Unit 7Unit 7Nutritional CounselingNutritional Counseling

Stacey Day, MS, RDStacey Day, MS, RD

Kaplan UniversityKaplan University

CounselingCounseling

Which stages are best suited for using Which stages are best suited for using motivational interviewing?motivational interviewing?

Motivational InterviewingMotivational Interviewing

The best stages for The best stages for using motivational using motivational interviewing are interviewing are the preaction the preaction stages of change– stages of change– precontemplation, precontemplation, contemplation, and contemplation, and prepartionprepartion

What are the four general principles What are the four general principles that guide MI?that guide MI?

Motivational InterviewingMotivational Interviewing

Express EmpathyExpress Empathy Develop Develop

discrepanciesdiscrepancies Roll with resistanceRoll with resistance Support self-Support self-

efficacyefficacy

It’s your turn!It’s your turn!

Write an example Write an example that expresses that expresses empathy in a empathy in a diabetic counseling diabetic counseling session.session.

It’s your turn!It’s your turn!

Write an example Write an example that develops that develops discrepancies in a discrepancies in a diabetic counseling diabetic counseling session.session.

It’s your turn!It’s your turn!

Write an example Write an example that rolls with that rolls with resistance in a resistance in a diabetic counseling diabetic counseling session.session.

It’s your turn!It’s your turn!

Write an example Write an example that supports self-that supports self-efficacy in a efficacy in a diabetic counseling diabetic counseling session.session.

Questions?Questions?

What are the warning signs of kidney What are the warning signs of kidney disease?disease?

Warning Signs of Warning Signs of Kidney DiseaseKidney Disease

High blood High blood pressurepressure

Swelling of the face Swelling of the face and anklesand ankles

Puffiness around Puffiness around the eyesthe eyes

Frequent urination Frequent urination (especially at (especially at night)night)

Acute Renal Failure (ARF)Acute Renal Failure (ARF) ARF – alteration in ARF – alteration in

ability to excrete ability to excrete metabolic wastemetabolic waste OliguriaOliguria

Production of less Production of less than 500mL in 24 than 500mL in 24 hourshours

OR normal urine flow OR normal urine flow decreasesdecreases

Occurs in healthy Occurs in healthy kidneyskidneys

Lasts few days – Lasts few days – several weeksseveral weeks

GFR – The quantity GFR – The quantity of glomerular of glomerular filtrate formed per filtrate formed per unit in all nephrons unit in all nephrons of both kidneys.of both kidneys.

Oliguria – Oliguria – Reduction of urine Reduction of urine outputoutput

Chornic Renal Failure (CRF)Chornic Renal Failure (CRF)

Inability of kidney function to return Inability of kidney function to return normal after ARF or progressive renal normal after ARF or progressive renal decline from disease.decline from disease.

Causes permanent reduction in fxn, Causes permanent reduction in fxn, leading to ESRD.leading to ESRD.

Azotemia is common in CRGAzotemia is common in CRG Excess urea and nitrogenous wastes in Excess urea and nitrogenous wastes in

the bloodstream.the bloodstream.

CRF CausesCRF Causes

DiabetesDiabetes Causes 15% new Causes 15% new

cases per year (1995)cases per year (1995) HypoparathyroidismHypoparathyroidism Regurrent acute or Regurrent acute or

chrnoic chrnoic glomerulonephiritisglomerulonephiritis

Tubular diseaseTubular disease Chronic Chronic

hypercalcemiahypercalcemia

Chronic hyperkalemiaChronic hyperkalemia Vascular diseaseVascular disease PyelonephritisPyelonephritis Renal caculi or Renal caculi or

neoplasmsneoplasms Systemic lupus Systemic lupus

erythematosus,erythematosus, AmyloidosisAmyloidosis Analgesic abuseAnalgesic abuse

CRF: Signs and SymptomsCRF: Signs and Symptoms

Severe headacheSevere headache DyspneaDyspnea Pitting Edema of Pitting Edema of

the hands and legsthe hands and legs Failing visionFailing vision Poor appetitePoor appetite N/VN/V Abdominal painAbdominal pain

Mouth ulcersMouth ulcers HiccupsHiccups Boing and joint Boing and joint

painpain FatigueFatigue Uremic convulsionsUremic convulsions PericarditisPericarditis

CRF: General CautionsCRF: General Cautions Decrease risksDecrease risks

Smoking, Chronic anemia, and HTN in renal pts Smoking, Chronic anemia, and HTN in renal pts may reduce death rates from CHD.may reduce death rates from CHD.

Early nutritional interventionEarly nutritional intervention Delay or prevent rapid progression of disease in Delay or prevent rapid progression of disease in

some patients.some patients. The Modified Diet in Renal DiseaseThe Modified Diet in Renal Disease

Study significantly correlates the delay of Study significantly correlates the delay of disease progression with control over protein disease progression with control over protein and Phospohorous.and Phospohorous.

CRFCRF

Chronic dialysis may be needed with Chronic dialysis may be needed with pts who have bone disease or pts who have bone disease or malnutrition.malnutrition.

Mortality Mortality with Alb < 3.5 mg/dl with Alb < 3.5 mg/dl Low Chol (Low Chol ( 100) = severe 100) = severe

malnutritionmalnutrition Infants and Children may need TF to Infants and Children may need TF to

meet catch-up growth needs.meet catch-up growth needs.

CRF: ObjectivesCRF: Objectives Control uremic symptoms and complications Control uremic symptoms and complications

from accumulation of nitrogenous waste.from accumulation of nitrogenous waste. AA = minimal RDAsAA = minimal RDAs

Restore and maintain electrolyte balanceRestore and maintain electrolyte balance Correct acidosis and anemiaCorrect acidosis and anemia

Limit further renal impairmentLimit further renal impairment Reduce kidney workloadReduce kidney workload

Minimize tissue catabolismMinimize tissue catabolism Negative nitrogen balanceNegative nitrogen balance

CRF: Objectives Continued...CRF: Objectives Continued... MaintainMaintain

Nutritional statusNutritional status WeightWeight MoraleMorale AppetiteAppetite

Postpone dialysisPostpone dialysis Maintain growthMaintain growth

CaloriesCalories VitsVits MineralsMinerals

CRF: Dietary and Nutritional CRF: Dietary and Nutritional RecsRecs

Adequate calories to prevent tissue Adequate calories to prevent tissue catabolismcatabolism

If edemicIf edemic Restrict sodium 1-3g NA, Restrict Restrict sodium 1-3g NA, Restrict

Phosphorous if needed: 8-12mg/kg IBW Phosphorous if needed: 8-12mg/kg IBW (mainly dairy foods).(mainly dairy foods).

If K If K , limit dietary K and salt , limit dietary K and salt substitutes.substitutes.

CRF: Dietary and Nutritional CRF: Dietary and Nutritional RecsRecs

Severe stages of CRFSevere stages of CRF Restrict Protein – 0.6 -0.6 g/kg IBWRestrict Protein – 0.6 -0.6 g/kg IBW 60-70% HBV, 30-40% LBV60-70% HBV, 30-40% LBV

Fluid IntakeFluid Intake Output + 500 – 1000 ml for insensible losses.Output + 500 – 1000 ml for insensible losses.

CHO intolerance commonCHO intolerance common Fructose, galactose, and sorbitol are well Fructose, galactose, and sorbitol are well

tolerated.tolerated.

CRF: Dietary and Nutritional CRF: Dietary and Nutritional RecsRecs

Adequate B6, folic acid, vitamin C.Adequate B6, folic acid, vitamin C. Calcium 1200 – 1600 mg/dayCalcium 1200 – 1600 mg/day TPN be careful with excess of TPN be careful with excess of

micronutrients.micronutrients. TF use special products such as TF use special products such as

Nepro or Suplena.Nepro or Suplena.

CRF: Patient EducationCRF: Patient Education Indicate which food sources must be Indicate which food sources must be

restricted or used more frequently.restricted or used more frequently. Referral to a renal dietitian, Referral to a renal dietitian,

especially if on dialysis.especially if on dialysis. Use more milk and eggs than meat.Use more milk and eggs than meat.

Meat produces more nitrogenous Meat produces more nitrogenous waste.waste.

HBV proteins consumed daily.HBV proteins consumed daily.

CRF: Patient EducationCRF: Patient Education

Taste changes may occurTaste changes may occur Sharp, distinct flavors may be better Sharp, distinct flavors may be better

tolerated.tolerated. Lack of red meats is common.Lack of red meats is common.

Low-protein wheat starch, hard Low-protein wheat starch, hard candy, and jellycandy, and jelly

Dietary restriction is a vital element Dietary restriction is a vital element in therapy.in therapy.

CRF: Patient EducationCRF: Patient Education

Have pt. weigh themselves daily.Have pt. weigh themselves daily. Read food labels and measure foods Read food labels and measure foods

is essential.is essential. Teach client how to read a restaurant Teach client how to read a restaurant

menu, plan for box lunches, and menu, plan for box lunches, and eating away from home.eating away from home.

Goal of MNT for CRFGoal of MNT for CRF

Slow the decline in Slow the decline in renal function, renal function, which will decrease which will decrease long-term health long-term health care cost and care cost and prolong an prolong an independent independent quality of life.quality of life.

What is DiabetesWhat is Diabetes

Problem with fuel delivery in bodyProblem with fuel delivery in body Body cells need glucoseBody cells need glucose Glucose cannot get into the cells without insulinGlucose cannot get into the cells without insulin

““Diabetes is a group of diseases marked by high Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in levels of blood glucose resulting from defects in insulin production or insulin action or both”insulin production or insulin action or both”

2007 National Diabetes Fact 2007 National Diabetes Fact SheetSheet

Carbohydrate food – digests Carbohydrate food – digests to glucose which enters the to glucose which enters the

blood blood Starches, bread, Starches, bread,

pasta, rice, cereal, pasta, rice, cereal, snacks, potatoes, snacks, potatoes, peas, cornpeas, corn

Fruit, juiceFruit, juice Milk, yogurtMilk, yogurt Desserts, candyDesserts, candy Sugar BeveragesSugar Beverages

Glucose requires insulin to Glucose requires insulin to move into the cells. move into the cells.

Insulin ResistanceInsulin Resistance

http://www.hivandhepatitis.com/0_images_2008/insualin2..jpg

Liver produces glucoseLiver produces glucose

Liver maintains glucose balance in the Liver maintains glucose balance in the bloodblood

Controlled by 2 hormones insulin and Controlled by 2 hormones insulin and glucagonglucagon

Important during sleep, between meals, Important during sleep, between meals, illness when we cannot eat. illness when we cannot eat.

Imbalance with diabetes in that the liver Imbalance with diabetes in that the liver also produces extra insulin when it is not also produces extra insulin when it is not needed. needed.

Types of DiabetesTypes of Diabetes

Type 1 – Insulin dependent, juvenile Type 1 – Insulin dependent, juvenile onset onset

Type 2 – Insulin ResistanceType 2 – Insulin Resistance

Gestational Diabetes Gestational Diabetes

Pre DiabetesPre Diabetes

Type I DiabetesType I Diabetes

Auto immune disorder resulting in the bodies Auto immune disorder resulting in the bodies immune system destroying the beta cells of the immune system destroying the beta cells of the pancreas that produce insulin.pancreas that produce insulin.

Insulin is needed to regulate blood glucoseInsulin is needed to regulate blood glucose Requires insulin injections to liveRequires insulin injections to live Affects children and young adultsAffects children and young adults 5-10% of diagnosed cases of Diabetes5-10% of diagnosed cases of Diabetes Risk factors – autoimmune, genetic, Risk factors – autoimmune, genetic,

environmentalenvironmental 2007 National Diabetes Fact Sheet2007 National Diabetes Fact Sheet

Type 2 DiabetesType 2 Diabetes

In adults accounts for 90-95% of casesIn adults accounts for 90-95% of cases Insulin resistance results in the pancreas being Insulin resistance results in the pancreas being

over worked to produce extra insulin and over time over worked to produce extra insulin and over time wearing out the Beta cells resulting in decreased wearing out the Beta cells resulting in decreased insulin production and elevated blood sugars.insulin production and elevated blood sugars.

Associated with adults, obesity, gestational Associated with adults, obesity, gestational diabetes, impaired glucose metabolism, physical diabetes, impaired glucose metabolism, physical inactivity, race and ethnicityinactivity, race and ethnicity

Increasing diagnosis occurring in overweight Increasing diagnosis occurring in overweight childrenchildren 2007 National Diabetes Fact Sheet2007 National Diabetes Fact Sheet

Gestational DiabetesGestational Diabetes Hormones produced during pregnancy results Hormones produced during pregnancy results

in insulin resistance. in insulin resistance. Elevated blood sugars can lead to birth Elevated blood sugars can lead to birth

defects for baby, spontaneous abortions, large defects for baby, spontaneous abortions, large size babies and complications during deliverysize babies and complications during delivery

Most common in Most common in African/Hispanic/Latino/American IndiansAfrican/Hispanic/Latino/American Indians Obese women with family history of DMObese women with family history of DM

5-10% of women with GDM found to have DM 5-10% of women with GDM found to have DM 22

40-60% chance to get DM in next 5-10 years40-60% chance to get DM in next 5-10 years

2007 National Diabetes Fact Sheet2007 National Diabetes Fact Sheet

Pre DiabetesPre Diabetes Also can be referred to asAlso can be referred to as

Impaired Glucose ToleranceImpaired Glucose Tolerance Impaired Fasting glucoseImpaired Fasting glucose

Prevalence 2003-2006 data ~26% of Prevalence 2003-2006 data ~26% of adults >20adults >20

2007 National Diabetes Fact 2007 National Diabetes Fact SheetSheet

Pre DiabetesPre Diabetes

Most people have pre diabetes before Most people have pre diabetes before progressing to Type 2 Diabetes.progressing to Type 2 Diabetes.

Most people will progress to Type 2 Most people will progress to Type 2 Diabetes within 10 years.Diabetes within 10 years.

Lifestyle intervention to Lifestyle intervention to lose weightlose weight, , increase activity can prevent or delay the increase activity can prevent or delay the onset of diabetesonset of diabetes

2007 National Diabetes Fact Sheet2007 National Diabetes Fact Sheet

Risk Factors for Risk Factors for DiabetesDiabetes

Age 45 and olderAge 45 and older Overweight (BMI Overweight (BMI ≥≥ 25) 25) HypertensionHypertension Abnormal lipid levelsAbnormal lipid levels Family history of diabetesFamily history of diabetes Race/ethnicityRace/ethnicity History of gestational History of gestational

diabetesdiabetes

American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.

• History of vascular disease• Signs of insulin resistance

(such as PCOS or acanthosis nigricans)

• Impaired glucose tolerance or• Impaired fasting glucose on previous test• Inactive lifestyle

Diagnostic Criteria for Diagnostic Criteria for Pre-diabetes and Pre-diabetes and

DiabetesDiabetesFasting Plasma

Glucose Test (FPG)2-Hour Glucose Challenge Test

Acceptable Below 100 mg/dl Below 140 mg/dl

Pre-diabetes

100-125 mg/dl (IFG) 140-199 mg/dl (IGT)

Diabetes 126 mg/dl or above 200 mg/dl or above

American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.

.

ComplicationsComplications

Heart Disease and Heart Disease and StrokeStroke

High Blood PressureHigh Blood Pressure BlindnessBlindness Kidney DiseaseKidney Disease Nervous System Nervous System

DiseasesDiseases AmputationsAmputations Dental DiseaseDental Disease Complications in Complications in

pregnancypregnancy

OtherOther Biochemical imbalances Biochemical imbalances

that can be life threatening that can be life threatening including: Ketosis, Comaincluding: Ketosis, Coma

More susceptible to More susceptible to illnesses, and often have illnesses, and often have worse prognosisworse prognosis

Persons >60 are 2-3 times Persons >60 are 2-3 times more likely to be have more likely to be have shortness of breath with shortness of breath with climbing stairs, walking, climbing stairs, walking, housework than persons housework than persons without diabetes at same without diabetes at same ageage

Controlling DiabetesControlling Diabetes

By managing the ABCs of diabetes, By managing the ABCs of diabetes, people with diabetes can reduce their people with diabetes can reduce their risk for heart disease and stroke.risk for heart disease and stroke.

AA stands for stands for AA1C1C

BB stands for stands for BBlood pressurelood pressure

CC stands for stands for CCholesterolholesterol

A1CA1C

A1CA1C measures average blood glucose measures average blood glucose over the last three months.over the last three months.

The higher the blood glucose the more The higher the blood glucose the more sugar attaches to Red Blood Cellssugar attaches to Red Blood Cells

A1C should be checked at least twice a A1C should be checked at least twice a year.year.

A1C goal is < 7A1C goal is < 7

To control A1CTo control A1C

Follow modified Carbohydrate meal planFollow modified Carbohydrate meal plan Don’t skip mealsDon’t skip meals Eat the right kind of carbohydrates & Eat the right kind of carbohydrates &

distribute evenly in daydistribute evenly in day Regular activity ~ 150 minutes per weekRegular activity ~ 150 minutes per week Weight lossWeight loss Take medications as prescribedTake medications as prescribed

Blood PressureBlood Pressure

High blood pressure increases risk High blood pressure increases risk for heart attack, stroke, eye for heart attack, stroke, eye problems and kidney disease. problems and kidney disease.

Check blood pressure at every Check blood pressure at every medical every visit.medical every visit.

Target BP = less than 130/80Target BP = less than 130/80

To control blood pressureTo control blood pressure

DASH diet – fruits, vegetables, whole DASH diet – fruits, vegetables, whole grainsgrains

1500-2300 mg sodium1500-2300 mg sodium Limit caffeine and alcoholLimit caffeine and alcohol Exercise 30 minutes most days of weekExercise 30 minutes most days of week Weight lossWeight loss Eliminate first and second hand smokeEliminate first and second hand smoke Take blood pressure medicationsTake blood pressure medications

CholesterolCholesterol

Blood LipidsBlood Lipids LDL (“louseyl”) cholesterolLDL (“louseyl”) cholesterol - can - can

narrow or block blood vesselsnarrow or block blood vessels HDL (“happy”) cholesterolHDL (“happy”) cholesterol - helps - helps

remove cholesterol depositsremove cholesterol deposits Triglycerides Triglycerides - can raise your risk - can raise your risk

for heart attacks/strokefor heart attacks/stroke

Cholesterol TargetsCholesterol Targets

Target LDL = less than 100Target LDL = less than 100

Target HDL = above 40 (men)Target HDL = above 40 (men)

above 50 (women)above 50 (women)

Target triglycerides = less than 150Target triglycerides = less than 150

To control cholesterolTo control cholesterol

Therapeutic Lifestyle Change “TLC” Therapeutic Lifestyle Change “TLC” (modified sodium and saturated fat)(modified sodium and saturated fat)

Physical activity 30 minutes most Physical activity 30 minutes most days/weekdays/week

10-20 pounds weight loss10-20 pounds weight loss Increase soluble fiberIncrease soluble fiber Add Omega 3 fatty acidAdd Omega 3 fatty acid Smoking cessationSmoking cessation

Goal:Goal:

Goal is to normalize blood glucose Goal is to normalize blood glucose

1.1. Diet - limit carbohydrate (CHO) – thus Diet - limit carbohydrate (CHO) – thus reducing blood glucosereducing blood glucose

2.2. Exercise (improves insulin efficiency)Exercise (improves insulin efficiency)

3.3. MedicationMedication Stimulate pancreas to make insulinStimulate pancreas to make insulin Increase insulin efficiency & reduce liver output Increase insulin efficiency & reduce liver output

of glucoseof glucose Insulin injectionsInsulin injections Preserve pancreas function in prediabetesPreserve pancreas function in prediabetes

How the body uses CHOHow the body uses CHO

Carbohydrate foods (grains, starches, fruit, Carbohydrate foods (grains, starches, fruit, sweets) break down to GLUCOSEsweets) break down to GLUCOSE

Protein foods (meats, nuts, beans) break Protein foods (meats, nuts, beans) break down to AMINO ACIDSdown to AMINO ACIDS

Fat foods (oils, butter, margarine, avocado, Fat foods (oils, butter, margarine, avocado, bacon) break down to FATTY ACIDS. bacon) break down to FATTY ACIDS.

CHO foods have greatest immediate CHO foods have greatest immediate influence of Blood Sugarinfluence of Blood Sugar

Individualized Meal PlanIndividualized Meal Plan Calorie & CHO goal (typically high fiber)Calorie & CHO goal (typically high fiber) Exercise recommendations Exercise recommendations Coaching & support for behavior changeCoaching & support for behavior change Weight lossWeight loss Additional factors for other health concernsAdditional factors for other health concerns

SodiumSodium FatsFats Calcium/Magnesium/PotassiumCalcium/Magnesium/Potassium Fluids/FiberFluids/Fiber

1 serving carbohydrate (15 1 serving carbohydrate (15 grams) Examples:grams) Examples:

1 small piece of fresh fruit (4 oz) 1 small piece of fresh fruit (4 oz) 1/2 cup of canned or frozen fruit 1/2 cup of canned or frozen fruit 1 slice of bread (1 oz) or 1 (6 inch) tortilla 1 slice of bread (1 oz) or 1 (6 inch) tortilla 1/2 cup of oatmeal 1/2 cup of oatmeal 1/3 cup of pasta or rice 1/3 cup of pasta or rice 4-6 crackers 4-6 crackers 1/2 English muffin or hamburger bun 1/2 English muffin or hamburger bun 1/2 cup of black beans or starchy vegetable 1/2 cup of black beans or starchy vegetable 1/4 of a large baked potato (3 oz) 1/4 of a large baked potato (3 oz)

1 serving carbohydrate (15 1 serving carbohydrate (15 grams) Examples:grams) Examples:

2/3 cup of plain fat-free yogurt or sweetened with 2/3 cup of plain fat-free yogurt or sweetened with sugar substitutes sugar substitutes

2 small cookies 2 small cookies 2 inch square brownie or cake without frosting 2 inch square brownie or cake without frosting 1/2 cup ice cream or sherbet 1/2 cup ice cream or sherbet 1 Tbsp syrup, jam, jelly, sugar or honey 1 Tbsp syrup, jam, jelly, sugar or honey 2 Tbsp light syrup 2 Tbsp light syrup 6 chicken nuggets 6 chicken nuggets 1/2 cup of casserole 1/2 cup of casserole 1 cup of soup 1 cup of soup 1/4 serving of a medium french fry1/4 serving of a medium french fry

Diabetes Meal Planning – 1Diabetes Meal Planning – 1stst Step: Determine Calorie LevelStep: Determine Calorie Level

You can use any of these methods:You can use any of these methods: Indirect calorimetryIndirect calorimetry REE Mifflin St JeorREE Mifflin St Jeor TEE using activity factorTEE using activity factor For weight loss For weight loss

3500 calories/pounds divide 7 days (week) = 500 = 3500 calories/pounds divide 7 days (week) = 500 = 1 pound/week1 pound/week

7000 calories/pound divide 7 days (week) = 1000 or 7000 calories/pound divide 7 days (week) = 1000 or 2 pound per week.2 pound per week.

Subtract 500 or 1000 calories from TEE for weight Subtract 500 or 1000 calories from TEE for weight lossloss

I usually go with calculated REE, and not less than I usually go with calculated REE, and not less than 1200 unless I have indirect caloriemtery results. 1200 unless I have indirect caloriemtery results.

Diabetes Meal Planning – 2nd Diabetes Meal Planning – 2nd Step: Determine Calorie LevelStep: Determine Calorie Level

Determine Calorie Level - 1800 calories Determine Calorie Level - 1800 calories exampleexample

Determine Nutrition Standards – ADA exampleDetermine Nutrition Standards – ADA example 40% CHO, 30-35% Fat, <10% Saturated Fat40% CHO, 30-35% Fat, <10% Saturated Fat

1800 calories x 40% = 720 calories1800 calories x 40% = 720 calories 4 calories/gram CHO4 calories/gram CHO 720 divided by 4 = 180 grams CHO for the day720 divided by 4 = 180 grams CHO for the day

1800 calories x 30-35% = 560- 630 grams1800 calories x 30-35% = 560- 630 grams 9 grams/calorie = 60-70 grams9 grams/calorie = 60-70 grams

1800 calories x 10% = 180 / 9 = 20 grams1800 calories x 10% = 180 / 9 = 20 grams

Diabetes Meal Planning – 3Diabetes Meal Planning – 3rdrd Step: Carbohydrate Step: Carbohydrate

DistributionDistribution 3 meals, and snacks as needed – depending on 3 meals, and snacks as needed – depending on medications.medications.

Meals:Meals: Women/weight loss : 30-45 grams carbohydrate per Women/weight loss : 30-45 grams carbohydrate per

meal (2-3 servings of carbohydrate)meal (2-3 servings of carbohydrate) Men/weight loss : 45 – 60 grams carbohydrate per Men/weight loss : 45 – 60 grams carbohydrate per

meal (3-4 servings of carbohydrate)meal (3-4 servings of carbohydrate) SnacksSnacks

Women/weight loss: 0-15 grams carbohydrate per Women/weight loss: 0-15 grams carbohydrate per snack (0-1 servings carbohydrate)/ add protein or snack (0-1 servings carbohydrate)/ add protein or veggiesveggies

Men/weight loss: 0-30 grams carbohydrate per Men/weight loss: 0-30 grams carbohydrate per snack (1-2 servings carbohydrate)/add protein or snack (1-2 servings carbohydrate)/add protein or veggiesveggies

Sample Meal PlanSample Meal Plan

1800 calories/180 g CHO1800 calories/180 g CHO Breakfast 500 calories/45 g CHO or 3 CHO choiceBreakfast 500 calories/45 g CHO or 3 CHO choice Lunch 500 calories/45 g CHO or 3 CHO choiceLunch 500 calories/45 g CHO or 3 CHO choice PM Snack 100 calories/30 g CHO or 2 CHO choicePM Snack 100 calories/30 g CHO or 2 CHO choice Supper 500 calories/45 g CHO or 3 CHO choiceSupper 500 calories/45 g CHO or 3 CHO choice HS Snack 200 calories/15 g CHO or 1 CHO choiceHS Snack 200 calories/15 g CHO or 1 CHO choice

Possible example if counting calories/CHO as we Possible example if counting calories/CHO as we do in our Diabetes Clinicdo in our Diabetes Clinic

Case Study #1Case Study #1 J.R., a 16 year old female is present with her mother to discuss elevated blood sugars. J.R., a 16 year old female is present with her mother to discuss elevated blood sugars.

Her mother tells you her daughter has had diabetes since the age of 8 and has always Her mother tells you her daughter has had diabetes since the age of 8 and has always done really well with it- monitoring, taking the correct amount of insulin and eating done really well with it- monitoring, taking the correct amount of insulin and eating about 45-60 gm of total carbohydrates at breakfast, lunch and dinner and about 30 gm about 45-60 gm of total carbohydrates at breakfast, lunch and dinner and about 30 gm of carbohydrates for an afternoon and possibly an evening snack. Her mother is of carbohydrates for an afternoon and possibly an evening snack. Her mother is concerned because for the past 6 months, or since she has started her junior year of concerned because for the past 6 months, or since she has started her junior year of high school and started to date a boy, her blood sugars have been erratic and more or high school and started to date a boy, her blood sugars have been erratic and more or less in the 300-500s. She reports she does not believe her daughter is checking her less in the 300-500s. She reports she does not believe her daughter is checking her blood sugars like she needs to be or eating correctly or even taking the right amount of blood sugars like she needs to be or eating correctly or even taking the right amount of insulin. She also indicates her daughter has lost about 30 lbs within these past 6 insulin. She also indicates her daughter has lost about 30 lbs within these past 6 months and she does not know what to do. The daughter or client was very quiet during months and she does not know what to do. The daughter or client was very quiet during this time, so you had asked both the client and her mother if it would be alright for the this time, so you had asked both the client and her mother if it would be alright for the mom to wait outside. The client eagerly agreed. When you had the client alone she mom to wait outside. The client eagerly agreed. When you had the client alone she tells you all her friends are super skinny and because of all this insulin she has to take tells you all her friends are super skinny and because of all this insulin she has to take she got fat (however when you look at her, she looks emaciated.). So she heard that if she got fat (however when you look at her, she looks emaciated.). So she heard that if you keep your blood sugars really high you can lose weight very quickly. She also tells you keep your blood sugars really high you can lose weight very quickly. She also tells you she eats 2 meals a day and does not even count carbohydrates any longer. She you she eats 2 meals a day and does not even count carbohydrates any longer. She informs you she takes half of the insulin amount she needs to and does not even do the informs you she takes half of the insulin amount she needs to and does not even do the correction factor.correction factor.

Height: 5’4” Weight: 110 lbs Weight history: 140 lbs (4 months ago per MD chart)Height: 5’4” Weight: 110 lbs Weight history: 140 lbs (4 months ago per MD chart) Labs: Blood sugar monitor for past 3 days only 4 numbers on there: 350-highLabs: Blood sugar monitor for past 3 days only 4 numbers on there: 350-high

Is this a form of an eating disorder and if so which type?Is this a form of an eating disorder and if so which type? How would you counsel this client?How would you counsel this client? Would you tell the mom your conversation?Would you tell the mom your conversation?

Case Study #2Case Study #2

A 42 year old woman, R.S., is present and very distraught that A 42 year old woman, R.S., is present and very distraught that she will have to be on dialysis in another year if she does not she will have to be on dialysis in another year if she does not start taking care of herself. When asked, the client told you start taking care of herself. When asked, the client told you the doctor told her this would happen. She informed you she the doctor told her this would happen. She informed you she does have a past medical history of diabetes, hypertension, does have a past medical history of diabetes, hypertension, renal failure and high cholesterol. She reports she is eating renal failure and high cholesterol. She reports she is eating very little protein, not that much salt and just does not know very little protein, not that much salt and just does not know what else to do. She brought in her most current labs- BUN 24, what else to do. She brought in her most current labs- BUN 24, Creatinine 2.3, Sodium 135, Potassium 4.1, Phosphorus 5.0, Creatinine 2.3, Sodium 135, Potassium 4.1, Phosphorus 5.0, Glucose 105. Height: 5’5” Weight: 130 pounds Glucose 105. Height: 5’5” Weight: 130 pounds

Medications: Multivitamins, Omega 3s, Lipitor, Lasix, AtenololMedications: Multivitamins, Omega 3s, Lipitor, Lasix, Atenolol

What stage of change do you believe the patient is in?What stage of change do you believe the patient is in? What is her BMI and what do her labs indicate to you?What is her BMI and what do her labs indicate to you? What nutrition information would you provide to her?What nutrition information would you provide to her? What goals would you establish with her?What goals would you establish with her? Would you follow up with her?Would you follow up with her?

Case Study #3Case Study #3

A 20 year old female, E.D., is present with type 1 diabetes and is coming to A 20 year old female, E.D., is present with type 1 diabetes and is coming to you because her blood sugars have been high for the past month. She you because her blood sugars have been high for the past month. She currently is in her 3currently is in her 3rdrd year of undergraduate studying engineering. She year of undergraduate studying engineering. She reports she has had diabetes since the age of 5 and knows how to reports she has had diabetes since the age of 5 and knows how to carbohydrate count and administer the correct amount of insulin to the carbohydrate count and administer the correct amount of insulin to the amount of carbohydrates consumed, she also checks her blood sugars at amount of carbohydrates consumed, she also checks her blood sugars at least 4 times per day and when she feels bad or is sick. She admits she least 4 times per day and when she feels bad or is sick. She admits she has been staying up later at night and eating more because of her difficult has been staying up later at night and eating more because of her difficult classes. She also goes out on Friday nights and will drink 2-3 bottles of classes. She also goes out on Friday nights and will drink 2-3 bottles of beer. She has not been exercising as much and has gained at least 10 beer. She has not been exercising as much and has gained at least 10 pounds within the past 6 months. She would like to know how many pounds within the past 6 months. She would like to know how many calories and carbohydrates she needs to consume per day and how to stop calories and carbohydrates she needs to consume per day and how to stop the late night eating.the late night eating.

Height: 5’9” Weight: 170 pounds Weight history: 160 pounds (6 months Height: 5’9” Weight: 170 pounds Weight history: 160 pounds (6 months ago)ago)

Labs for the past 24 hours: fasting 150, before lunch 200, before dinner Labs for the past 24 hours: fasting 150, before lunch 200, before dinner 180, before bed 300180, before bed 300

Medications: Rapid acting insulin (Novolog), Long acting insulin (Lantus)Medications: Rapid acting insulin (Novolog), Long acting insulin (Lantus)

What is her BMI?What is her BMI? What do her labs mean to you and what about the medications? What do her labs mean to you and what about the medications? What stage of change is the client in?What stage of change is the client in? How many calories and carbohydrates would you provide to her?How many calories and carbohydrates would you provide to her? Would you provide her with anymore nutrition information?Would you provide her with anymore nutrition information? What goals would you establish with her?What goals would you establish with her? Would you follow up with her?Would you follow up with her?