Adult Type 2 Diabetes Mellitus:

Transition to Insulin
Aurielle Lowery, Sarah Liu, Sarah Vacher, and Xiaolu Hou
Source: http://www.slideshare.net/reliablerxpharmacy/r-rx-diabetes

Objectives

To examine the history, etiology, and physical

effects of Type 2 Diabetes Mellitus (T2DM).
To explain the nutritional impact of T2DM
To identify nutrition diagnoses for T2DM patients
including our case study patient
To identify common nutrition interventions for
T2DM patients including our case study patient
To discuss typical goals and outcomes to evaluate
for nutrition monitoring and evaluation

Case Study Patient: MEET MITCH!

52 year-old Caucasian male,
59, and 215#
Type 2 Diabetes Mellitus
with long history of
noncompliance with
diabetes medication

Admitted to the emergency

room with severe
hyperglycemia and
dehydration
Sources: http://www.propublica.org/images/ngen/gypsy_big_image/emergency_room-630x420.jpg
http://askdrcastelli.com/wp-content/uploads/2014/04/type2-diabetes.jpg

Diabetes Prevalence

Type 1 vs. Type 2 DM

Type 1 Diabetes (5-10%):
Known as Insulin-Dependent Diabetes Mellitus or Juvenile
Diabetes
Pancreas is unable to make insulin or makes insufficient insulin
Progressive cell destruction results in insulin deficiency
Controlled with exogenous insulin daily injections or pump

Type 2 Diabetes (90-95%)

Known as Non-Insulin Dependent Diabetes Mellitus and previously
called Adult Onset Diabetes but many youth now diagnosed with this

Characterized by insulin resistance, usually develops slowly over time

Pancreas still makes insulin but tends to decrease over time
Source: http://imgarcade.com/1/diabetes-mellitus-type-1-cartoon/

Risk Factors for Type II Diabetes

Age

Overweight/obesity

Issues During
Pregnancy

Hypertension

Family history

Ethnicity

Hypercholesterolemia

Source: http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/#3

Risk Factors for Type II Diabetes

Polycystic ovary
syndrome

Pre-diabetes

Acanthosis nigricans

CVD Disease History

Sedentary

Sleep disorders

Waist
circumference

Practice CDE Exam Question

Acanthosis nigricans presents as a brown to black pigmentation
usually seen in the neck or armpit areas. In relation to diabetes, this
may indicate:
A. Granuloma annulare

B. Diabetic dermopathy
C. Type 1 diabetes

D. Insulin resistance

Source: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg

Nutrition Assessment

Glucose Metabolism
Glycogenolysis
Gluconeogenesis

Diet

Lactate
Pyruvate
Amino acids
Glycerol

Plasma
Glucose
Source: Chapter 2: Normal Glucose Homeostasis from Principles of Diabetes Mellitus. doi: 10.1007/978-0-387-09841-8_2

Glucose Metabolism
Oxidative

Acetyl CoA,
Krebs Cycle

ENERGY!

Non-oxidative

Lactate or
Alanine Formation

Gluconeogenesis

Glycolysis
Plasma Glucose
Glycogen storage

Source: Chapter 2: Normal Glucose Homeostasis from Principles of Diabetes Mellitus. doi: 10.1007/978-0-387-09841-8_2

Regulating Glucose
Glucose must stay within a tight range
Insulin promotes glucose uptake in tissues
Hormones that increase plasma glucose:

Glucagon
Catecholamines
Cortisol
Growth hormone

Non-hormonal factors:
Diet, exercise, other substrates (FFAs)

Sources: Chapter 2: Normal Glucose Homeostasis from Principles of Diabetes Mellitus. doi: 10.1007/978-0-387-09841-8_2
http://www.diabetes.co.uk/images/article_images/glucose.jpg

Practice CDE Exam Question

Which of the following statements is NOT correct related to the
use of glucagon in diabetes management?
A. Glucagon is a hormone secreted by the pancreas, which triggers
the liver to release glucose stores into the bloodstream.
B. Glucagon is normally administered to an individual with diabetes
when they are unconscious in response to hypoglycemia.
C. Individuals with depleted glycogen stores may not respond to a
glucagon injection.
D. Glucagon must be administered through an intravenous injection.
Sources: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
http://www.studyguidezone.com/cde.htm

What Happens in Type 2 Diabetes?

Peripheral insulin resistance + inadequate insulin
secretion

Develops in liver, muscle, and adipose tissue first

Decreased insulin, increased glucagon and GIP
Hyperglycemia 2 inappropriate hepatic
gluconeogenesis
Beta-cell dysfunction
Atrophy of the pancreas
Sources: Chapter 2: Normal Glucose Homeostasis from Principles of Diabetes Mellitus. doi: 10.1007/978-0-387-09841-8_2
http://emedicine.medscape.com/article/117853-overview#aw2aab6b2b2
NCM Type 2 Diabetes

What Happens in Type 2 Diabetes

Glucotoxicity

Increased ROS generation

Hexose biosynthetic pathway (HBP)
Loss of beta cells from apoptosis
Endoplasmic reticulum stress

Lipotoxicity
Lipolysis, circulating free fatty acids (FFAs)
Decreases glucose utilization, increases gluconeogenesis
Also oxidative stress, apoptosis

Eventual reliance on medications, exogenous insulin

Sources: NCM & http://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2009.02847.x/epdf

Diagnostic Criteria
A1C > 6.5%
Fasting plasma glucose > 126 mg/dL
2-hour BG post OGTT > 200 mg/dL
If random blood sugar draw is > 200 mg/dL
with symptoms of diabetes

Sources: http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/#3
http://www.hrmc.org/news_photos/diabetic.jpg

Practice CDE Exam Question

Which of the following are current diagnostic criteria used for the
diagnosis of diabetes?
A. Fasting plasma glucose (PG) >126 mg/dl, casual PG >200 mg/dl with
symptoms of diabetes, and/or glycated hemoglobin A1c (A1c) >6.0%
B. Oral-glucose-tolerance test (OGTT) with 2 hour PG >200 mg/dl and/or
A1c >6.0%
C. OGTT with 2-hour PG >200 mg/dl, fasting PG >126 mg/dl, and/or
casual PG >200 mg/dl with symptoms of diabetes

D. Fasting PG >100 mg/dl, A1c >6.5%, OGTT >200 mg/dl with symptoms
of diabetes, and/or casual PG > 200 mg/dl with symptoms of diabetes
Source: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg

How Diabetes Affects the Body

Nerves
Eyes

Heart
Kidneys

Complications of LT Diabetes
Eyes
Cataracts
Glaucoma
Retinopathy

Kidney disease
Swelling of hands,
feet, face
Edema
Itchiness and/or
drowsiness

Heart disease, strokes

Sources: http://my.clevelandclinic.org/health/diseases_conditions/hic_Diabetes_Basics/hic_Long-Term_Problems_for_People_with_Diabetes
http://www.pjsaine.com/OphthalmicPhotography/Images/DiabeticRetinopathy.3.jpg

Complications of LT Diabetes
Poor wound healing
Amputations

Nerve damage
Sexual dysfunctional
Numbness or burning
pain

Neuropathy

Gastroparesis
Postural hypotension
Diarrhea
Peripheral/autonomic
nerve damage

Sources: http://my.clevelandclinic.org/health/diseases_conditions/hic_Diabetes_Basics/hic_Long-Term_Problems_for_People_with_Diabetes
http://www.podiatrypractice.com.au/wp-content/uploads/2013/03/diabetic-foot-ulcer.jpg

ROS Production in the Electron Transport Chain

Michael Brownlee Diabetes 2005;54:1615-1625

2005 by American Diabetes Association

Inactivation of GAPDH by ROS

Michael Brownlee Diabetes 2005;54:1615-1625

2005 by American Diabetes Association

Practice CDE Exam Question

The large fluid-filled blister that is most often seen on the hands and
the feet of individuals with diabetes is a:
A. Diabetic bulla.

B. Diabetic dermopathy
C. Granuloma annulare
D. Diabetic thick skin

Source: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg

Diabetic Ketoacidosis (DKA)

Shift from glycolysis to fat oxidation

Ketones lead to acidosis

Condition more common in type 1 diabetes

Elevated energy needs or improper insulin

dosage
Patients experience dehydration and can
progress to neurological symptoms
Sources: http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html
http://www.ncbi.nlm.nih.gov/pubmed/15871546
http://care.diabetesjournals.org/content/27/suppl_1/s94.full

Hyperosmolar Hyperglycemic State

(HHS)
Also characterized by dehydration and
neurological symptoms
Mortality rate ranges from 10-50%

Common in older patients + condition reducing

fluid intake
Glucosuric diuresis
Insulin resistance
Sources: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
http://care.diabetesjournals.org/content/27/suppl_1/s94.full
http://emedicine.medscape.com/article/1914705-overview

DKA vs. HHS

High levels of ketones
Breath has fruity odor

N/V more prevalent

Bloody, coffee grounds

Abdominal pain
Acidosis hallmark (pH
and bicarbonate)
Can occur in <24 hours
Occurs in type 1 diabetic
patients

Little or no ketones
Acidosis not present

Usually takes days or

weeks to develop
Higher mortality rate
More severe
hyperglycemia
Type 2 diabetic patients

Kussmaul respirations
Source: http://care.diabetesjournals.org/content/27/suppl_1/s94.full

DKA vs. HHS

Source: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6

HHS Signs and Symptoms

Weakness/muscle cramps
Problems in vision

Severe dehydration skin turgor, mucous

membranes,
Fever (100.5 degrees F)
Tachycardia, hypotension (105 BPM, 90/70 BP)
Neurological symptoms (drowsiness, confusion)
Nausea/vomiting
Sources: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
http://www.nlm.nih.gov/medlineplus/ency/article/000304.htm

HHS Risk Factors

Stressful event
Congestive heart failure
Poor kidney function
Impaired thirst
Limited access to water (coffee and diet soda, no water
consumption reported)
Older age
Poor management of diabetes
Stopping insulin or other prescribed drugs
Certain medications (dyazide diuretic)
Sources: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
http://www.nlm.nih.gov/medlineplus/ency/article/000304.htm

HHS Diagnostic Criteria

Diagnostic Standard /
Normal Range

Mitchs Values

>600 mg/dL

1524 mg/dL

>320 mOSm/kg water

349 mOsm/kg water

>7.30

----

Ketonuria

Negative

Positive

Potassium

3.5 5.3 mEq/L

3.9 mEq/L

Creatinine

0.6 1.2 mg/dL

1.9 mg/dL

5 20 mg/dL

31 mg/dL

39-49% (M)

57%

135-153 mEq/L

156 mEq/L

Parameters
Blood glucose
Serum osmolarity
pH

BUN
Hct
Sodium

Source: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6

HHS - Treatment

Sources: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
Guillermo E. Umpierrez et al. Diabetes Spectr 2002;15:28-36

Estimated Energy Needs: Case Study

53 year old M
Pts Weight: 214# (97.3 kg)
Height: 59 (175 cm)
Body Mass Index: 31.8 (Obesity, class 1)

Try your hand at calculating the estimated number of

daily calories needed by our patient to:
(1) maintain weight and (2) lose weight
Source: http://www.planmylife.in/wp-content/uploads/2014/04/calculator.jpg

Assessment of Case Study Pt Values

Goal Values

Mitchs Values

<7%

15.2%

70 130 mg/dL

1524 mg/dL

Peak post-prandial
plasma glucose

<180 mg/dL

----

LDL

<100 mg/dL

123 mg/dL

TG

<150 mg/dL

185 mg/dL

HDL

>40 mg/dL

55 mg/dL

<140 SYS; <80 DYS

129/92 mm Hg

Parameters

Hb A1C
Pre-prandial plasma
glucose

BP

Source: NCM Type 2 Diabetes

Medical Treatments for T2DM

Self Management of BG (SMBG)

Accuchecks:
Monitoring of daily BG patterns
Typical test times
Before meals
After meals (1-2 hrs)
Bedtime (HS)
Overnight
Source: www.diabeteshealth.com

Common Side Effects

Hypoglycemia

Treatment

Shakiness, anxiety

BG <70 treated immediately,

Diaphoresis

Provide 15 g CHO, wait &

Palpitations

Recheck, repeat until WNL

Hunger
Confusion
Slurred speech
Seizures
Loss of consciousness
Coma / Death

Medical Treatments for T2DM

Thiazolidinediones (TZDs)

Function: Insulin sensitizers

Side Effects: Weight gain, Edema

Ex: Avandia

-Glucosidase Inhibitors

Function: Delays CHO absorption

Side Effects: Lower GI upset:

Ex: Acarbose, Miglitol

Medical Treatments for T2DM

Insulin Secretagogues

Function: Stimulates insulin secretion.

Side effects: hypoglycemia & weight gain

Ex: Glipizide, Glyburide, Nateglinide

Biguanides

Function: Insulin sensitizers and decrease hepatic

glucose production.
Side Effects: GI upset
Ex: Metformin

Medical Treatments for T2DM

Insulin Therapy

Other types of insulin

Imperative for BG control: SQ

fat injection

Premixed insulin

Pulmonary insulin

Described in terms of: Onset,

Peak and Duration

IV insulin

Four classes of insulin:

Rapid-acting

Short-acting

Intermediate-acting

Long-acting

Significant to Determine:

Insulin-to-carb ratio

Insulin pump therapy

Continuous insulin
administration

Sliding scale insulin (SSI)

Practice CDE Exam Question

Which of the following would be LEAST likely to cause

hypoglycemia with Metformin monotherapy?

A. Deficient calorie intake
B. Missing one meal
C. Alcohol consumption
D. Strenuous exercise

Sources: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
http://www.testprepreview.com/certifieddiabeteseducator.htm

Practice CDE Exam Question

The current American Diabetes Association (ADA)
recommendation for protein restriction in patients
with early-stage of nephropathy is:
A. 1.0-2.0 g/kg body weight/day
B. 1.5 g/kg body weight/day

C. 0.5 g/kg body weight/day

D. 0.8-1.0 g/kg body weight/day

Sources: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
http://www.studyguidezone.com/cde.htm

Nutrition Diagnosis

Common Nutrition Diagnoses

for T2DM Patients
Unintended weight loss (NC-3.2)
Altered nutrition related lab values (NC-2.2)
Excessive energy intake (NI-1.3)

Excessive fat intake (NI-5.6.2)

Overweight/Obesity (NC-3.3)
Intakes of carbohydrate inconsistent with needs (NI-5.8.3)
Food and nutrition related knowledge deficit (NB-1.1)
Not ready for diet/lifestyle change (NB-1.3)
Disordered eating pattern (NB-1.5)
Limited adherence to nutrition recommendations (NB-1.6)
Physical inactivity (NB-1.2)
Inability to manage self care (NB-2.3)
Impaired ability to prepare food/meals (NB-2.4)
Source: http://www.acefitness.org/acefit/healthy-living-article/60/1886/what-can-working-with-a-registered-dietitian/

Assessment of Case Study Pt Values

Goal Values

Mitchs Values

<7%

15.2%

70 130 mg/dL

1524 mg/dL

Peak post-prandial
plasma glucose

<180 mg/dL

----

LDL

<100 mg/dL

123 mg/dL

TG

<150 mg/dL

185 mg/dL

HDL

>40 mg/dL

55 mg/dL

<140 SYS; <80 DYS

129/92 mm Hg

Parameters
Hb A1C
Pre-prandial plasma
glucose

BP

Source: NCM

Lets Practice!
Write an example PES statement given the following
information about our case study patient:
Male, 53 yo
Mildly obese
Glucose: 475 mg/dl
BUN: 20 mg/dl
A1C: 15.2%
Pt has never had diabetes education except what physician has told him.

Typical intake: often eats out, makes meals high in carbohydrates, avoids sweets.
Pt lives alone and is noncompliant with diabetes medications.
Never received diabetes education except for what physician told him at onset
Dx: Uncontrolled DM with HHS.

Source: http://www.conci.com/wp-content/uploads/2012/12/What-Your-Dietitian-Does-for-Exercise.jpg

Suggested Nutrition Dx for Case Study Pt

Limited adherence to nutrition-related recommendations (NB-1.6)
r/t food and nutrition knowledge related deficit (NB-1.1) AEB
inappropriate usual intake for type II diabetic and report of no
diabetes teaching.
Excessive carbohydrate intake (NI-5.8.2) r/t poorly controlled T2DM
AEB foods from usual dietary recall and blood glucose level of 1524
mg/dL at admission and HbA1C of 15.2%.
Altered blood glucose lab values (NC-2.2) r/t inappropriate
carbohydrate intake AEB 475 mg/dl blood glucose, HbA1C of 15%,
and elevated urine glucose levels.

Nutrition Intervention

Overall MNT Treatment Goals

Attain & maintain optimal blood glucose, lipid/lipoprotein profile, and

blood pressure levels to reduce risk of vascular disease

Prevent and treat chronic complications by modifying nutrient intake &

lifestyle

Address individual nutritional needs, taking into account personal and

cultural preferences and willingness to change

Maintain pleasure of eating by only limiting food choices when

indicated by scientific evidence

SPECIFIC GOALS:
of A1C by 1% in pts w/ newly dx T1DM
of A1C by ~2% in pts w/ newly diagnosed T2DM
of A1C by 1% in pts w/ T2DM of 4 yrs
LDL-C by 15-25 mg/dL in 3-6 months
Source: http://care.diabetesjournals.org/content/35/2/434.full

Common Nutrition Interventions

for T2DM Patients
General/healthful diet (ND-1.1)
Modification of distribution, type, or amount of food
and nutrients within meals or at a specified time (ND-1.2)
Specific foods/beverages (ND-1.3)
Initiation of/change to nutrition-related medication
(ND-6.1 and ND-6.2)
Initial/brief nutrition education (E-1.1 through E-1.3)
Comprehensive nutrition education (E-2.1 through E-2.3)
Nutrition counseling (C-1.2 through C-1.5)
Strategies (C-2.1 through C-2.10)
Coordination of nutrition care (RC-1.1 through RC-1.4)
Source: https://nhlbiepi.files.wordpress.com/2012/11/20456762-jigsaw-pieces1.jpg

National Diabetes Education Program Video

https://youtu.be/LYGNf3SSWVE?t=42s

Source: http://mattgoss.la/wp-content/uploads/2010/01/video-icon.jpg

Nutrition Intervention - Energy/Nutrient Needs

ENERGY NEEDS:

Standard predictive equations apply

Less if weight loss desired / appropriate

MACRONUTRIENT NEEDS:

No ideal % of calories from macronutrients reported for all

people with diabetes

Macronutrient distribution should be based on individualized

assessment

Follow DRIs for healthy adults:

CHO 45-65%
Protein 10-35%
Fat 20-35%
Source: http://bed56888308e93972c04-0dfc23b7b97881dee012a129d9518bae.r34.cf1.rackcdn.com/sites/default/files/20946-308.jpg

Nutrition Intervention - Diet/Recommendations

2 most common diet regimes for T2DM:

CHO Counting v. Food Lists (formerly Exchange Lists)

Goals of meal planning:

Keep blood glucose levels in control

Keep blood fat levels in control to reduce risk
of CVD

Reach and keep a healthy body weight

Lower blood pressure (decrease sodium)
Consume nutritionally balanced meals

Healthy eating guidelines:

Eat a variety of foods

Cut back on added fats as well as salty, convenience, and fast foods

Choose lean meats and low fat dairy

Eat at least 5 servings of fruits and vegetables and 3 whole grains/day

Source: USDA

Nutrition Intervention - PA Recommendations

Physical Activity
Shown to improve insulin sensitivity, glycemia, & lipids;
reduce CVD risk; and help maintain wt loss
Recommendation: 90 - 150 min/week MVPA and
strength training 3 times/week
For wt maintenance: 60 - 90 min PA nearly every day
Beware of hypoglycemia and teach pts how to avoid
and treat it

Sources: NCM Type 2 Diabetes

http://www.bhfactive.org.uk/training-and-events-item/71/index.html

Nutrition Intervention - Weight Loss

The American Diabetes Association (ADA) recommends

overweight/obese adults with T2DM be encouraged to make lifestyle
modifications that reduce caloric intake while maintaining a healthy
eating pattern and increase PA to improve glycemia, lipids, and HTN.

Sources: http://www.liftingrevolution.com/wp-content/uploads/2013/03/weight-loss-women.jpg
NCM Type 2 Diabetes

REFRESHER: Nutrition Dx for Case Study Pt

Limited adherence to nutrition-related recommendations (NB-1.6)
r/t food and nutrition knowledge related deficit (NB-1.1) AEB
inappropriate usual intake for type II diabetic and report of no
diabetes teaching.
Excessive carbohydrate intake (NI-5.8.2) r/t poorly controlled T2DM
AEB foods from usual dietary recall and blood glucose level of 1524
mg/dL at admission and HbA1C of 15.2%.
Altered blood glucose lab values (NC-2.2) r/t inappropriate
carbohydrate intake AEB 475 mg/dl blood glucose, HbA1C of 15%,
and elevated urine glucose levels.

Nutrition Interventions for Case Study Pt

Administration of insulin medications (ND-6.1): Continue Lispro (rapidacting) and Glargine (intermediate-acting) insulin therapy to bring BG to
150-200 mg/dL. Then work with pt needs and preferences to develoop an
appropriate home insulin regimen.
Carbohydrate- and energy-modified diet (ND-1.2): Gradually progress
PO intake as tolerated from clear liquids to solid foods to meet EEN of
~2,350 kcal/d and ~270 g CHO/d using small, consistent meals spaced
throughout the day
Initial/brief diabetes-related nutrition education (E-1.1): Topics to
include foods containing CHO, relationship between nutrition and health,
CHO and BG self-monitoring, basic healthy eating and PA guidelines, and
identification and treatment of hypoglycemia and short-term illness.
Coordination of nutrition care (RC-1.2; RC-1.3): Collaborate with or refer
pt to CDE for further diabetes education and counseling. Consider referral
to medically-supervised weight loss program following discharge

Recommendations for Mitch!

Calorie
Level

Breakfast
CHO
Choices

Lunch
CHO
Choices

Dinner
CHO
Choices

Snack
CHO
Choices

Total
Protein
Choices for
the Day

Total Fat
Choices For
the Day

1200

3 = 45 gm

2 = 30 gm

2 = 30 gm

2 = 30 gm

5 = 35 gm

3 = 15 gm

1500

3 = 45 gm

3 = 45 gm

3 = 45 gm

2 = 30 gm

6 = 42 gm

4 = 20 gm

1800

4 = 60 gm

4 = 60 gm

4 = 60 gm

2 = 30 gm

6 = 42 gm

6 = 30 gm

2000

4 = 60 gm

4 = 60 gm

4 = 60 gm

3 = 45 gm

7 = 49 gm

6 = 30 gm

2200

5 = 75 gm

4 = 60 gm

4 = 60 gm

3 = 45 gm

8 = 56 gm

7 = 25 gm

2400

5 = 75 gm

5 = 75 gm

5 = 75 gm

3 = 45 gm

9 = 63 gm

8 = 40 gm

2800

6 = 90 gm

6 = 90 gm

6 = 90 gm

4 = 60 gm

9 = 63 gm

9 = 45 gm

3000

6 = 90 gm

6 = 90 gm

6 = 90 gm

5 = 75 gm

10 = 70 gm 10 = 50 gm

Nutrition Intervention - Education/Counseling

INpatient v. OUTpatient
Prioritize dxs - nutrition often not the highest priority
in the hospital
How is the pts state of mind?
Typically more motivation / engagement in the
outpatient setting
Thus, this may not be the best time to attempt indepth counseling and education with Mitch

Depending on pt needs and your expertise / comfort

level, it may also be appropriate to refer to a CDE

Nutrition Intervention - Education/Counseling

5 As Model for Behavioral Change
Integrates several counseling models including MI

Recommended by NCM to guide nutrition counseling/education

5 Steps:
Ask
Assess
Advise
Agree
Arrange
Sources: https://mytruthsetsmefree.files.wordpress.com/2013/02/a.jpg
NCM Type 2 Diabetes

Nutrition Intervention - Barriers

Limited financial resources

Food and medication can be very costly

Low literacy / English language skills

Low health literacy / numeracy

Medication side effects / DNIs

Food intolerances / allergies

Limited ability to identify appropriate food choices

Limited time and/or ability to plan for and prepare appropriate food
choices

Frequent travel or eating away from home

Lack of readiness to change nutrition-related behaviors

Lack of social support for change (e.g., others in household)

Alcohol use

Physical disability / psychosocial issues

Nutrition Monitoring
& Evaluation

 Focus on the HERE

and NOW!!

Monitoring and
Evaluation in the
Hospital Setting

Pertinent Laboratory Values

Metabolic Control
Food Intake

Medications
Weight loss is NOT a
primary goal
Source: http://www.medscape.com/viewarticle/832289

Nutrition Monitoring & Evaluation for the

Case Study Patient Post Discharge
Monitor weight over next 6 weeks to 3 months
Encourage 0.5 - 1 lb per week weight loss
Target weight 160 lbs
Acceptable Weight Range: 144 - 176 lbs

Monitor and evaluate with progression of disease:

Pertinent Lab Values
Medications
Diet
Hydration Level

Nutrition Monitoring & Evaluation

Nutrition reassessment should generally be evaluated
between 6 weeks and 3 months after implementation
The purpose of nutrition monitoring and evaluation is to
evaluate the progress made by the patient and determine
whether goals are being met.

During reassessment, it is vital to monitor:

Metabolic control
Food Intake
Physical activity & exercise
Anthropometric Measurements
Medications
Pertinent lab values

Questions / Comments?

Source: http://cdn2.hubspot.net/hub/38219/file-13929501-jpg/images/fotolia_14605019_xs.jpg