ACTIVITIES AT A GLANCE. Check them off as you complete them.

By midnight (11:55 pm) SUNDAY, complete Unit 6 Study Questions for 10 points (be certain you've FIRST done ALL of the Unit Preparation Questions below). (If you have any questions, post them in our "Forum Week 6" in Moodle.)

Sometime BEFORE SUNDAY, participate in our "Forum Week 6" by making at least two postings throughout the week with at least one of the postings BEFORE Friday evening. So the total MINIMUM is 2 postings on TWO different days. (A posting can be either posting a question you have or replying to a classmate's question or comment. You don't have to respond to all of the threads if you don't feel you have anything to add. You can also choose to respond more often.)

OBJECTIVES

After reading the assigned reading, filling out the Unit Preparations below, participating in the "Forum Week 6", and completing the Unit 6 Study Questions, you will be able to:

• Define the different types of diabetes and how they are diagnosed.
• Describe the most common complications associated with diabetes and how the risk of these complications can be reduced through glycemic control.
• Name the ABCs of Diabetes Control, and describe the role that nutrition, physical activity, and medications play in managing diabetes.
• Understand the different therapeutic dietary modifications that may be ordered with diabetes and when they may be appropriate.
• Continue understanding common medical nutrition terminology and relevant laboratory values.
   

RESOURCES

• Unit 6 Preparations (this document)
• Mosby's Pocket Guide Series Nutrition Assessment and Care, Ch 17: Diabetes Mellitus pp. 448-472
  
• Reading Calendar (above Week 1 in Moodle)
• Merriam Webster medical dictionary: http://www.merriam-webster.com/ (select "medical")
• Please use the online medical dictionary to look up any terminology you may not understand.

OPTIONAL RESOURCES

• Diabetes Awareness Education "It's Not Just About Sugar Anymore!"
• Artificial Sweetener May Disrupt Body's Ability To Count Calories, According To New Study  by sciencedaily.com. June 30, 2004 
  
• Are Artificial Sweeteners a Good Alternative To Sugar-Laden Foods? by Lindzie O'Reilly Nutrition Matters September 20, 2011
  
• Do Artificial Sweeteners Help You Lose Weight? by Rita Carey Rubin Today's Dietitian September 2011
  
• The Influence of Caffeine on Energy Content of Sugar-Sweetened Beverages- The 'Caffeine-Calorie Effect' by the European Journal of Clinical Nutrition (2011) 65, 1338-1344
  
• Center for Science in the Public Interest "Chemical Cuisine"
• Artificial Sweeteners or Sugar Substitutes by the Academy of Nutrition and Dietetics Evidence Analysis Library
  

WEEKLY FORUMS:
Each week, there will be a FORUM that will allow you to post any questions you have about the lecture or materials covered as well as allow the instructor to post any changes or corrections that need to be communicated.

A SQ will ask if you participated at least twice in this week's forum. (Refer the syllabus for additional details.)

FORUM WEEK 6: (Go to our Moodle classroom and click on "Forum Week 6" to participate.)

1. "Student Questions": Do you have any questions about the Unit 6 Preparations? Please post your questions/concerns in the forum for others to be able to respond.

2. "Preventing Diabetes: Small Changes Have Big Payoff": Click on the following link: Preventing Diabetes: Small Changes Have Big Payoff by Allison Aubrey.
   After listening to the story, please share anything new or interesting you learned or something you already knew but was confirmed in the clip.
   

3. "Ice Creams & Labeling": After completing the Unit Preparations section about "Carbohydrate Counting" below, what did you learn from the example of two ice creams? How can you apply this information to your current eating habits? (Do you buy "sugar-free" versions of different food items?)
   

4. "Diabetes Myths": Click on the following link: Diabetes Myths. Did you find out that you believed any of the myths included on the ADA website? If so, which one(s) did you think were true and what did you learn? (There are A LOT of misconceptions about diabetes and nutrition, such as diabetics cannot consume sugar. I hope this week we can challenge those misconceptions, and what better way than learning from those who have diabetes themselves.) Consider checking out the optional resources above for additional myth busting information too.
   

5. "15-30gm CHO Snacks": Once you've completed this week's Unit Preparations, specifically page 86 of your packet, share a possible daytime or bedtime snack that would be appropriate for someone with diabetes. The snack should be one carbohydrate choice (~15grams of CHO) if during the day and two carb choices if before bedtime. The snack should also include a food that is also good source of protein.

6. CORRECTIONS / CLARIFICATIONS: (Please check our weekly forum for additional corrections and clarifications.)

The following topics will be covered this week:
 

I. Chapter 17: Diabetes Mellitus


Read chapter 17 in your text and answer the following questions:
 

OVERVIEW OF DIABETES

Diabetes is seen in three primary forms: 

• Type 1 diabetes,
  
• Type 2 diabetes, and
  
• Gestational diabetes

Diabetes is a group of diseases characterized by hyperglycemia (high blood glucose levels) as a result from no insulin being secreted by the pancreas, or a defect in insulin action, or both. 

Without sufficient insulin, or a cell’s resistance to insulin, hyperglycemia occurs. High blood glucose results because insulin is the key that opens the door within cells for glucose to enter. Without insulin, glucose remains elevated in the blood. Hyperglycemia results in both short-term and long-term complications. Some acute, life-threatening consequences include ketoacidosis and nonketotic hyperosmolar syndrome. The long-term complications that arise from diabetes result from the blockage or destruction of capillaries that feed vital organs and tissue, and this causes the tissue to die from lack of nourishment. Problems include impaired circulation to extremities often leading to amputation, kidney and cardiovascular disease, impaired vision or blindness, nerve damage, and skin problems.

In 2007, the Centers for Disease Control and Prevention released data stating that 24 million Americans have diabetes and are estimating that another 57 million Americans have prediabetes. Type 2 diabetes is the most prevalent type of diabetes, and it is a progressive disease that is often present long before it is diagnosed. There are many risk factors associated with type 2 diabetes including weight and family history. Click on the below link to assess your risk for diabetes.

DIABETES RISK CALCULATOR

What was your risk level and what were your risk factors according to the diabetes risk calculator?

Diagnosis of Diabetes (Pg. 448 in text)

·   Plasma glucose level of ______ mg/dl or higher PLUS ____________ of diabetes, which include: polyuria (excessive urination), polydipsia (excessive thirst), and unexplained weight loss.

·   Fasting plasma glucose level of _______ mg/dl or higher.

·   Plasma glucose level of _______ mg/dl or higher 2 hours after an oral glucose tolerance test.

Classification of Diabetes (Pg. 448-449 in text)

• Type 1 diabetes- is characterized by insulin ______________.  Most individuals with type 1 diabetes are ___________ weight or ________weight.  ____________ treatment is needed to survive.
• Type 2 diabetes- is characterized by insulin _____________ (decreased uptake of glucose by cells in response to insulin). The majority of individuals with type 2 diabetes are _____________ or ___________.
• Gestational diabetes- any glucose intolerance that is recognized during _____________.

Of the three types of diabetes listed above, which one is the most prevalent amongst adults?

Prediabetes and Diabetes Prevention (Pg. 449 in text)

• ____________________________ (IFG) and _________________________ (IGT) are considered prediabetes
• Individuals with IFG and IGT are at increased risk for developing ____________.
• Diagnosis includes fasting glucose of _______ to ______ mg/dl or impaired glucose tolerance 2-hour values between _______ mg/dl and _______ mg/dl. 

What kind of diet and lifestyle changes should a prediabetic be encouraged to make?

Click on the following link:  Preventing Diabetes:  Small Changes Have Big Payoff by Allison Aubrey.

The following questions can be answered by reading the above article. I would encourage you to listen to the radio show as well, which gives a bit more detail than the article, and it is quite fun to listen to the Daly brothers being interviewed.

• According to the results of a large national study conducted at 27 sites around the country, are small lifestyle changes or drugs more successful at warding off diabetes?

• What kind of lifestyle changes did Tim make to ward off diabetes?

• True or False.  There is strong evidence that exercise, in the absence of weight loss, can help improve blood sugars.

Complications of Diabetes (Pg. 449-450 in text)

• Acute complications include diabetic ketoacidosis (DKA) and _______________ (low blood sugar) in type 1 diabetics.
• Acute complications include hyperglycemic hyperosmolar nonketotic syndrome (HHNS) and _________________ in type 2 diabetics.
• Chronic complications in both type 1 and type 2 diabetics include diseases of the heart, kidneys, eyes, and nerves.

What are some similarities and differences between DKA and HHNS?

Click on the following link:  Diabetes Complications to read more about how the heart, kidneys, eyes, and nerves can be affected by diabetes.

What complication did you read about?  What did you learn that was new or interesting?

Treatment Goals (Pg. 450-459 in text)

Diabetes is a chronic disease that requires lifetime changes in lifestyle since the management of diabetes depends on diet, exercise, and medications. The healthcare team (physicians, nurses, dietitians, and other health professionals) provides the diabetic with the tools needed to achieve the best possible control of carbohydrate, protein, and fat metabolism to prevent complications.

The patient and family must be able to understand and carry out the treatment with a great deal of ______________________.

Planning of care begins with _____________________ measurements and a thorough _________________ and ___________ history to assess the person's usual patterns.

Fill in the following values using Table 17-1 on pg. 454. (These are a summary of treatment goals by the American Diabetes Association (ADA) for adults with diabetes.)

• A1C < ____ %

• Preprandial (before meals) plasma glucose ____ - ____ mg/dl

• 1-2 hours Postprandial (after meals) plasma glucose < ______ mg/dl

• Blood Pressure < ____/____ mm Hg

• LDL < _____ mg/dl

• Triglycerides < _____ mg/dl

• HDL > _____ mg/dl

 
The A1C test is the primary target for glycemic (blood glucose) control, but what exactly is the A1C?  Click on the following link:  FACTS ABOUT A1C to answer the below questions about A1C.

• The A1C test measures your ___________ blood glucose control for the past ____ to ____ months.
• A diabetic’s A1C should be checked ___________ a year at a minimum.
• True or False.  A1C can replace daily self-testing of blood glucose.
• If a diabetic wants to know how their long-term blood glucose control has been, which test should they use?  A1C or home blood glucose meter?

Medications

• Type 1 diabetics (and sometimes type 2 as well) need __________.  This can either be administered through multiple injections, or with an insulin pump.
• Type 2 diabetes progresses along a ___________________, such that diet and lifestyle modifications may be sufficient to control blood glucose _______________, but eventually one or more noninsulin hypoglycemic agents and/or ____________ may need to be added.
  
• Once type 2 diabetics can no longer manage their diabetes through diet and exercise, noninsulin medications may be needed.  Noninsulin medications include:
  • Insulin sensitizers- stimulate __________ uptake by tissue
  • Insulin secretagogues- stimulate pancreas to release __________.
  • Incretins- stimulate __________ release, suppress glucagon secretion, and delay ___________ (stomach) emptying
• Both diabetes and overweight are risk factors for ____________________ disease.
  

What affect do insulin sensitizers, insulin secretagogues, and incretins have on blood sugar levels?

What are the 2 risks of intensive glycemic control (mentioned on pg. 456 in text)?

NUTRITION ASSESSMENT AND CARE (Pg. 459-464 in text)

Self-monitoring of blood glucose (SMBG)

• SMBG is done a minimum of _____ times daily in type 1 diabetes.
• SMBG is recommended for type 2 diabetics who are treated with _________ or sulfonylureas or who are not achieving their blood glucose _________. 

Medical Nutrition Therapy Goals

1. Maintain optimal blood pressure, glucose and lipids to normal as possible levels.

                Remember: The ABC’s OF DIABETES CONTROL

                ·    “A”: Keep your A1C under 7%.

                ·    “B”: Maintain your Blood pressure in the normal range (120/80).

                ·    “C”: Manage your Cholesterol with LDL (bad cholesterol) <100mg/dl.

2. Prevent and/or slow development of chronic complications.
3. Address ____________ needs.  Including cultural and personal needs while respecting willingness to change.
4. Maintain the ____________ of eating by not limiting any foods unless indicated by scientific evidence.

What information should be included in a basic patient education program?

Nutrition Guidelines

Nutrition therapy is an essential component of diabetes management.  People with diabetes usually have the same nutritional requirements as the general population.  Therefore, the dietary recommendations to promote health (lose weight if overweight, eat less saturated fat and cholesterol, eat more fiber and less sodium) in the general population are also appropriate for people with diabetes.  Since diabetics are at an increased risk for coronary heart disease (coronary heart disease is the leading cause of death amongst people with diabetes) the nutrition recommendations issued by the ADA to prevent and treat diabetes are similar to the recommendations made by the American Heart Association (AHA) to prevent heart disease.

Energy Balance

• A decreased Calorie intake and increased physical activity should be combined to achieve modest weight loss.
• Modest weight loss of ____ % to ____ % of body weight can improve insulin resistance and improve diabetic control. (For example, if an individual weighed 200 pounds, a modest weight loss would be 10 to 14 pounds.)
  

Explain why a high-protein, low-carbohydrate diet is not recommended for people with diabetes?

Carbohydrate

There are many misconceptions that diabetics have about carbohydrates. The muddiest points I have found diabetics to have is confusion about where you find carbohydrates in foods, and how much carbohydrate they should be consuming. There is a lot of education that needs to take place between the diabetic patient and the nutrition support staff about carbohydrates because this is one of the cornerstones in treatment for managing blood glucose levels. Here are some main points that diabetics should know about carbohydrates:

·        Carbohydrates will account for _____ % or more of Calories consumed in a day.  (Many diabetics are surprised their carbohydrate intake can be so high.)

·    Foods that contain carbohydrate are needed for energy. Carbohydrates break down into glucose and will raise blood sugar.  Carbohydrates from any food will have the same effect on blood glucose.

·    The source of carbohydrate is not as critical as the total amount of carbohydrate consumed at a meal or snack.  Substantial evidence from clinical studies shows that when sucrose is substituted for starch (at the same calorie level) there is no difference in glycemic control.  Sucrose and sucrose-containing foods do not have to be restricted but should be substituted for other carbohydrate containing foods, not eaten as "extras".  Care should be taken when choosing foods high in sugar as they are usually nutrient poor and may also be high in fat which can lead to excess Calorie intake.

·    Carbohydrates should be spread as _________ as possible across meals.

·    Eat healthy, well-balanced meals 4-5 hours apart on a regular schedule.

·    Carbohydrates with fiber should be a focus. At least ______ to _____ g of fiber daily is recommended, with even higher recommendations for men.

·    Sugar alcohols are often used in diabetic foods, but be careful because excessive amounts can cause ___________ (pg. 462 in text).

·    Special diabetic foods are not necessary, and a wide variety of whole foods can make up a healthy diabetic diet.

·    Nonnutritive sweeteners (aspartame, acesulfame K, sucralose, and saccharin) do not affect blood glucose levels. (Refer to the optional resources above for more information.)

·    Utilizing the glycemic index to decrease one's risk of disease still remains uncertain.

·    Monitoring of carbohydrates will depend on the skills and interest of the diabetic.  The following are some of the most commonly used methods:

1.      Exchange lists

2.      Carbohydrate Counting

3.      Plate Method

1. Exchange Lists

Click on the following link to look at how different foods are categorized within the exchange list and answer the questions below:  Exchange Lists

Which groups do not contain carbohydrates or minimal carbohydrates (5g or less per serving)? (Note: The website did not list the carbohydrate content for the milk group, but if you look at the milk label that was included in week 1 preparations, you will see that milk has about 12g of carbohydrate per cup.)

Which groups contain 15g of carbohydrate per serving (and therefore count as a carb choice)?

Which of the following types of foods are listed in the starch group?

a.      grains

b.      beans or legumes

c.       non-starchy vegetables

d.      starchy vegetables (e.g. corn, potato, peas)

According to the food lists, ½ c. carrots would have ____g of carbohydrate, and ½ c. corn would have _____ g of carbohydrate.

List some of the foods that fall into each of the groups:

    Vegetables-

    Milk-

    Protein-

    Fruits-

    Starches-

    Fats-

The above link is a summary, not a detailed list of the exchange lists.  If you are interested in seeing a more detailed list click on the following link: 

Food Nutrient Data for Choose Your Foods: Exchange Lists for Diabetes, 2007

2. Carbohydrate Counting

Carbohydrate counting is gaining popularity as an easier and more flexible alternative to exchange lists. Based on a client's usual pattern of eating and daily calorie allowance, clients are given an individualized meal pattern that specifies the number of carbohydrate "choices" (1 choice = 15g of carbohydrate).  In general, most women need 3-4 carb choices (45-60 grams of carbohydrates) per meal. Men need 5-6 carb choices (75-90 grams of carbohydrate) per meal. A reasonable snack is one (1) carb choice (15 grams of carbohydrate) during the day. Two (2) carb choices (30 grams of carbohydrate) at bedtime. 

Note: "Carb choices" are foods that fall into categories that contain 15g of carbohydrate per serving.

To help individuals identify sources of carbohydrates and the appropriate portion sizes, clients are given carbohydrate choice lists, similar to the exchange lists, but generally focused specifically on carbohydrates, not protein or fat. Clients will also need to learn to read food labels to accurately count carbohydrates. 

When determining how much carbohydrate a food contains look at the total carbohydrate per serving, which includes sugar, starch, and fiber. Check the grams of fiber per serving. If a serving provides >5 g total fiber, subtract 1/2 the total grams of fiber from the grams of carbohydrates. If the food contains sugar alcohols, half of the total grams of sugar alcohols can be subtracted from the total carbohydrate. If more than one serving is consumed, the carbohydrate must be adjusted accordingly. 

Compare the carbohydrate content of the following two ice creams:

Which ice cream has the least amount of carbohydrate?

Are you surprised by these findings?

What can you learn from this example?

3. Plate Method

• The plate method is a simple technique used to help diabetics with their carbohydrate portions without having to actually count carbohydrates.
• Rule of thumb is that ½ of the plate should be filled with non-starchy vegetables (broccoli, greens, carrots, zucchini), ¼ of the plate is a lean meat, and ¼ of the plate (about the size of a fist) is a carbohydrate containing food (rice, beans, potato).  Usually there is still room for one more carbohydrate choice on the side (for example a cup of milk).

 
Protein

• Adults with diabetes with normal kidney function have protein needs ___________ to those of the general population (10-35% of total energy needs).
• If chronic kidney disease develops, protein should be lowered to ___ to __ g/kg/day. 

Fat

• Total dietary fat should be moderate (____ % to ____ % of total energy needs).
• Monounsaturated and polyunsaturated (plant fats) should be emphasized.
• Saturated fats should be < ____ % of total energy intake.
• Trans fat should be minimal (less than 2grams a day).
• Cholesterol intake should be < _____ mg/day and _____ mg/day for those with elevated cholesterol.
• Eat 2 or more servings of fish a week. 

Alcohol

• Guidelines similar to general population, no more than ____ drinks for men, and _____ drink for women per day.
• Alcohol should be consumed with food, because drinking on an empty stomach may lead to __________________.

Vitamins, Minerals and Sodium

• No evidence of a benefit from vitamin or mineral supplementation.
• No evidence that supplements of _____________ have any benefit.
• Reduce sodium to less than ________ mg/day.

Often people seek alternative therapies for managing their health conditions. One alternative therapy popular amongst diabetics is chromium supplementation. Click on the following link to learn more about chromium.

• How might chromium help a diabetic manage their disease?

• Mosby mentions that there is NO evidence supporting benefits of chromium supplements.  Does the information in the above website agree or disagree with Mosby?

Physical Activity

• May improve insulin sensitivity, reduce cardiovascular risk factors, help control weight, and improve well-being.
• At least ______ min/week of moderate-intense aerobic activity.
• Resistance training _____ times per week.
• The person should not exercise if ______________ is present.
• If exercise is __________________, the insulin dosage can be ______________ to prevent hypoglycemic, but if it is _________________, extra _________________ will be needed.
  

Pregnancy and Lactation

• An infant of a diabetic in poor control at the time of conception is at risk for malformations or _________.

• Infants of diabetic women are at increased risk of ______________, respiratory distress syndrome, and excessive body size.

• To prevent congential anomalies, it is best if intensive therapy being before ____________________.

Coping with Acute Illness

True or False: It is not recommended to take insulin or other hypoglycemic medications when sick.

What is recommended when a diabetic becomes sick?

Hypoglycemia

• Blood glucose of < _____ mg/dL

• Can occur in both type 1 and type 2 diabetics

• Diabetic ketoacidosis occurs primarily in individuals with type ___ diabetes, whereas HHNS (hyperglycemic hyperosmolar nonketotic syndrome) is more common in the individual with type ___ diabetes.
  

What are the factors that can cause hypoglycemia?

What are some signs and symptoms of hypoglycemia?

How can hypoglycemia be corrected?

Diabetic Gastroparesis

What is diabetic gastroparesis?

What medical nutrition therapy is recommended for an individual with gastroparesis?

Using the Diet Manual

Read about The Reduced Concentrated Sweets Diet (RCS) and The Controlled Carbohydrate Diet (CCHO) in the diet manual, IMPAC (pgs. 45 & 46) and answer the questions below:

How are the RCS diet and the CCHO diet similar and different?

Which diet do you think would be most appropriate in a long-term care setting? Why?