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MANNY BLUM, 67, is admitted toyour unit with diabetes and a footinfection. While taking his admis-sion history, you ask him about hisdiet at home.

His wife chimes in, Thats whyhes here todayhis diets allwrong. He shouldnt eat fruit, andlast week he even had a piece of our grandsons birthday cake. Mrs.Blum asks you to talk some senseinto her husband. Are you up tothis patient-teaching challenge?

In this article, well review keypoints from the American DiabetesAssociation (ADA) 2006 guidelinesfor medical nutrition therapy fordiabetes. (See Goals of medicalnutrition therapy .) No longer favor-ing prescribed food plans andexchange lists, the ADA now takes

a more flexible approach to mealplanning and places greater empha-sis on patients making choices.Carbohydrates are a primary focus,but well also cover other nutritionguidelines you can teach yourpatient to help him improve hishealth and quality of life.

Carbs are keyYour patient teaching may hold afew surprises for Mr. and Mrs.

Blum. Reassure them that by learn-ing how to plan his own meals,Mr. Blum may be able to controlhis blood glucose levels better thanhe could by simply following aprescribed diet. Explain that nofood, including an occasionalpiece of birthday cake, is off-limitsif he learns how to structure hisfood plan to fit it in.

When you get down tospecifics, explain that of all thefoods we consume, carbohydratesaffect blood glucose levels most.

for DIABETES

Learn about counting

carbohydrates and other

practices your patient can

use to control his blood

glucose levels andmaintain his health.

N U T R I T I O N

all in a days work

BY SHARON A. WATTS, RN-C, CDE, ND,AND JANET ANSELMO, RD, BC-ADM, CDE, MS

N U T R

I T I O N

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Normal amounts of protein and fathave little effect. So emphasize thatthe amount of carbohydrate heconsumes is the key to managinghis diabetes. Maintaining consis-tent carbohydrate intake at eachmeal and over the course of a day

will help him get a more pre-dictable response to his medica-tions and achieve his target bloodglucose levels. For most men, 60 to75 carbohydrate grams per meal isreasonable; 45 to 60 grams isappropriate for most women.

The ADA recommends variousmethods for counting carbs with-out forbidding any particular foods.The patient learns to make educat-ed choices, even choosing to have asweet now and then because heunderstands the implications andadapts his food plan accordingly.

Meals can be planned using sev-eral frameworks: planning by serv-ing size, counting carbohydrategrams, and advanced carbohydratecounting (measuring his blood glu-cose response to insulin and carbo-hydrate action). Heres how theseapproaches compare.

Planning by serving size is prob-ably the simplest approach. Thepatient must be able to identifyfood portions that contain about15 carbohydrate grams and con-sume the appropriate number permeal. This would mean four serv-ings to get 60 carbohydrate gramsor five to get 75 grams per meal.

Whether the 15 grams come in aslice of bread or a small apple, thebody converts the carbohydrates

into about the same amount of glu-cose in approximately the samelength of time. ( Sizing up 15 gramsprovides other examples.)

Counting carbohydrate gramsrelies on tracking the number of available grams indicated on foodlabels and in measured food por-tions to plan the appropriateamount for each meal. Using thismethod, Mr. Blum can choose a2-inch (5-cm) square of birthdaycake (containing 30 grams) andcompensate by not having a large

potato (also 30 grams) with hismeal. Counting grams is a precisemethod that might appeal to some-one taking insulin whos interestedin advanced carbohydrate counting.

Although counting total carbo-hydrates is the most important

nutritional approach to glycemiccontrol, monitoring the glycemicindex (GI) of foods may help yourpatient reduce his hemoglobinA1C level by 0.5% to demonstratethe overall success of his treatment.The type of carbohydrate a food con-tains is reflected in its GI, measuredby its effect on postprandial glucoselevels. High-GI foods include bagels,candy, snack foods, and juice drinks.Low-GI choices include fresh fruitsand vegetables, whole grains, andnuts. (Numerous books and listsindicate the GI of many foods.) Onesimple way to lower the GI of a mealis to replace one high-GI food withone low-GI food.

Advanced carbohydrate count-ing is a method by which someonewho takes multiple daily insulininjections bases dosing on hisinsulin/carbohydrate ratio. Using

his blood glucose levels before and2 hours after meals, he determinesif his mealtime insulin accuratelycompensated for the amount of carbohydrates he consumed. Yourpatient should work with a dia-betes educator to learn the tech-nique. (See Is your patientsinsulin/carbohydrate ratio on track?to learn more.)

Another factor in advanced car-bohydrate counting is fiber content

of foods. When a meal contains5 grams or more of fiber, the num-ber of fiber grams is subtractedfrom the total carbohydrate grams.Fiber-rich foods include legumes,cereals with more than 5 grams of fiber per serving, fruits, vegetables,and whole-grain products.

Looking beyond carbohydratesBecause diabetes is associated withmany complications and risk fac-tors, Mr. Blum needs educationabout additional nutrition factors

he can control to protect hishealth, including fat, alcohol, min-erals, sugar substitutes, and snacks.

Dietary fat provides energy, car-ries fat-soluble vitamins, and pro-vides essential fatty acids, but some

types are less-healthy choices. Forexample, saturated fat and transfatty acids can contribute to plaquebuildup in the arteries, leading tocardiovascular disease. The ADArecommends the following: Limit saturated fat (such as ani-mal fat and coconut and palm oils)to less than 7% of total calories. Minimize intake of trans fattyacids (unsaturated fats withhydrogen addedcommonlyfound in processed foods) toreduce the risk of heart disease.

Sizing up 15 grams These are examples of serving sizes:

apple, 1 small (4 ounces) bran cereals, 1 2 cup bread, 1 slice (1 ounce) cookie, fat-free, 2 small cupcake, no frosting, 1 small ice cream (light), 1 2 cup milk, 8 ounces orange juice, 1 2 cup (4 ounces) potato, mashed, 1 2 cup

rice,1

3 cup cooked saltine-type crackers, 6 sugar or honey, 1 tablespoon yogurt, fat-free, sweetened with

sugar substitute, 1 cup.

Goals of medicalnutrition therapyMeal planning for a patient with dia-betes should aim for the following: Achieve and maintain optimal

metabolic outcomes to prevent orreduce complications.

Modify nutrient intake and lifestyleto prevent and treat obesity, dys-lipidemia, cardiovascular disease,hypertension, and nephropathy.

Improve health through foodchoices and physical activity.

Allow for the patients nutritionaland psychosocial needs and prefer-ences.

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Choose monounsaturated fats (asin olives and nuts) and omega-3polyunsaturated fats (in certainfish, walnuts, and canola oil). Try to consume about 2 gramsper day of plant sterol and stanolesters. When these substances are

added to some fat-containingfoods (such as margarine listingliquid oil as the first ingredientand no trans fats), they blockcholesterol absorption.

Alcohol isnt converted to bloodglucose, but it can pose a risk of hypoglycemia because it blocksglucose release from the liver. Con-suming large amounts can con-tribute to hypertension and elevateblood triglyceride levels. A moder-ate amount is less than one drinkper day for women and less thantwo per day for men so long as thepatient eats his planned meals.Omitting food could trigger hypo-glycemia. Explain that one drink isa 12-ounce beer, 5 ounces of wine,or 11 2 ounces of hard liquor.

A patient with a history of alco-holism or binge drinking shouldnttake metformin (Glucophage) for

type 2 diabetes. Alcohol potentiatesmetformins effect on lactate metab-olism; impaired liver function sec-ondary to alcohol abuse may signif-icantly limit his ability to clear lac-tate, increasing his risk of lactic aci-dosis, a medical emergency.

Minerals play an important rolein many body functions. Becausesodium retention and hypertensionare common with diabetes, yourpatient may benefit from limiting

his sodium intake. Teach himabout hidden sources of sodium,such as canned and processedfoods, and to read food labels tochoose low-sodium foods (140 mgor less per serving). Fresh, frozen,and dried foods contain less sodi-um than canned or conveniencefoods. Low-sodium snacks includevegetables, fruits, and grains.

Other minerals such as calcium,magnesium, and potassium helpcombat hypertension. Vegetables,fruits, and low-fat dairy products

are good sources of these minerals.Sweeteners used to replace 15

carbohydrate grams per tablespoonof table sugar may be natural orartificial. Nutritive sweeteners suchas fructose and sugar alcohols con-tain calories but dont increase post-prandial glucose levels as much astable sugar. The Food and DrugAdministration has approved thefollowing nonnutritive sweeteners: saccharin (SweetN Low) aspartame (Equal, NutraSweet) acesulfame potassium (Sweet

One) sucralose (Splenda) neotame.

Snacking may help preventhypoglycemia, but generally a bed-time snack isnt necessary unlessthe patient takes intermediateinsulin (NPH) at suppertime, hisbedtime glucose level is between110 and 150 mg/dl, or he hashypoglycemia unawareness. Intype 2 diabetes, the liver convertsexcessive amounts of glycogen toglucose at night, so fasting blood

glucose levels are typically elevat-ed and a bedtime snack couldincrease them even more. If yourpatient needs a bedtime snack, 100calories or about 15 grams of car-bohydrate generally prevent devel-opment of hypoglycemia over-

night. A child, an adolescent, or avery active adult may need more.

Off to a good startNow that youve given Mr. Blumthe basics on medical nutritiontherapy, arrange a consult with aregistered dietitian who can givehim more details about meal plan-ning and encourage him and hiswife to attend diabetes classes afterhis discharge. Enjoying food addsto quality of life. By teaching Mr.Blum about the current ADA rec-ommendations, youve started himon the way to more flexibility inmanaging his diabetes.

SELECTED REFERENCESAmerican Diabetes Association. Standards of medical care in diabetes2006. Diabetes Care.29(Suppl. 1):S4-S42, January 2006.

Brand-Miller J, et al. The New Glucose Revolu-tion: The Authoritative Guide to the Glycemic In-dexThe Dietary Solution for Lifelong Health.New York, N.Y., Marlowe & Co., 2003.

Department of Health and Human Services. Foodlabeling nutrient content claims, Definition of sodium levels for the term healthy. Federal Reg-ister. 70(188):56828-56849, September 29, 2005.

Franz MJ (ed). A Core Curriculum for DiabetesEducation, 5th edition. Chicago, Ill., AmericanAssociation of Diabetes Educators, 2003.

Franz MJ, et al. Evidence-based nutrition princi-ples and recommendations for the treatmentand prevention of diabetes and related compli-cations. Diabetes Care. 26(Suppl. 1):S51-S61,

January 2003.

Knowler WC, et al. Reduction in the incidenceof type 2 diabetes with lifestyle intervention ormetformin. The New England Journal of Medi-cine. 345(6):393-403, February 7, 2002.

Warshaw HS, Bolderman KM. Practical Carbo-hydrate Counting . Fairfax, Va., American Dia-betes Association, 2001.

Sharon A. Watts is a nurse practitioner and certifieddiabetes educator at the Skeggs Diabetes Center and

Janet Anselmo is a clinical coord inator in diabeteseducation for the nutrition and food service, both atthe Louis Stokes Cleveland (Ohio) VA Hospital.

Is your patientsinsulin/carbohydrate ratioon track?Insulin/carbohydrate (I:C) ratio is thenumber of insulin units a patientuses to cover the total amount of car-bohydrate he consumes at a meal. If his 2-hour postprandial blood glu-cose level is 180 mg/dl or less, hesusing the right I:C ratio.

Jack Quinn takes four units of fast-acting insulin to cover 60 grams of carbohydrates at a meal (4/60 =1:15 ratio). His blood glucose levelbefore lunch was 100 mg/dl, and his2-hour postprandial blood glucose is140 mg/dl. This indicates that fourunits of insulin adequately covered

the 60 grams of carbohydrate heconsumed at lunch.If Mr. Quinns 2-hour postprandial

blood glucose reading were 250mg/dl, a 1:15 I:C ratio would beinappropriate, and his carbohydratecounting would have to be reevaluat-ed and revised.

SELECTED WEB SITESFood and Nutrition Information Center, NationalAgricultural Library: Diabeteshttp://www.nal.usda.gov/fnic/etext/000013.htmlJoslin Diabetes Center: Carbohydrate Counting:As Easy as 1-2-3http://www.joslin.org/managing_your_diabetes_ 2854.aspLast accessed on May 1, 2006.

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