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Carbohydrates\tshould\tbe\tdistributed\tthroughout\tthe\n\tday\tinto\tthree\tsmall-to-moderate\tsize\tmeals\nand\ttwo\tto\tfour\tsnacks.\tAll\tpregnant\twomen\trequire\ta\tminimum\tof\t175\tg\tof\tcarbohydrates\tdaily\n(\nAcademy\tof\tNutrition\tand\tDietetics\tEvidence\tAnalysis\tLibrary,\t2016\n).\tAn\tevening\tsnack\tusually\tis
|
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] |
breakfast.\tTo\tsatisfy\thunger,\tprotein\tfoods\tcan\tbe\tadded\tbecause\tthey\tdo\tnot\taffect\tblood\tglucose\nlevels.\nAccording\tto\tthe\tEBNPG,\tthe\tRDN\tshould\tindividualize\tthe\tcalorie\tprescription\tbased\ton\ta\nthorough\tnutrition\tassessment\twith\tguidance\tfrom\trelevant\treferences\t(DRIs,\tthe\tIOM)\n\tand
|
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] |
and\nencourage\tadequate\tcaloric\tintake\tto\tpromote\tfetal/neonatal\tand\tmaternal\thealth,\tachieve\tglycemic\ngoals,\tand\tpromote\tappropriate\tgestational\tweight\tgain.\tWeight\tgain\tduring\tpregnancy\tfor\twomen\nwith\tGDM\tshould\tbe\tsimilar\tto\tthat\tof\twomen\twithout\tdiabetes.
|
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] |
as\tan\tadjunct\tto\tnutrition\ttherapy\tto\timprove\tmaternal\nglycemia.\tThe\tideal\tform\tof\texercise\tis\tunknown,\tbut\ta\tbrisk\twalk\tafter\tmeals\tis\toften\trecommended.\nWomen\twith\tGDM\t(and\twomen\twith\tpreexisting\tdiabetes)\tshould\tbe\tencouraged\tto\tbreastfeed\nbecause\tbreastfeeding\tis\tassociated\twith\ta\treduced\tincidence\tof\tfuture\tT2DM\t(\nADA,\t2018\n)\t(see\nChapter\t14
|
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] |
ADA,\t2018\n)\t(see\nChapter\t14\n).\tFor\twomen\twith\tGDM\twho\tare\toverweight/obese\tor\n\twith\tabove-recommended\tweight
|
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gain\tduring\tpregnancy,\tweight\tloss\tis\tadvised\tafter\tdelivery.\tWeight\tloss\tmay\taid\tin\treducing\tthe\trisk\nof\trecurrent\tGDM\tor\tfuture\tdevelopment\tof\tT2DM\t(\nReader,\t2012\n).\nOlder\tadults.\nThe\tprevalence\tof\tdiabetes\tand\tIGT\tincreases\tdramatically\tas\tpeople\tage.\tMany\tfactors\tpredispose
|
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older\tadults\tto\tdiabetes:\tage-related\tdecreases\tin\tinsulin\tproduction,\tadiposity,\tdecreased\n\tphysical\nactivity,\tmultiple\tprescription\tmedications,\tgenetics,\tand\tcoexisting\tillnesses.\tA\tmajor\tfactor\tappears\nto\tbe\tinsulin\tresistance.\tControversy\tpersists\tas\tto\twhether\tthe\tinsulin\tresistance\tis\ta\tprimary
|
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] |
change\tor\twhether\tit\tis\tattributable\tto\treduced\tphysical\tactivity,\tdecreased\tlean\tbody\tmass\n(sarcopenia),\tand\tincreased\tadipose\ttissue,\twhich\tare\tcommon\tin\tolder\tadults.\tFurthermore,\nmedications\tused\tto\ttreat\tcoexisting\tdiseases\tmay\tcomplicate\tdiabetes\ttherapy\tin\tolder\tadults.
|
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] |
Despite\tthe\tincrease\tin\tglucose\tintolerance\twith\tage,\taging\tshould\tnot\tbe\ta\treason\tfor\tsuboptimal\ncontrol\tof\tblood\tglucose.\tPersistent\thyperglycemia\thas\tdeleterious\teffects\ton\tthe\tbody’s\tdefense\nmechanisms\tagainst\tinfection.\tIt\talso\tincreases\tthe\tpain\tthreshold\tby\texacerbating\tneuropathic\tpain,\nand
|
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] |
and\n\tit\thas\ta\tdetrimental\teffect\ton\tthe\toutcome\tof\tcerebrovascular\taccidents.\nHowever,\twhile\tit\tis\timportant\tto\tcontrol\tblood\tglucose\tlevels\tin\tthis\tpopulation,\tthe\nrecommendations\tin\tblood\tglucose\ttargets\tfor\tolder\tadults\twith\tdiabetes\thave\tchanged.\tOlder\tadults
|
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who\tare\totherwise\thealthy\twith\tfew\tcoexisting\tchronic\tillnesses\tand\tintact\tcognitive\tfunction\tand\nfunctional\tstatus\tshould\thave\tlower\tglycemic\n\tgoals\t(A1C\t<7.5%\t[58\tmmol/mol]),\twhile\tthose\twith\nmultiple\tcoexisting\tchronic\tillnesses,\tcognitive\timpairment,\tor\tfunctional\tdependence\tshould\thave
|
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] |
less\tstringent\tglycemic\tgoals\t(A1C\t<8.0%\tto\t8.5%\t[64\tto\t69\tmmol/mol])\t(\nADA,\t2018\n).\nNutrition\trecommendations\tfor\tolder\tadults\twith\tdiabetes\tshould\tinclude\tmeeting\tthe\tDRI\tfor\tage\nfor\tnutrients,\tdrinking\tadequate\tfluid,\tavoiding\tsignificant\tweight\n\tloss,\tand\tbeing\tsensitive\tto
|
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] |
loss,\tand\tbeing\tsensitive\tto\nindividual\tpreferences\tand\tlongstanding\tfood\thabits\twhile\tadvocating\tgood\tnutrition\t(\nStanley,\t2012\n)\n(see\t\nChapter\t19\n).\tRestrictive\tdiets\tare\tcontraindicated.\tPhysical\tactivity\tcan\treduce\tthe\tdecline\tin\naerobic\tcapacity\tsignificantly\tthat\toccurs\twith\tage,\timprove\trisk\tfactors\tfor\tatherosclerosis,\tslow\tthe
|
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individual\tpreferences\tto\tincrease\tflexibility,\tmuscular\tstrength,\tand\tbalance\t(\nADA,\t2018\n).\nMalnutrition,\tnot\tobesity,\tis\tthe\tmore\tprevalent\tnutrition-related\tproblem\tin\tolder\n\tadults.\tIt\toften\nremains\tsubclinical\tor\tunrecognized\tbecause\tthe\tresult\tof\tmalnutrition—excessive\tloss\tof\tlean\tbody
|
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mass—resembles\tthe\tsigns\tand\tsymptoms\tof\tthe\taging\tprocess.\tMalnutrition\tand\tdiabetes\tadversely\naffect\twound\thealing\tand\tdefense\tagainst\tinfection,\tand\tmalnutrition\tis\tassociated\twith\tdepression\nand\tcognitive\tdeficits.\tThe\tmost\treliable\tindicator\tof\tpoor\tnutrition\tstatus\tin\tolder\n\tadults\tis\ta\tchange
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adults\tis\ta\tchange\nin\tbody\tweight;\tinvoluntary\tweight\tgain\tor\tloss\tof\tmore\tthan\t10\tpounds\tor\t10%\tof\tbody\tweight\tin\tless\nthan\t6\tmonths\tindicates\ta\tneed\tto\tevaluate\tthe\treason.\nIt\tis\tessential\tthat\tolder\tadults,\tespecially\tthose\tin\tlong-term\tcare\tsettings,\tfocus\ton\tenjoyment\tof
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population;\thowever,\troutine\tmeals\twith\tconsistent\tportion\tsizes\tcan\tassist\twith\tblood\tsugar\tcontrol\n(\nSwift,\t2012\n).\nHyperglycemia\tand\tdehydration\tcan\tlead\tto\ta\tserious\tcomplication\tof\tdiabetes\tin\tolder\tadults:\nhyperglycemic\thyperosmolar\tstate\t(HHS)\n.\tPatients\twith\tHHS\thave\ta\tvery\thigh\tblood\tglucose
|
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0.018790556117892265
] |
.\tPatients\twith\tHHS\thave\ta\tvery\thigh\tblood\tglucose\nlevel\t(>600\tmg/dL\t[33.3mmol/L])\twithout\tketones\t(\nPasquel\tand\tUmpierrez,\t2014\n).\tPatients\tare\nmarkedly\tdehydrated,\tand\tmental\talterations\trange\tfrom\tmild\tconfusion\tto\thallucinations\tor\tcoma.\nPatients\twho\thave\tHHS\thave\tsufficient\tinsulin\tto\tprevent\tlipolysis\tand\tketosis.\tTreatment\tconsists\tof
|
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] |
hydration\tand\tsmall\tdoses\tof\tinsulin\tto\tcontrol\thyperglycemia.\nThe\tnutrition\tprescription\nTo\tdevelop,\teducate,\tand\tcounsel\tindividuals\tregarding\tthe\tnutrition\tprescription,\tit\tis\tessential\tto\nlearn\tabout\ttheir\tlifestyle\tand\teating\thabits.\tFood\tand\teating\thistories\tcan\tbe\tdone\tseveral\tways,
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with\tthe\tobjective\tof\tdetermining\ta\tschedule\tand\tpattern\tof\teating\tthat\twill\tbe\tthe\tleast\tdisruptive\tto\nthe\tlifestyle\tof\tthe\tindividual\twith\tdiabetes\tand,\tat\tthe\tsame\n\ttime,\twill\tfacilitate\timproved\tmetabolic\ncontrol.\tWith\tthis\tobjective\tin\tmind,\tasking\tthe\tindividual\teither\tto\trecord\tor\treport\twhat,\thow\tmuch,
|
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0.06915291398763657,
0.030687017366290092,
-0.019180143252015114
] |
and\twhen\the\tor\tshe\ttypically\teats\tduring\ta\t24-hour\tperiod\tmay\tbe\tthe\tmost\tuseful.\tAnother\tapproach\nis\tto\task\tthe\tindividual\tto\tkeep\tand\tbring\ta\t3-day\tor\t1-week\tfood\tintake\trecord\t(see\t\nChapter\t4\n\tand\nFigs.\t4.5\n\tand\t\n4.6\n).\tThe\trequest\tto\tcomplete\ta\tfood\trecord\n\tcan\tbe\tmade\twhen\tan\tappointment\twith
|
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] |
can\tbe\tmade\twhen\tan\tappointment\twith\nthe\tRDN\tis\tscheduled.\tIt\tis\talso\timportant\tto\tlearn\tabout\tdaily\troutine\tand\tschedule.\tThe\tfollowing\ninformation\tis\tneeded:\t(1)\ttime\tof\twaking;\t(2)\tusual\tmeal\tand\teating\ttimes;\t(3)\twork\tschedule\tor\nschool\thours;\t(4)\ttype,\tamount,\tand\ttiming\tof\texercise;\t(5)\tusual\tsleep\thabits;\t(6)\ttype,\tdosage,\tand
|
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] |
timing\tof\tdiabetes\tmedication;\tand\t(7)\tSMBG\tdata.\nUsing\tthe\n\tassessment\tdata\tand\tfood\tand\tnutrition\thistory\tinformation,\ta\tpreliminary\teating\tplan\ncan\tthen\tbe\tdesigned\tand,\tif\tthe\tindividual\tdesires,\tsample\tmenus\tprovided.\tDeveloping\tan\teating\nplan\tdoes\tnot\tbegin\twith\ta\tset\tcalorie\tor\tmacronutrient\tprescription;\tinstead\tit\tis\tdetermined\tby
|
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] |
modifying\tthe\tindividual’s\tusual\tfood\tintake\tas\tnecessary.\tThe\tworksheet\tin\t\nFig.\t29.4\n\tcan\tbe\tused\tto\nrecord\tthe\tusual\n\tfoods\teaten\tand\tto\tmodify\tthe\tusual\tfood\tand\tnutrient\tintake\tas\tnecessary.\tThe\nmacronutrient\tand\tcaloric\tvalues\tfor\tthe\tfood\tlists\tare\tlisted\ton\tthe\tform\tand\tin\t\nTable\t29.8\n;\tsee\nAppendix\t18
|
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] |
Table\t29.8\n;\tsee\nAppendix\t18\n\tfor\tportion\tsizes\tof\tthe\tfoods\ton\tthe\tfood\tlists.\tThese\ttools\tare\tuseful\tin\tevaluating\nnutrition\tassessments.
|
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] |
FIG.\t29.4\nWorksheet\tfor\tassessment\tand\tdesign\tof\ta\tmeal\tor\tfood\tplan.\t\nCHO\n,\tCarbohydrate.\nTABLE\t29.8\nMacronutrient\tand\tCaloric\tValues\tfor\tFood\tLists\n*\nFood\tList\nCarbohydrate\n(grams)\nProtein\n(grams)\nFat\n(grams)\nCalories\nCarbohydrates\nStarch:\tbreads,\tcereals\tand\tgrains,\tstarchy\nvegetables,\tcrackers,\tsnacks,\tand\tbeans,\tpeas,\nand\tlentils\n15\n3\n1\n80
|
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] |
vegetables,\tcrackers,\tsnacks,\tand\tbeans,\tpeas,\nand\tlentils\n15\n3\n1\n80\nFruits\n15\n—\n—\n60\nMilk\tand\tmilk\tsubstitutes\nFat-free,\tlow-fat,\t1%\nReduced-fat,\t2%\nWhole\n12\n12\n12\n8\n8\n8\n0-3\n5\n8\n100\n120\n160\nSweets,\tdesserts,\tand\tother\tcarbohydrates\n15\nVaries\nVaries\nVaries\nNonstarchy\tvegetables\n5\n2\n—\n25\nProteins\nLean\n—\n7\n2\n45\nMedium-fat\n—\n7\n5\n75\nHigh-fat\n—\n7\n8\n100
|
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] |
2\n—\n25\nProteins\nLean\n—\n7\n2\n45\nMedium-fat\n—\n7\n5\n75\nHigh-fat\n—\n7\n8\n100\nPlant-based\tprotein\n—\n7\nVaries\nVaries\nFats\n—\n—\n5\n45\nAlcohol\t(1\talcohol\tequivalent)\nVaries\n—\n—\n100\n*\nSee\t\nAppendix\t18\n.\nFrom\tAmerican\tDiabetes\tAssociation\tand\tAcademy\tof\tNutrition\tand\tDietetics:\t\nChoose\tyour\tfoods:\tFood\tlists\tfor\tdiabetes,\n\tAlexandria,\tVA,\tChicago,
|
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0.07149740308523178,
0.050873856991529465,
0.09778350591659546,
0.008093476295471191
] |
Choose\tyour\tfoods:\tFood\tlists\tfor\tdiabetes,\n\tAlexandria,\tVA,\tChicago,\n2014\tAmerican\tDiabetes\tAssociation,\tAcademy\tof\tNutrition\tand\tDietetics.\nUsing\tthe\tform\tin\t\nFig.\t29.4\n,\tthe\tRDN\tbegins\tby\ttotaling\tthe\tnumber\tof\tservings\tfrom\teach\tfood\tlist\nand\tmultiplying\tthis\tnumber\tby\tthe\tgrams\tof\tcarbohydrate,\tprotein,\tand\tfat\tcontributed\tby\teach.
|
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] |
Next,\tthe\tgrams\tof\tcarbohydrate,\tprotein,\tand\tfat\tare\ttotaled\tfrom\teach\tcolumn.\tThen\tthe\tgrams\tof\ncarbohydrates\tand\tprotein\tare\n\tmultiplied\tby\t4\t(4\tkcal/g\tof\tcarbohydrates\tand\tprotein),\tand\tthe\tgrams\nof\tfat\tare\tmultiplied\tby\t9\t(9\tkcal/g\tof\tfat).\tTotal\tcalories\tand\tpercentage\tof\tcalories\tfrom\teach
|
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] |
macronutrient\tcan\tthen\tbe\tdetermined.\tNumbers\tderived\tfrom\tthese\tcalculations\tare\tthen\trounded\noff.\t\nFig.\t29.5\n\tprovides\tan\texample\tof\ta\tpreliminary\teating\tplan.\tIn\tthis\texample\tthe\tnutrition\nprescription\twould\tbe\tthe\tfollowing:\n\t1900\tto\t2000\tcalories,\t230\tg\tof\tcarbohydrates\t(50%),\t90\tg\tof
|
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1900\tto\t2000\tcalories,\t230\tg\tof\tcarbohydrates\t(50%),\t90\tg\tof\nprotein\t(20%),\tand\t65\tg\tof\tfat\t(30%).\tThe\tnumber\tof\tcarbohydrate\tchoices\tfor\teach\tmeal\tand\tsnack\tis\nthe\ttotal\tof\tthe\tstarch,\tfruit,\tand\tmilk\tservings.\tVegetables,\tunless\tstarchy\tor\teaten\tin\tvery\tlarge
|
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amounts\t(three\tor\tmore\tservings\tper\tmeal),\tgenerally\tare\tconsidered\t“free\tfoods.”\tThe\tcarbohydrate\nchoices\tare\tcircled\tunder\teach\tmeal\tand\n\tsnack\tcolumn.
|
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] |
FIG.\t29.5\nAn\texample\tof\ta\tcompleted\tworksheet\tfrom\tthe\tassessment,\tthe\tnutrition\tprescription,\tand\ta\tsample\n1900-\tto\t2000-calorie\tmeal\tplan.\t\nCHO\n,\tCarbohydrate.\nThe\tnext\tstep\tis\tto\tevaluate\tthe\tpreliminary\teating\tplan.\tFirst\tand\tforemost,\tis\tthe\teating\tplan
|
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] |
feasible\tand\twill\tit\tfit\tinto\tthe\tindividual’s\tlifestyle?\tSecond,\tis\tit\tappropriate\tfor\tdiabetes\nmanagement?\tThird,\tdoes\tit\tencourage\n\thealthful\teating?\tFourth,\tif\tthe\tindividual\tis\ttaking\tdiabetes\nmedicine,\tis\tthe\teating\tplan\tcoordinated\twith\tthe\tmedication\tplan\tto\treduce\trisk\tof\thypoglycemia\nand/or\tminimize\tpostprandial\thyperglycemia?
|
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] |
and/or\tminimize\tpostprandial\thyperglycemia?\nTo\tdiscuss\tfeasibility,\tthe\teating\tplan\tis\treviewed\twith\tthe\tindividual\tin\tterms\tof\tgeneral\tfood\nintake.\tTiming\tof\tmeals\tand\tsnacks\tand\tapproximate\tportion\tsizes\tand\ttypes\tof\tfoods\tare\tdiscussed.\nCalorie\tlevels\tare\tonly\tapproximate,\tand\tadjustments\tin\tcalories\tcan\tbe\tmade\tduring\tfollow-up\tvisits.
|
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A\tmeal-planning\tapproach\tcan\tbe\tselected\tlater\tthat\twill\tassist\tthe\tpatient\tin\tmaking\tfood\tchoices.\tAt\nthis\tpoint\tit\tmust\tbe\tdetermined\twhether\tthis\teating\tplan\tis\treasonable.\nTo\tdetermine\tthe\tappropriateness\tof\tthe\teating\tplan\tfor\tdiabetes\tmanagement,\tdistribution\tof\tthe\nmeals\tor\tsnacks\tmust
|
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meals\tor\tsnacks\tmust\n\tbe\tassessed\talong\twith\tthe\ttypes\tof\tmedications\tprescribed\tand\ttreatment\ngoals.\tOften\tthe\teating\tplan\tbegins\twith\tthree\tor\tfour\tcarbohydrate\tservings\tper\tmeal\tfor\tadult\nwomen\tand\tfour\tor\tfive\tfor\tadult\tmen\tand,\tif\tdesired,\tone\tor\ttwo\tfor\ta\tsnack.\tEating\tsnacks\twhen\tnot
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] |
hungry\tsimply\tprovides\tunnecessary\tcalories.\tAdding\tprotein\tto\ta\tsnack\tmay\tpromote\tmeal\tbalance\nand\toptimize\tdaily\tintake\tof\tmacronutrients;\n\thowever,\tresearch\tdoes\tnot\tsupport\tthe\tneed\tfor\tprotein\nfor\toptimal\tglucose\tcontrol\t(\nADA,\t2018\n).\tResults\tof\tblood\tglucose\tmonitoring\tbefore\tthe\tmeal\tand\t2
|
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] |
).\tResults\tof\tblood\tglucose\tmonitoring\tbefore\tthe\tmeal\tand\t2\nhours\tafter\tthe\tmeal,\tplus\tfeedback\tfrom\tthe\tperson\twith\tdiabetes,\tare\tused\tto\tassess\tif\tthese\nrecommendations\tare\tfeasible\tand\trealistic\tand\tto\tdetermine\twhether\ttarget\tglucose\tgoals\tare\tbeing\nachieved.\nAnother\tstrategy\tfor\tmeal\tplanning\tis
|
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] |
achieved.\nAnother\tstrategy\tfor\tmeal\tplanning\tis\n\tthe\tU.S.\tDepartment\tof\tAgriculture\t(USDA)\tMyPlate\tmethod,\nwhich\trecommends\tmaking\thalf\tyour\tplate\tnonstarchy\tvegetables,\tone\tquarter\tprotein,\tand\tone\nquarter\tcarbohydrates.\tMany\tpatients\tfind\tthis\tstyle\tof\teating\tmore\tflexible\tand\tuser\tfriendly.
|
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] |
For\tpeople\twho\trequire\tinsulin,\tthe\ttiming\tof\teating\tis\timportant,\tas\tinsulin\tmust\tbe\tsynchronized\nwith\tfood\tconsumption\t(see\t\nMedications\n\tearlier\tin\n\tthe\tchapter).\tIf\tthe\teating\tplan\tis\tdetermined\tfirst,\nan\tinsulin\tregimen\tcan\tbe\tselected\tthat\twill\tfit\twith\tit.\tThe\tbest\tway\tto\tensure\tthat\tthe\teating\tplan
|
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] |
promotes\thealthful\teating\tis\tto\tencourage\tindividuals\tto\teat\ta\tvariety\tof\tfoods\tfrom\tall\tthe\tfood\ngroups.\tThe\tDietary\tGuidelines\tfor\tAmericans,\twhich\tincludes\ta\tsuggested\tnumber\tof\tservings\tfrom\neach\tfood\tgroup,\tcan\tbe\tused\tto\tcompare\tthe\tindividual’s\n\teating\tplan\twith\tthe\tnutrition\nrecommendations\tfor\tall\tAmericans\t(see\t\nChapter\t10\n).
|
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] |
recommendations\tfor\tall\tAmericans\t(see\t\nChapter\t10\n).\nNutrition\teducation\tand\tcounseling\nImplementation\tof\tMNT\tbegins\twith\tthe\tRDN\tselecting\tfrom\ta\tvariety\tof\tinterventions\t(reduced\nenergy\tand\tfat\tintake,\tcarbohydrate\tcounting,\tsimplified\tmeal\tplans,\thealthy\tfood\tchoices,
|
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] |
individualized\tmeal\tplanning\tstrategies,\tinsulin-to-carbohydrate\tratios,\tphysical\tactivity,\n\tand\nbehavioral\tstrategies)\t(\nPastors\tand\tFranz,\t2012\n).\tAll\tof\tthe\tabove\tinterventions\thave\tbeen\tshown\tto\nlead\tto\timproved\tmetabolic\toutcomes.\tFurthermore,\tnutrition\teducation\tand\tcounseling\tmust\tbe
|
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] |
sensitive\tto\tthe\tindividual\twith\tdiabetes,\tincluding\tpersonal\tneeds,\twillingness\tto\tchange,\tand\tability\nto\tmake\tchanges\t(\nFig.\t29.6\n).\tAssessing\tthe\tindividual’s\thealth\tliteracy\tand\tnumeracy\talso\tmay\tbe\nbeneficial.\tNo\tsingle\teating\tplan\tapproach\thas\tbeen\tshown\tto\tbe\tmore\teffective\tthan\tany\tother,\tand
|
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the\teating\tplan\tapproach\tselected\tshould\tallow\tindividuals\twith\tdiabetes\tto\tselect\tappropriate\tfoods\nfor\tmeals\tand\tsnacks.
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] |
FIG.\t29.6\nA\twoman\twith\ttype\t1\tdiabetes\tmellitus\tis\tlearning\tabout\tcarbohydrate\tcounseling\tfrom\ther\tRDN\ncounselor.\nA\tpopular\tapproach\tto\tmeal\tplanning\tis\tcarbohydrate\tcounting.\tCarbohydrate-counting\teducational\ntools\tare\tbased\ton\tthe\tconcept\tthat\tthe\tcarbohydrate\tin\tfoods\tis\tthe\tmajor\tpredictor\tof\tpostprandial
|
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portions,\tamount\tof\tcarbohydrates\tthat\tshould\tbe\teaten,\tand\tlabel\treading.\tAdvanced\tcarbohydrate\ncounting\temphasizes\tthe\timportance\tof\trecord\tkeeping,\tcalculating\tinsulin-to-carbohydrate\tratios,\nand\n\tpattern\tmanagement.\nAn\timportant\tgoal\tof\tnutrition\tcounseling\tis\tto\tfacilitate\tchanges\tin\texisting\tfood\tand\tnutrition-
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related\tbehaviors\tand\tthe\tadoption\tof\tnew\tones.\tThe\tcombined\tuse\tof\tbehavior\tchange\ttheories\tmay\npotentially\thave\ta\tgreater\timpact\tthan\tany\tindividual\ttheory\tor\ttechnique\tused\talone\t(\nFranz\tet\tal,\n2012\n).\tThe\tfollowing\tfive\t\nA\n’s\tcan\tguide\tthe\teducation/counseling\tsessions:\tstep\t1:\n\task;\tstep\t2:\tassess;
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ask;\tstep\t2:\tassess;\nstep\t3;\tadvise;\tstep\t4:\tagree;\tand\tstep\t5:\tarrange.\tThe\t“ask”\tstep\temphasizes\tthe\timportance\tof\nquestions\tas\tthe\tRDN\taims\tto\tdevelop\ta\trelationship\twith\tthe\tclient.\tMotivational\tinterviewing\ntechniques\tare\tused\tinitially\tand\tthroughout\tall\tof\tthe\tencounters.\tIn\tthe\t“assess”\tstep,\tthe\tRDN
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0.10299583524465561,
0.11780709773302078,
0.006644648499786854,
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] |
evaluated\tthe\tclient’s\treadiness\tto\tchange.\tDifferent\tintervention\tstrategies\tmay\tbe\tneeded\n\tfor\nindividuals\tat\tdifferent\tstages\tof\tthe\tchange\tprocess\t(see\t\nChapter\t13\n).\nNutrition\tmonitoring\tand\tevaluation\nFood\tintake,\tmedication,\tmetabolic\tcontrol\t(glycemia,\tlipids,\tand\tblood\tpressure),\tanthropometric
|
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] |
measurements,\tand\tphysical\tactivity\tshould\tbe\tmonitored\tand\tevaluated.\tMedical\tand\tclinical\noutcomes\tshould\tbe\tmonitored\tafter\tthe\tsecond\tor\tthird\tvisit\tto\tdetermine\twhether\tthe\tindividual\n\tis\nmaking\tprogress\ttoward\testablished\tgoals.\tIf\tno\tprogress\tis\tevident,\tthe\tindividual\tand\tRDN\tmust
|
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reassess\tand\tperhaps\trevise\tnutrition\tinterventions.\tBlood\tglucose\tmonitoring\tresults\tcan\tbe\tused\tto\ndetermine\twhether\tadjustments\tin\tfoods\tand\tmeals\twill\tbe\tsufficient\tto\tachieve\tblood\tglucose\tgoals\nor\tif\tmedication\tadditions\tor\tadjustments\thave\tto\tbe\tcombined\twith\tMNT.\tNutrition\tcare\tmust\tbe\ncoordinated\twith\tan\tinterdisciplinary\tteam.
|
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coordinated\twith\tan\tinterdisciplinary\tteam.\nDocumentation\tin\tthe\tindividual’s\tmedical\trecord\tserves\tas\ta\tcommunication\ttool\tfor\tmembers\tof\nthe\thealth\tcare\tteam.\tThe\tmedical\trecord\talso\tserves\tas\ta\tlegal\tdocument\tof\twhat\twas\tdone\tand\tnot\ndone\tand\tsupports\treimbursement\tof\tnutrition\tservices\tbilled\tto\tinsurance\tcarriers.\tThere\tare\tmany
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different\tformats\tavailable\tfor\tmedical\trecord\tdocumentation.\n\tThe\tappropriate\tformat\tdepends\ton\nwhere\tthe\tRDN\tpractices\tand\twhether\telectronic\thealth\trecords\tare\tused.\tRegardless\tof\tthe\tspecific\nformat,\tthe\tRDN\tcan\tdocument\tusing\tthe\tassessment,\tdiagnosis,\tinterventions,\tmonitoring,\tand\nevaluation\t(ADIME)\tcontent\t(\nBox\t29.4\n).\nBOX\t29.4
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] |
evaluation\t(ADIME)\tcontent\t(\nBox\t29.4\n).\nBOX\t29.4\nNutrition\tCare\tDocumentation\nNutrition\tassessment\n•\t\nDate\tand\ttime\tof\tassessment\n•\t\nPertinent\tdata\tcollected\tand\n\tcomparisons\twith\tstandards\t(e.g.,\tfood\tand\tnutrition\thistory,\nbiochemical\tdata,\tanthropometric\tmeasurements,\tclient\thistory,\tmedical\ttherapy,\tand\nsupplement\tuse)\n•
|
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] |
supplement\tuse)\n•\t\nPatient’s\treadiness\tto\tlearn,\tfood\tand\tnutrition-related\tknowledge,\tand\tpotential\tfor\tchange\n•\t\nPhysical\tactivity\thistory\tand\tgoals
|
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•\t\nReason\tfor\tdiscontinuation\tof\tnutrition\ttherapy,\tif\tappropriate\nNutrition\tdiagnoses\n•\t\nDate\n\tand\ttime\n•\t\nConcise\twritten\tstatement\tof\tnutrition\tdiagnosis\t(or\tnutrition\tdiagnoses)\twritten\tin\tthe\nproblem,\tetiology,\tsigns\tand\tsymptoms\t(PES)\tformat.\tIf\tthere\tis\tno\texisting\tor\tpredicted
|
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] |
nutrition\tproblem\tthat\trequires\ta\tnutrition\tintervention,\tstate\t“no\tnutrition\tdiagnosis\tat\tthis\ntime”\nNutrition\tinterventions\n•\t\nDate\tand\ttime\n•\t\nSpecific\ttreatment\tgoals\tand\texpected\toutcomes\n•\t\nRecommended\n\tnutrition\tprescription\tand\tnutrition\tinterventions\t(individualized\tfor\tthe\npatient)\n•\t\nAny\tadjustments\tto\tplan\tand\tjustifications\n•
|
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patient)\n•\t\nAny\tadjustments\tto\tplan\tand\tjustifications\n•\t\nPatient’s\treceptivity\tregarding\trecommendations\n•\t\nChanges\tin\tpatient’s\tlevel\tof\tunderstanding\tand\tfood-related\tbehaviors\n•\t\nReferrals\tmade\tand\tresources\tused\n•\t\nAny\tother\tinformation\trelevant\tto\tproviding\tcare\tand\tmonitoring\tprogress\tover\ttime\n•\t\nPlans\tfor\tfollow-up\n\tand\tfrequency\tof\tcare
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•\t\nPlans\tfor\tfollow-up\n\tand\tfrequency\tof\tcare\nNutrition\tmonitoring\tand\tevaluation\n•\t\nDate\tand\ttime\n•\t\nSpecific\tnutrition\toutcomes\tindicators\tand\tresults\trelevant\tto\tthe\tnutrition\tdiagnosis\t(or\ndiagnoses)\tand\tintervention\tplans\tand\tgoals,\tcompared\twith\tprevious\tstatus\tor\treference\ngoals\n•\t\nProgress\ttoward\tnutrition\tintervention\tgoals\n•
|
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] |
goals\n•\t\nProgress\ttoward\tnutrition\tintervention\tgoals\n•\t\nFactors\tfacilitating\tor\thindering\tprogress\n•\t\nOther\tpositive\tor\tnegative\toutcomes\n•\t\nFuture\tplans\tfor\tnutrition\tcare,\tmonitoring,\tand\tfollow-up\tor\tdischarge\nAdapted\tfrom\tWriting\tgroup\tof\tthe\tnutrition\tcare\tprocess/standardized\tlanguage\tcommittee:\tNutrition
|
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care\tprocess\tpart\tII:\tUsing\tthe\tinternational\tdietetics\tand\tnutrition\tterminology\tto\tdocument\tthe\tnutrition\ncare\tprocess,\t\nJ\tAm\tDiet\tAssoc\n\t108:1287,\t2008.\nFollow-up\tencounters\nSuccessful\tnutrition\ttherapy\tinvolves\n\ta\tprocess\tof\tassessment,\tproblem\tsolving,\tadjustment,\tand
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] |
a\tprocess\tof\tassessment,\tproblem\tsolving,\tadjustment,\tand\nreadjustment.\tFood\trecords\tcan\tbe\tcompared\twith\tthe\teating\tplan,\twhich\twill\thelp\tto\tdetermine\nwhether\tthe\tinitial\teating\tplan\tneeds\tchanging,\tand\tcan\tbe\tintegrated\twith\tthe\tblood\tglucose–\nmonitoring\trecords\tto\tdetermine\tchanges\tthat\tcan\tlead\tto\timproved\tglycemic\tcontrol.
|
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] |
Nutrition\tfollow-up\tvisits\tshould\tprovide\tencouragement\tand\tensure\n\trealistic\texpectations\tfor\tthe\nindividual\twith\tdiabetes.\tA\tchange\tin\teating\thabits\tis\tnot\teasy\tfor\tmost\tpeople,\tand\tthey\tbecome\ndiscouraged\twithout\tappropriate\trecognition\tof\ttheir\tefforts.\tIndividuals\tshould\tbe\tencouraged\tto
|
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speak\tfreely\tabout\tproblems\tthey\tare\thaving\twith\ttheir\teating\tplan.\tFurthermore\tthere\tmay\tbe\tmajor\nlife\tchanges\tthat\trequire\tchanges\tin\tthe\teating\tplan.\tJob\tand\tschedule\tchanges,\n\ttravel,\tillness,\tand\nother\tfactors\tall\thave\tan\timpact\ton\tthe\tmeal\tplan.\nAcute\tcomplications
|
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] |
Acute\tcomplications\nHypoglycemia\tand\tDKA\tare\tthe\ttwo\tmost\tcommon\tacute\tcomplications\trelated\tto\tdiabetes.\nHypoglycemia\nA\tlow\tblood\tglucose,\tor\t\nhypoglycemia\t(or\tinsulin\treaction)\n,\tis\ta\tcommon\tside\teffect\tof\tinsulin\ntherapy,\talthough\tindividuals\ttaking\tinsulin\tsecretagogues\talso\tcan\tbe\taffected.\t\nAutonomic\nsymptoms\n\tarise
|
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] |
Autonomic\nsymptoms\n\tarise\n\tfrom\tthe\taction\tof\tthe\tautonomic\tnervous\tsystem\tand\tare\toften\tthe\tfirst\tsigns\tof\nmild\thypoglycemia.\tAdrenergic\tsymptoms\tinclude\tshakiness,\tsweating,\tpalpitations,\tanxiety,\tand\nhunger.\t\nNeuroglycopenic\tsymptoms\n,\trelated\tto\tan\tinsufficient\tsupply\tof\tglucose\tto\tthe\tbrain,\talso
|
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include\ta\tslowing\tdown\tin\tperformance\tand\tdifficulty\tconcentrating\nand\treading.\tAs\tblood\tglucose\tlevels\tdrop\tfurther,\tthe\tfollowing\tsymptoms\toccur:\tconfusion\tand\ndisorientation,\tslurred\tor\trambling\tspeech,\tirrational\tor\tunusual\tbehaviors,\textreme\tfatigue\tand
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] |
lethargy,\tseizures,\tand\tunconsciousness.\tWhile\tsymptoms\tdiffer\tfrom\tperson\tto\tperson,\tthey\ttend\tto\nbe\tconsistent\tfrom\tepisode\tto\tepisode\n\tfor\tany\tone\tindividual.\tSeveral\tcommon\tcauses\tof\nhypoglycemia\tare\tlisted\tin\t\nBox\t29.5\n.\nBOX\t29.5
|
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] |
Common\tCauses\tof\tHypoglycemia\nMedication\terrors\n•\t\nInadvertent\tor\tdeliberate\terrors\tin\tmedication\t(generally\tinsulin)\tdosages\n•\t\nExcessive\tinsulin\tor\toral\tsecretagogue\tdosages\n•\t\nReversal\tof\tmorning\tor\tevening\tinsulin\tdoses\n•\t\nImproper\ttiming\tof\tinsulin\tin\trelation\tto\tfood\tintake\nNutrition\n\ttherapy\tor\texercise\n•\t\nOmitted\tor\tinadequate\tfood\tintake
|
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] |
Nutrition\n\ttherapy\tor\texercise\n•\t\nOmitted\tor\tinadequate\tfood\tintake\n•\t\nTiming\terrors;\tdelayed\tmeals\tor\tsnacks\n•\t\nUnplanned\tor\tincreased\tphysical\tactivities\tor\texercise\n•\t\nProlonged\tduration\tor\tincreased\tintensity\tof\texercise\nAlcohol\tand\tdrugs\n•\t\nAlcohol\tintake\twithout\tfood\n•
|
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Alcohol\tand\tdrugs\n•\t\nAlcohol\tintake\twithout\tfood\n•\t\nImpaired\tmentation\tassociated\twith\talcohol,\tmarijuana,\tor\tother\tillicit\tdrugs\nAdapted\tfrom\tKaufman\tF:\t\nMedical\tmanagement\n\tof\ttype\t1\tdiabetes,\n\ted\t6,\tAlexandria,\tVA,\t2012,\tAmerican\nDiabetes\tAssociation.\nIn\tT1DM\tand\tT2DM\tit\thas\tbeen\tdemonstrated\tthat\tcounterregulatory\tresponses\tto\thypoglycemia
|
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] |
steadily\tdecline\twith\tfrequent\tand\trepetitive\tepisodes.\tIt\tcan\tbecome\ta\tvicious\tcycle\tas\thypoglycemic\nepisodes\timpair\tdefenses\tagainst\ta\tsubsequent\thypoglycemic\tepisode\tand\tthus\tcan\tresult\tin\nrecurrent\thypoglycemia.\n\tHypoglycemia\tcauses\tincreased\tmorbidity\tin\tmost\tpeople\twith\tT1DM\tand\nmany\twith\tlong-duration\tT2DM.
|
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] |
many\twith\tlong-duration\tT2DM.\nIn\tgeneral,\ta\tblood\tglucose\tof\t70\tmg/dL\t(3.9\tmmol/L)\tor\tlower\tshould\tbe\ttreated\timmediately.\nTreatment\tof\thypoglycemia\trequires\tingestion\tof\tglucose\tor\tcarbohydrate-containing\tfood.\tAlthough\nany\tcarbohydrate\twill\traise\tglucose\tlevels,\tglucose\tis\tthe\tpreferred\ttreatment.\tThe\tform\tof\ncarbohydrates
|
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] |
carbohydrates\n\t(i.e.,\tliquid\tor\tsolid)\tused\tto\ttreat\tdoes\tnot\tmake\ta\tdifference.\tCommercially\tavailable\nglucose\ttablets\thave\tthe\tadvantage\tof\tbeing\tpremeasured\tto\thelp\tprevent\tovertreatment.\tIngestion\nof\t15\tto\t20\tg\tof\tglucose\tis\tan\teffective\tbut\ttemporary\ttreatment.\tNote\tthat\tpure\tglucose\tis\tthe
|
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] |
preferred\ttreatment,\tbut\tany\tform\tof\tcarb\tthat\tcontains\tglucose\twill\tincrease\tblood\tglucose\tlevels.\nInitial\tresponse\n\tto\ttreatment\tshould\tbe\tseen\tin\tabout\t10\tto\t20\tminutes;\thowever,\tblood\tglucose\nshould\tbe\tevaluated\tagain\tin\tabout\t60\tminutes\tas\tadditional\tcarbohydrate\tmay\tbe\tnecessary\t(\nBox\n29.6\n)\t(\nADA,\t2018\n).\nBOX\t29.6\nTreatment\tof\tHypoglycemia
|
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] |
Box\n29.6\n)\t(\nADA,\t2018\n).\nBOX\t29.6\nTreatment\tof\tHypoglycemia\n•\t\nImmediate\ttreatment\twith\tcarbohydrates\tis\tessential.\nIf\tthe\tblood\tglucose\tlevel\tfalls\tbelow\t70\tmg/dL\t(3.9\tmmol/L),\ttreat\twith\t15\tg\tof\tcarbohydrates,\nwhich\tis\n\tequivalent\tto:\n15\tg\tcarbohydrate\tfrom\tglucose\ttablets\t(4)\tor\tglucose\tgel\n4-6\tounces\tof\tfruit\tjuice\tor\tregular\tsoft\tdrinks
|
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4-6\tounces\tof\tfruit\tjuice\tor\tregular\tsoft\tdrinks\n6\tounces\t(1/2\tcan)\tof\tregular\tsoda\tpop\t(not\tsugar-free)\n8\tounces\t(1\tcup)\tof\tsports\tdrink\t(not\tsugar-free)\n1\ttablespoon\tof\tsugar,\tsyrup\tor\thoney\n•\t\nRetest\tin\tapproximately\t10-15\tminutes.\tIf\tthe\tblood\tglucose\tlevel\tremains\t<70\tmg/dL\t(<3.9\nmmol/L),\ttreat\twith\tan\tadditional\n\t15\tg\tof\tcarbohydrates.\n•
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] |
mmol/L),\ttreat\twith\tan\tadditional\n\t15\tg\tof\tcarbohydrates.\n•\t\nRepeat\ttesting\tand\ttreatment\tuntil\tthe\tblood\tglucose\tlevel\treturns\tto\twithin\tnormal\trange.\n•\t\nIf\tit\tis\tmore\tthan\t1\thour\tto\tthe\tnext\tmeal,\ttest\tagain\t60\tminutes\tafter\ttreatment\tas\tadditional\ncarbohydrate\tmay\tbe\tneeded.\nAdapted\tfrom\tKaufman\tF:\t\nMedical\tmanagement\tof\tType\t1\tdiabetes
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] |
Adapted\tfrom\tKaufman\tF:\t\nMedical\tmanagement\tof\tType\t1\tdiabetes\n,\ted\t6,\tAlexandria,\tVA,\t2012,\tAmerican\nDiabetes\tAssociation.\nSeverely\tlow\tblood\n\tglucose\tcan\tcause\tloss\tof\tconsciousness\tor\tseizures.\tIf\tindividuals\tare\tunable\tto\nswallow,\tadministration\tof\tsubcutaneous\tor\tintramuscular\tglucagon\tmay\tbe\tneeded.\tParents,
|
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siblings,\tfriends,\tand\tspouses\tshould\tbe\ttaught\thow\tto\tmix,\tdraw\tup,\tand\tadminister\tglucagon\tso\tthat\nthey\tare\tproperly\tprepared\tfor\temergency\tsituations.\tKits\tthat\tinclude\ta\tsyringe\tprefilled\twith\ndiluting\tfluid\tare\tavailable.\n\tAfter\tthe\tinjection,\tturn\tthe\tpatient\ton\ttheir\tside\tto\tprevent\tchoking\tin
|
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] |
case\tof\tvomiting.\tNausea\tand\tvomiting\tare\tcommon\tside\teffects\tof\tglucagon.\tThe\tpatient\tshould\tbe
|
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] |
given\tfood\tor\tbeverage\tcontaining\tcarbohydrate\tas\tsoon\tas\tthey\tregain\tconsciousness\tand\tcan\nswallow.\nSMBG\tis\tessential\tfor\tprevention\tand\ttreatment\tof\thypoglycemia.\tChanges\tin\tinsulin\tinjections,\neating,\texercise\tschedules,\n\tand\ttravel\troutines\twarrant\tincreased\tfrequency\tof\tmonitoring.\tSome
|
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] |
and\ttravel\troutines\twarrant\tincreased\tfrequency\tof\tmonitoring.\tSome\npatients\texperience\thypoglycemia\tunawareness,\twhich\tmeans\tthat\tthey\tdo\tnot\texperience\tthe\tusual\nsymptoms\tof\thypoglycemia.\tPatients\tmust\tbe\treminded\tof\tthe\tneed\tto\ttreat\thypoglycemia,\teven\tin\nthe\tabsence\tof\tsymptoms.\tHypoglycemia\tunawareness,\tor\tone\tor\tmore\tepisodes\tof\tsevere
|
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hypoglycemia,\twarrants\treevaluation\tof\tthe\ttreatment\tregimen.\n\tA\tCGM\tmay\tbe\ta\tuseful\ttool\tin\tthose\nwith\thypoglycemia\tunawareness\tand/or\tfrequent\thypoglycemic\tepisodes\t(\nADA,\t2018\n).\nHyperglycemia\tand\tdiabetic\tketoacidosis\nHyperglycemia\tcan\tlead\tto\tDKA,\ta\tlife-threatening\tbut\treversible\tcomplication,\twhich\toccurs\twhen
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hydroxybutyric\tacid\tfrom\tfatty\tacids.\tKetones\tspill\tinto\tthe\turine;\thence\tthe\treliance\ton\turine\ttesting\nfor\tketones.\nDKA\tis\tcharacterized\tby\tan\televated\tserum\tglucose\tlevel\t(greater\tthan\t250\tmg/dL\t[13.88\tmmol/L]),\nan\televated\tserum\tketone\tlevel,\n\ta\tpH\tless\tthan\t7.3,\tand\ta\tserum\tbicarbonate\tlevel\tless\tthan\t18\nmEq/L\t(18\tmmol/L)\t(\nWesterberg,\t2013
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] |
mEq/L\t(18\tmmol/L)\t(\nWesterberg,\t2013\n).\tSymptoms\tinclude\tpolyuria,\tpolydipsia,\thyperventilation,\ndehydration,\tthe\tfruity\todor\tof\tketones,\tand\tfatigue.\tSMBG,\ttesting\tfor\tketones,\tand\tmedical\nintervention\tcan\thelp\tprevent\tDKA.\tIf\tleft\tuntreated,\tDKA\tcan\tlead\tto\tcoma\tand\tdeath.\tTreatment\nincludes\tsupplemental\tinsulin,\tfluid\tand\telectrolyte
|
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] |
includes\tsupplemental\tinsulin,\tfluid\tand\telectrolyte\n\treplacement,\tand\tmedical\tmonitoring.\tAcute\nillnesses\tsuch\tas\tflu,\tcolds,\tvomiting,\tand\tdiarrhea,\tif\tnot\tmanaged\tappropriately,\tcan\tlead\tto\tthe\ndevelopment\tof\tDKA.\tPatients\tneed\tto\tknow\tthe\tsteps\tto\ttake\tduring\tacute\tillness\tto\tprevent\tDKA\n(\nBox\t29.7
|
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] |
(\nBox\t29.7\n).\tDuring\tacute\tillness,\toral\tingestion\tof\tabout\t150\tto\t200\tg\tof\tcarbohydrates\tper\tday\t(45\tto\n50\tg\tevery\t3\tto\t4\thr)\tshould\tbe\tsufficient,\talong\twith\n\tmedication\tadjustments,\tto\tkeep\tglucose\tin\tthe\ngoal\trange\tand\tto\tprevent\tstarvation\tketosis.\nBOX\t29.7\nSick-Day\tGuidelines\tfor\tPersons\tWith\tDiabetes\n1.
|
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BOX\t29.7\nSick-Day\tGuidelines\tfor\tPersons\tWith\tDiabetes\n1.\t\nDuring\tacute\tillnesses,\tusual\tdoses\tof\tinsulin\tand\tother\tglucose-lowering\tmedications\tare\nrequired.\tThe\tneed\tfor\tinsulin\tcontinues,\tor\tmay\teven\tincrease,\tduring\tperiods\tof\tillness.\nFever,\tdehydration,\tinfection,\tor\tthe\tstress\tof\tillness\n\tcan\ttrigger\tthe\trelease\tof
|
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] |
can\ttrigger\tthe\trelease\tof\ncounterregulatory\tor\t“stress”\thormones,\tcausing\tblood\tglucose\tlevels\tto\tbecome\televated.\n2.\t\nBlood\tglucose\tlevels\tand\turine\tor\tblood\ttesting\tfor\tketones\tshould\tbe\tmonitored\tat\tleast\nfour\ttimes\tdaily\t(before\teach\tmeal\tand\tat\tbedtime).\tBlood\tglucose\treadings\texceeding\t250
|
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] |
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