm) or 1/2 cupRambutan 8 pcs (3 cm diameter each)Santol 1 pc (7 cm diameter)Sineguelas 5 pcs (3 cm diameter each)Starapple 1/2 of 6 cm diameterWatermelon 1 slice (12x6x3 cm) or 1 cupJuice 1/3 cup unsweetened

Prunes 3 pcs unsweetenedBuko water 1 cupBuko meat 1/2 cupMangosteen 3 pcs (6 cm diameter each)Tamarind, ripe 2 of 6 segments each

Milk Exchange ListWhole milkMilk, evaporatedMilk, freshMilk, powdered

1/2 cup undiluted1cup4 level tbsp

Low fat milkPowderedLight low fat milk

1/4 cup or 4 level tbsp1 tetra brick

Skimmed (nonfat)Buttermilk:

LiquidPowdered

2/3 cup1/4 cup or 4 level tbsp

Longlife skimmedMilk

Yogurt1 cup1/2 cup

Rice Exchange List

Rice 1/2 cupLugaw 1 cupSuman sa ibos 1 pc (8x4x2 cm)Pan americano 2 slices (9x8x1 cm)Pan de sal 2 pcs (7x4 cm)Pan de limon 1 pc (6x5x4 cm)Rolls 1 pc (11x4x3 cm)Wheat bread 2 pcs (11 1/2x8x1 cm each)Galyetas de patatas 10 pcs (4x4x1/2 cm diameter each)Binatog 1/2 cupCorn, boiled 1 pc (12x4 cm)Corn flakes 1 cupCorn canned 1 cup

Noodles (bihon, macaroni, sotanghon, spaghetti) 1 cupSweet potato 1/2 of 11 cm long x 4 1/2 cm diameterCassava 1 pc (5 cm long x 4 1/2 cm diameter)Potato 2 pcs (1/2 of 7 cm long x 4 cm diameter)Chestnut 11 pcs large or 20 smallCrackers 8 pcs (5x4x1/2 cm)French fries 1 cupOatmeal, cooked 1 cup, thick consistencyPopcorn plain 2 cupsSkyflakes 4 pcs

Meat Exchange ListLean Meat

Lean beef, carabeef, chicken 1 slice, matchbox size (5x 3 1/2 x 1 1/2 cm)Lean pork 1 slice matchbox size (6 1/2 x 3x1 1/2 cm)Chicken leg small (13 1/2 cm long x3 cm diameter)Chicken breast 1/4 (6 cm long)Liver, blood, gizzard, heart, lungs, small intestines, spleen, tripe 3/4 cupFish 1 slice (18x 4 1/2 cm)Alamang 1 1/4 tbspAlimango, alimasag meat 1/4 tbsp or 1/2 pc mediumLobster 2 tbspsShrimps 5 pcs (12 cm each)Prawns 2 pcs (13 cm each)Squid 3 pcs (7x3 cm each)

Halaan 1/3 cup shelled or 3 cups with shellKuhol 1/2 cup shelled or 2 cups with shellMonggo 1/2 cupCottage cheese 1/3 cupVegemeat 1 1/2 slicesDaing 1 pc mediumFishball 6 pcsTinapa, bangus 1/4 of 20 x 8 cmTuyo (sapsap, tunsoy) 3 pcs (11 1/2 x8 cm)Dried pusit 1 pc (8x1 cm)Salmon, canned 1/3 cup flakedTuna in brine/water 1/3 cup flakedTocino lean w/o sugar 1 slice (11x4x 1/2 cm)

Medium Fat MeatBeef (flank, brisket plate, chuck) 1 slice, matchbox size (5x 3 1/2x 1 1/2 cm)Pork, pata 1 slice (4 cm diameter x 2 cm thick)Brain (beef, pork, carabeef), 3/4 cupFish 1 sliceChicken egg 1 pcQuail’s egg 9 pcsCheddar cheese, 1 slice (6x3x2 cm)Soybean (utaw) 1/2 cupSardines, canned in oil/tomato sauce, 1 pcTuna sardines 1 1/2 of 6x4x3 cmTofu 1/2 cupTokwa 1 pc (6x6x2 cm)Corned beef 3 tbsps

Fat Exchange ListSaturated

Bacon, 1 strip 10x3 cm

Butter, coconut oil, margarine, mayonnaise 1 tbsp

Coconut cream, cream cheese, sandwich spread, whipping cream 1 tbsp

Sitsaron 2 pcs (5x3 cm each)

Polyunsaturated

Oil (corn, soybean, safflower, sesame, rapeseed canola, sunflower) 1 tsp

Monounsaturated

Avocado 1/2 of 12x7 cm

Peanut, olive oil, shortening 1 tsp

Butong pakwan 1 tbsp

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 gVegetables 1/2 cup - 1 cup 16 3 1 0Fat-free or very low fat milk 3/4 - 1 cup 80 12 8 0

Lean protein varies 41 0 8 1Medium fat protein varies 86 0 8 6High fat protein varies 122 0 8 10Fruits varies 40 10 0 0Rice varies 100 23 0 0Fats 1 tsp - 1 tbsp 45 0 0 5

What are some indicators that carbohydrate counting will be helpful?

Issu

e 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


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


Choose CHO counting if the patient is frustrated with or confused by perceived dietary restrictions on sweets and desserts

Di ko makain ang gusto ko!

Bawal lahat ng matamis!

“Sucrose-containing food can be substituted for other CHO in the meal plan or if added to the meal plan, covered with insulin or other glucose-lowering medication. Care should be taken to avoid excess energy intake.”

ADA Recommendation


Ok lang kahit marami ang makain, basta sugar free!

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)


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


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


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.


Choose CHO counting if the patient reports unexplained problems with

hypoglycemia, hyperglycemia or both

Meal plan should match the medication schedule


Choose CHO counting if the patient is unable to correctly identify single portion sizes of CHO foods that they use regularly


Choose CHO counting if the patient uses insulin, but makes no adjustments for

hyperglycemia and/or hypoglycemia


Choose CHO counting if the patient is looking for a fresh approach

to diabetes meal planning


Choose CHO counting if the patient has poor diabetes control (HbA1c >8%)

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

Issu

e 5

Teaching point about restaurant foodAcknowledge the pitfalls: portions, fat and

sodium content, large servings of meat. Use the meals they typically eat to demonstrate.


Teaching point about restaurant foodAsk if they can decrease the number of

times per week they eat away from home


Dok, araw araw ako sa Jollibee!

Teaching point about restaurant foodHelp 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 patients about it?

Issu

e 6

Teaching point for portion control at homeAdvise 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


Teaching point for portion control at homeWhen purchasing produce (fruits,

vegetables, starches), buy the smallest ones

Look for small apples, bananas and potatoes.

Teaching point for portion control at homeUse smaller plates, such as a lunch-size plate


Large dinner plates promote overfilling and overeating.


Teaching point for portion control at homeDo not prepare too much food

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

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


Teaching point for portion control at homeDo not place bowls, pots or casserole pans on the table within easy reach.

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


Teaching point for portion control at homeIf the habit of eating seconds is difficult to break, consider splitting the portions

into two servings - firsts and seconds


Teaching point for portion control at homeWeighing and measuring foods at home trains the eyes to estimate

portions when eating restaurant food


giantgrande

supremeextra large

jumbodoubletriple

double-deckerking-size

super

Teaching point for portion control at the restaurantDo not order large servings unless you plan to split them


juniorsinglequeen

regularpetitekiddie

Teaching point for portion control at the restaurantOrder small menu items

Do not upsize portions; do not go for deals or bargains

that promote overeating!


Teaching point for portion control at the restaurantBe 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


Teaching point for portion control at the restaurantUse 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

Handful = 1 cup

Palm = 3 oz

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?

Issu

e 7

Nutrient Claims and % Daily Value

Free Low ReducedCalorie <5 cal/serving <40 cal/serving

Fat <0.5 g fat or saturated fat/serving

3 g or less of total fat

Saturated fat <0.5 g saturated fat or trans fat 1 g or less at least 25% less than

regular version

Sugar <0.5 g/serving at least 25% less than regular version

Salt <5 mg Na/serving140 mg Na or less,

very low 35 mg or less

at least 25% less than regular version

Cholesterol <2 mg/serving 20 mg or less at least 25% less than 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

The Serving Size

(#1 on sample label):

The first place to start when you look at the Nutrition Facts label is the

serving size and the number of servings in the package. Serving sizes are

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?

Thank Youwww.endocrine-witch.info

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.


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Health & Medicine

Practical Dietary Prescription for Ambulatory Diabetic Patient