Helping your patient with diabetes manage his diet

By Carole Yass, MS, RD, CDE and
Jamie Dillinger RN, MSN, CDE
Principals,
Diabetes Educators, Inc.

Imagine these four scenarios:

Mrs. Smith
Having learned during morning rounds that this patient has diabetes, you walk into her room after lunch and notice she ate all the food on her lunch tray. You also notice that it was a "regular" tray.

Mr. Jones
You walk into his room and note that he's consumed a fruit platter that his neighbors sent him. Mr. Jones has had Type 1 diabetes for 10 years.

Mrs. Rogers
At 10 p.m., you find that Mrs. Rogers' blood glucose level is 181 mg/dl. You administer her bedtime medication. Some 30 minutes later, you realize that her bedtime snack is still in the refrigerator.

Mr. Ogilvy
Having just been diagnosed with diabetes, this patient is ready for discharge. As he gets ready to leave, he informs you that he's going to the supermarket to purchase only dietetic or sugar-free foods.

Was Mrs. Smith in trouble? Did you think that Mr. Jones understood his diet management for diabetes? Did you wake Mrs. Rogers to have her eat her bedtime snack? Finally, did you reinforce Mr. Ogilvy's understanding about food selection?

In helping your patient with diabetes, you have to take many factors into consideration.
Among the most important ones are meal planning and understanding new nutrition guidelines. In this article, we'll provide some of the latest information in these crucial areas.

Reinforcing nutrition concepts
In June 1993, the American Diabetes Association released the findings of the Diabetes Control and Complication Trial (DCCT). The study showed tight blood glucose control reduced the complications of diabetes, including retinopathy (reduced by 60%); neuropathy (reduced by 60%); and nephropathy (reduced by 56%). The study also magnified the importance of nutrition management in diabetes.

Historically, physicians and nurses relied on dietitians to instruct patients in this area. However, you need to reinforce nutrition concepts to promote tight blood glucose control, which can reduce the risks for complications of diabetes.

Carbohydrate counting, one meal planning approach used in the DCCT, has gained widespread acceptance across the United States. In 1994, the Diabetes Nutrition Recommendations gave priority to the total amount of carbohydrates, rather than the source of carbohydrate.

As you know, carbohydrates are the main factor to affect postprandial blood glucose levels. Each gram of carbohydrate has the potential to raise a blood glucose level 3 to 4 mg/dl from 20 to 90 minutes depending on the complexity of the carbohydrate. An average breakfast meal containing 60 grams of carbohydrate can raise blood glucose 180 mg/dl.

Research shows sugar and sweets or ‘simple sugars" don't raise blood glucose levels any more than starches or "complex carbohydrates." Currently, sugar and candy aren't considered "bad" foods for the patient with diabetes unless they're consumed in excess amounts. This has eliminated the need for the American Diabetes Association or "diabetic" diet.

Of utmost importance, instead, is that the person with diabetes learn how to count carbohydrates. It's also important that you understand the concept of carbohydrate counting.

Now let's return to our four patients.

Mrs. Smith
You noted that she consumed a "regular" tray. This wasn't a mistake as long as her carbohydrates were accurately calculated based on her height, weight, and diabetes medication. She can still enjoy dessert and keep her blood glucose level within normal range by counting her carbohydrates. If a cake that Mrs. Smith ate contained 30 grams of carbohydrates, then she would cover her carbohydrates with one unit of insulin to 15 grams of carbohydrates. This means that Mrs. Smith would take 2 units of insulin for this cake.

Mr. Jones
This patient is from the old school of thought that fruit is a "natural" sugar and therefore can't raise his blood glucose. He was told that only candy and cookies are "bad" for him. We now know that he can have fruit as long as he's calculated the fruit's carbohydrate content and it doesn't exceed the amount of carbohydrate that his body can handle at one meal.

The fruit contained 75 grams of carbohydrate. When Mr. Jones tested his blood glucose level four hours after eating the fruit, he was surprised that it was 250 mg/dl instead of normal (range, 80 to 120 mg/dl).

Mrs. Rogers
Recall that this patient's blood glucose level was 181 mg/dl. You note that Mrs. Rogers hasn't eaten her bedtime snack, which consists of 3 graham crackers (15 grams of carbohydrates) and one cup of skim milk (12 grams of carbohydrates). This snack has the potential to raise Mrs. Rogers' blood glucose level a range of 81 to 108 mg/dl. Unless she receives insulin to match this snack, her fasting blood glucose level may be elevated in the morning.

Mr. Ogilvy
This patient misunderstands his diet management and needs further explanation about carbohydrate counting and healthy nutrition, such as eating less fat and more whole grains, fruits and vegetables. He'll need to learn that even starch, fruit, and milk contain carbohydrates and to read a food label to determine the total carbohydrates. He'll also need to learn and understand that foods referred to as "sugar free" can contain carbohydrates.

Teaching points
To help your patient manage his diabetes effectively, keep the following points in mind:

• Advise him to purchase a scale, measuring cups, and measuring spoons.
  
• Once he's mastered the skill of weighing and measuring foods, he can learn to estimate the correct amount of foods and the carbohydrate content of the food he consumes.
  
• The concept of carbohydrate counting as it pertains to individuals with Type 1 diabetes or individuals who take insulin is to match the person's insulin to what he's eating and not have to cover high blood glucose levels after they occur.
  
• The concept of carbohydrate counting as it pertains to individuals with Type 2 diabetes or individuals who take oral medication is to determine the effects of the carbohydrates on blood glucose levels after eating.
  
• All patients with diabetes need to carefully calculate the carbohydrate content of meals and frequently monitor blood glucose levels to determine if the carbohydrate amount results in normal blood glucose levels after eating.
  
• Carbohydrate counting can lead to more flexibility in meal planning, which can improve the quality of life for the patient with diabetes.