The American Dietetic Association recommends a diet that emphasizes fruits, vegetables, whole grains, and fat free milk. This diet includes lean meats, poultry, fish, beans, eggs, and nuts. It is low in saturated fats, trans fats, cholesterol, salt, and added sugars. There is no perfect diet for everyone and diet should be individualized for each person based on age, activity, and preferences. My Pyramid can be found on the American Dietetic Association's website and the patient can input his or her own information and receive recommendations for dietary consumption.

Carbohydrate counting is generally accepted as the "state of the art" in diabetes management. Every patient with diabetes should be taught carbohydrate counting from the onset/diagnosis of diabetes. Carbohydrate counting is easy and practical and anyone can understand the concept. All food items have carbohydrates listed on the package somewhere. Patients need to be taught to look at the total carbohydrates since this is the most critical to blood glucose levels. Patients of any age are quite good at counting carbohydrates; even the elderly are able to master this task. If patients understand how many carbohydrates to consume, they are able to manage blood glucose levels and control weight. Women should not consume more than 45 to 60 g of carbohydrate per meal and 15 to 30 g for snacks. This should be individualized based on physical activity. If an elderly woman moves very little, she may need fewer than 45 g of carbohydrate per meal. If a woman is athletic, she may need more than 60 g of carbohydrate per meal, but this is a good starting point. Men need 60 to 75 g of carbohydrate per meal and 30 to 45 g for snacks. This also needs to be adjusted based on the activity level and age of the man.

Carbohydrate, protein, and fat all raise blood glucose levels. Carbohydrate raises glucose levels more quickly than protein or fat and usually has a peak effect of 90 to 120 minutes after the meal is consumed. Protein raises glucose levels closer to 4 hours after the meal and fat closer to 8 hours after the meal. This is critical to know in order to take the appropriate amount of insulin to cover the meal. Most insulin users have an insulin:carbohydrate ratio. This means that they take a certain amount of insulin to cover a certain amount of carbohydrate. They must be taught, however, the effect of high protein meals and high fat meals. The average starting point for an adult is one unit of insulin for 15 g of carbohydrate. This needs to be adjusted based on postprandial glucose levels. If glucose levels 1 to 2 hours after the meal are greater than 180 mg/dL (3), the insulin:carbohydrate ratio is not adequate. This, of course, is assuming that the preprandial glucose level is 70 to 120 mg/dL and the person bolused at least 15 minutes before the meal. Small changes can be made if the person is treated with an insulin pump as the pump can be programmed with small changes of the insulin:carbohydrate ratio. If a person were taking 1 unit/15 g of carbohydrate and was > 180 mg/dL 1.5 to 2 hours after the meal, the insulin:carbohydrate ratio could be changed to 1:12. This would also need to be tested until appropriate postprandial glucose levels are reached. If a person is consuming a large amount of fat at the meal, the bolus may need to be increased and extended. When a person with diabetes consumes a meal such as pizza, he or she will need to add extra carbohydrates to their estimate and set a combination bolus with a percent given immediately and a percent extended over several hours. My suggestion to patients eating a meal such as pizza is to add 20 to 30 g of carbohydrate to their estimate and take 70% before the meal and 30% over the next 5 to 6 hours. This helps to cover the initial rise of glucose from the carbohydrates and the later increase in absorption of the fat content. People usually continue to make adjustments to this until they achieve success, that is, glucose levels less than 180 mg/dL after the meal and 70 to 120 mg/dL before the next meal. A correction factor also needs to be calculated into the bolus dose of insulin. The pump will also do this once the correction factor/sensitivity factor is calculated for the patient. The patient would enter the glucose, if it is not already there, and the pump will calculate the amount of insulin it takes to reach the target glucose (my suggestion is 100 mg/dL for the target) so that the glucose comes closer to the desired range. If a patient is on injections, it is more difficult to determine all these calculations and draw them up in a syringe as you cannot calculate to an exact amount this way. Most people have to do this on multiple daily injections, but the outcome is not as good as it is with a pump simply because the dose is an estimate and not exact and syringes can only measure down to 0.5 unit where pumps can measure all the way to the 0.05 unit of insulin. It is simply not possible to duplicate this with injections.

When all is said and done, we simply eat too much in this country and this needs to be addressed in our nutrition counseling. In a survey of > 2000 adults with diabetes, the most frequently cited barrier to achieving self-management goals was adherence to diet and exercise (4). We eat too much fat and not enough vegetables and fruits, and do not exercise enough (5). Everyone is looking for the easy way out, a pill, that will fix it all for them. We know that medical nutrition therapy does make a difference (6). Diabetes medical nutrition therapy trials and outcome studies have demonstrated reductions in HbA1c of approximately 1% in type 1 diabetes (3). When a health-care provider advises a patient on weight loss (not just telling them they need to lose weight), patients are nearly three times as likely to act on the recommendation (7). Patients are more satisfied with their interactions with health-care providers when they receive information, support, and resources, especially when our messages are positive, nonjudgmental, and understanding of the difficulties of changing behavior (8). Patients should be referred to a dietitian who is knowledgeable and skilled in developing an individualized diabetes meal plan.

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