Amy P. Campbell, MS, RD, CDE, and Richard S. Beaser, M.D.
The weeks excerpt answers the following questions:
- The best way to approach "Behavioral Change"?
- What is the "Nutrition Prescription"?
- The 17 Questions you need to ask in the "Patient Nutrition Assessment"?
Initiating Medical Nutrition Therapy
From the initial diagnosis of diabetes, it is important that all healthcare professionals emphasize the central role that medical nutrition therapy has in the overall treatment strategy. While the availability of newer medications lightens the burden on dietary adherence in achieving glucose control goals, reaching such goals is not nearly as likely to occur without a proper medical nutrition program. Patients need to hear this message from the beginning, and repeatedly throughout the course of treatment.
A medical nutrition therapy program for a person with diabetes should be designed and prescribed just as any other medical treatment would be.In designing this program, the theories discussed above are translated into practical guidelines for individuals to follow. The American Diabetes Association, the American Dietetic Association and Joslin Diabetes Center have developed guidelines and curricula for nutrition education.
Nutrition education is not a one-time event. It is an ongoing process. The first time patients are presented with the nutrition prescription, they tend to be overwhelmed, and reinforcement after they have tried to follow that prescription can increase the efficacy of the process. Behavioral change takes time and needs to be approached in small steps rather than by attempting to make one large lifestyle adjustment. For that reason, follow-up visits with a dietitian are very important.
The registered dietitian (RD) is an important part of the diabetes healthcare delivery team. An RD is a medical professional with a postgraduate degree in the field of nutrition and has passed a national qualifying exam. The RD may be certified by the National Certification Board for Diabetes Educators, indicated by the initials "CDE" or "Certified Diabetes Educator" used after his or her name, and/or may be a "Board Certified-Advanced Diabetes Manager," designated by the credentials "BC-ADM."
The role of the dietitian in the prescription and implementation of the medically prescribed nutrition recommendations can be the crucial link to successful lifestyle changes. Healthcare providers should identify dietitians in their area with interest and expertise in the design of meal plans for people with diabetes and use their consultative services regularly. The local American Diabetes Association chapter, The American Dietetic Association, other diabetes groups, or local hospitals can be resources for identifying such dietitians.
The nutrition prescription, which, optimally, is designed by a registered dietitian, involves calculating caloric levels and determining appropriate combinations of nutrients while taking into account the weight, clinical goals, activities level, and health status of the patient. Goals for healthy eating should include the following:
• individualized calorie levels for growth/maintenance or weight loss
The first step in implementing a nutrition prescription is to perform a careful patient assessment. This assessment should cover the patient’s current habits, issues and needs with respect to the nutritional recommendations. Identifying the patient’s readiness to learn will affect the ultimate treatment plan with respect to time, course of initiation, degree of changes to be anticipated, and prospects for ultimate success. The issues and questions included in the following checklist may be included in a nutritional assessment:
Patient Nutrition Assessment
- Is the patient performing self-monitoring of blood glucose?
- Is the patient keeping, or has he ever kept, a food record?
- What type and how much physical activity does she presently do? Is she planning to change (increase) her activity level?
- Does he have any concerns relating to finances or psychosocial issues that might impede his success at lifestyle changes?
- What cultural factors and beliefs might be influencing her food choices and eating style?
- How might behavioral factors influence eating habits?
- What are his present medications and nutritional supplements?
- What is the patient’s weight history? Weight goals?
- What are his recent laboratory values for A1C, lipid profile, microalbumin/creatinine ratio?
- What is the patient’s blood pressure?
- What is the patient’s current eating style?
- Does the patient currently follow any meal plan?
- How much effort is made to change to a healthier meal plan?
- How close is the patient’s actual intake to that prescribed by the meal plan?
- How skilled is the patient at assessing food choices?
- What foods does the patient avoid?
- What foods does the patient eat excessively? (Based on the answers to the two questions above, an initial focus on food choice instruction can be determined.)
- Does the patient know how to read a food label accurately?
- Is the patient able to describe how different foods affect his blood glucose levels?
- How skilled is the patient at assessing portion sizes?
- Are portion sizes reasonable and controlled?
- Are portions estimated or measured?
- Does the patient need help estimating portion size?
- Does the patient time meals and other food consumption appropriately?
- Does he eat balanced meals?
- Does she skip meals?
- Does he "graze"?
- Are the intervals between meals optimal?
- Have the diabetes medications and/or insulin been accurately based on the patient’s usual eating style?
- If the patient is adjusting his insulin intake based on the amount of carbohydrate he eats, is he doing this correctly?
- Are the patient’s eating habits consistent? How important it is to eat at regular intervals and to eat about the same amount of carbohydrate may vary, depending on treatment. For those not adjusting insulin, it is crucial to be consistent about eating times. For those who do make compensatory adjustments, more flexibility may be allowed. Nevertheless, the degree of variability must be determined:
- Does your patient eat about the same time each day?
- Is the amount of carbohydrate eaten fairly consistent from day to day?
Once the patient has been assessed and overall treatment goals have been determined with the patient, a meal plan is designed based on lifestyle and dietary preferences. Individualized degrees of consistency and nutritional balance are incorporated into this plan.
The meal planning approaches are categorized from basic to advanced:
- following healthy eating guidelines
- use of preplanned menus
- use of exchange or food choice lists
- use of counting methods (carbohydrate counting, fat gram counting)
Healthy Eating Guidelines
Patients who are new to diabetes can make immediate improvements in their eating habits until they have the opportunity to meet with an RD. They can be given guidance in choosing healthy foods using a picture of a plate divided into suggested servings (see Figure 5-1). It is not expected that calories would be calculated at this point in the process; this is just a starting point. The key changes targeted by healthy eating guidelines include:
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Please Note: Reasonable measures have been taken to ensure the accuracy of the information presented herein. However, drug information may change at any time and without notice and all readers are cautioned to consult the manufacturer’s packaging inserts before prescribing medication. Joslin Diabetes Center cannot ensure the safety or efficacy of any product described in this book.
Professionals must use their own professional medical judgment, training and experience and should not rely solely on the information provided in this book to make recommendations to patients with regard to nutrition or exercise or to prescribe medications.
This book is not intended to encourage the treatment of illness, disease or any other medical problem by the layperson. Any application of the recommendations set forth in the following pages is at the reader’s discretion and sole risk. Laypersons are strongly advised to consult a physician or other healthcare professional before altering or undertaking any exercise or nutritional program or before taking any medication referred to in this book.