Clinical Diabetes
25:101-103,
2007
DOI: 10.2337/diaclin.25.3.101
© 2007 by the American Diabetes Association
Nutrition 911: The First Responders' Guide to Food and Diabetes
Dianne L. Davis, RD, LDN, CDE and
Rebecca P. Gregory, MS, RD, LDN, CDE
 |
Introduction
|
|---|
Although benefits of medical nutrition therapy (MNT) in the
management of diabetes have been well established, lack of time to address
nutrition or the many other diabetes self-management tasks is an obstacle for
most physicians. This article offers some simple strategies for physicians to
use to address nutrition with both type 1 and type 2 diabetes patients before
they are able to see a registered dietitian (RD).
|
Why Weight Loss Is not Always enough for Patients With Type 2 Diabetes
|
|---|
Weight loss is not always enough to bring blood glucose values into target
range. There are several potential reasons:
- If loss of β-cell function is severe, weight loss is unlikely to
compensate.
- Weight loss does not address postprandial blood glucose excursions.
- Many patients have failed at weight loss or the maintenance of weight loss
and need success to build confidence.
Although weight loss is important for a variety of reasons, asking patients
who have made multiple unsuccessful attempts at long-term weight loss to again
attempt dieting can be frustrating for both patients and physicians. Patients
with a poor weight loss track record may tune out additional weight loss
advice. Changing the focus from losing weight to controlling carbohydrate
intake may allow this type of patient to gain success and build
confidence.
|
Initial nutritional counseling for Patients With Type 2 Diabetes
|
|---|
Identifying and reducing excessive carbohydrate intake may reduce
postprandial glucose excursions. High postprandial blood glucose has been
shown to be an independent risk factor for cardiovascular disease; targeting
it has been shown to improve blood glucose control. To assist patients in this
goal:
- Help patients identify large servings of juice or milk, carbonated
beverages, pasta, bread, cereal, potatoes, or other carbohydrate foods
(Table 1).
- Encourage them to make substitutions, such as lean protein and nonstarchy
vegetables, to increase meal volume. As patients increase their intake of
nonstarchy vegetables, their intake of calories, fat, and sodium will
decrease. Because this approach is not perceived as a diet, it is often more
readily adopted by patients.
- Reassure patients that carbohydrates are a vital part of a healthful diet,
but remind them that when and how much they consume are also important. The
American Diabetes Association (ADA) nutrition recommendations state that,
"sucrose-containing foods can be substituted for other carbohydrates in
the meal plan or, if added to the meal plan, covered with additional insulin
or glucose-lowering medications. Care should be taken to avoid excess energy
intake. A dietary pattern that includes carbohydrates from fruits, vegetables,
whole grains, legumes, and low-fat milk is encouraged for good
health."
- Review self-monitoring of blood glucose (SMBG) results to determine a
carbohydrate threshold (i.e., how much carbohydrate a patient can eat at a
given meal or snack without experiencing excessive postprandial glucose
excursions). This can be an indirect measure of a patient's β-cell
responsiveness.
|
SMBG and Patients With Type 2 Diabetes
|
|---|
Targeted SMBG may give patients great insight while introducing the value
of regular blood glucose monitoring. Patients who perform SMBG can often
discover for themselves the results of carbohydrate overconsumption and make
self-directed changes in their diet and exercise. To encourage patients to
perform SMBG:
- Ask patients to check their blood glucose 2 hours after beginning their
meal to catch the peak postprandial blood glucose response. The ADA 2-hour
postprandial target is < 180 mg/dl.
- To minimize the number of tests patients must perform, suggest that they
begin testing and recording results immediately before and 2 hours after one
meal for 2-3 consecutive days. Then have them perform the same testing at a
different meal for the same number of days. Finally, have them perform the
same testing at the third meal of the day. Varying the timing of SMBG, as
shown in Table 2, will provide
a wealth of information about postprandial blood glucose control without
requiring six or more checks per day.
This approach allows patients to see the value of SMBG and to feel invested
in any necessary changes in their eating patterns. It will also provide
guidance for the RD regarding which meals need to be addressed. Finally,
maintaining a consistent carbohydrate intake while performing targeted SMBG
can help identify the appropriate amount of carbohydrate for a particular
patient to include in each meal.
|
Nutritional considerations for Patients With Type 1 Diabetes
|
|---|
A physiological insulin regimen, which includes separate basal and prandial
components, allows patients to adjust their insulin doses to match their
carbohydrate intake and physical activity and thus provides more flexibility
in carbohydrate intake from meal to meal and day to day without compromising
blood glucose control. Adjusting prandial insulin doses based on the
carbohydrate content of a meal can facilitate tighter postprandial blood
glucose control. Referring patients with type 1 or insulin-requiring type 2
diabetes who use a multiple daily injection regimen to an RD to learn
carbohydrate counting can help them control meal-mediated fluctuations in
blood glucose and normalize their eating habits.
Patients whose insulin regimen involves fixed doses of short- and
intermediate-acting insulin need to achieve day-to-day consistency in
carbohydrate intake. Referring these patients to an RD for help in adopting a
consistent-carbohydrate diet can decrease their risk of hyper- and
hypoglycemia. Matching each meal's insulin dose to a patient's preferred
carbohydrate intake increases the likelihood that the patient will adhere to
carbohydrate targets.
|
Preparing Patients for an RD Visit
|
|---|
Achieving and maintaining nutrition-related goals takes the coordinated
effort of a team. The team may be a specialty diabetes practice or may include
only a physician, an RD, and a patient. Physicians play a crucial role in
patients' success, by making timely referrals to an RD and by reinforcing the
importance of MNT to patients. A positive approach from physicians can have a
positive influence on patients' ability to achieve adequate blood glucose
control. The way MNT is introduced can influence patients' success and may
increase their likelihood of following through with their RD appointments.
Most patients are initially afraid of seeing an RD and worry that they will
not be able to follow their recommended diet or meal plan. Physicians can
instill confidence by assuring patients that the RD will help them control
their diabetes through simple changes in their eating habits. To support
patients' dietary changes and ease their concerns:
- Advise patients not to attempt too many lifestyle changes at one time. At
diagnosis, patients must change several other behaviors simultaneously, such
as starting new medications, monitoring their blood glucose, and beginning an
exercise program. Encouraging gradual dietary changes will allow them to see
improvement in glycemic control while they gain confidence in their ability to
positively affect their medical condition.
- Provide simple, practical, tangible steps that focus on behavioral goals
("I will walk for 15 minutes, three times each week") rather than
weight loss goals ("Let's shoot for losing 10 pounds over the next 3
months").
- Research has shown that diabetes patients who have no outpatient education
have more than a fourfold increased risk of developing complications than
those who do receive education. Early referral to an RD soon after diagnosis
can help patients achieve better glucose control, decrease their risk of
complications, and develop positive self-management behaviors at the
outset.
- Prepare patients for a positive encounter with the RD by explaining that
they will learn how to eat in a way that is satisfying, includes their
favorite foods, and helps to control their blood glucose.
MNT is a foundation of diabetes care. Positive messages from physicians
regarding its importance are the first step in building a good foundation for
diet-related behavior change for patients with diabetes.
|
Footnotes
|
|---|
Dianne L. Davis, RD, LDN, CDE, is a research and clinical dietitian,
and Rebecca P. Gregory, MS, RD, LDN, CDE, is the nutrition coordinator at the
Vanderbilt University School of Medicine Diabetes Research & Training
Center in Nashville, Tenn.
 CiteULike  Del.icio.us  Digg  Reddit  Technorati What's this?
|
|
|
Top
Introduction
Why Weight Loss Is...