Diabetes Management

ABCDES

When creating a care plan, you want to consider the ABCDES of diabetes management:

Creating a Nutrition Care Plan for Diabetes

Make sure to review the following 8 key areas:

• Hypoglycemia
• Hyperglycemia
• Medication and Insulin
• Carbohydrate (CHO) Intake
• Macronutrient Distribution
• Meal Timing
• Cholesterol
• Physical Activity

Common PES Statement Terminology

As you interpret the data from the assessment, you can form Problem, Etiology, Symptoms (PES) statements or nutrition diagnoses that help identify nutrition concerns that need to be addressed in your plan. If you are not familiar with how to write a PES statement please review this resource from the Academy of Nutrition and Dietetics.

Here are some common nutrition problems that patients with diabetes experience.

• Excessive energy intake
• Less than optimal intake of types of carbohydrate (specify)
• Food- and nutrition-related knowledge deficit
• Not ready for diet/lifestyle change
• Physical inactivity
• Unintended weight loss
• Altered nutrition-related laboratory values (specify)
• Inconsistent carbohydrate intake
• Less than optimal intake of types of fats (specify)
• Disordered eating pattern
• Inability to manage self-care
• Impaired ability to prepare foods/meals

You can create a PES statement for Penelope as we go through each of the 8 key areas.

Here is Penelope’s biochemical data from the assessment section. It may be helpful to refer to when creating your PES statements.

Hypoglycemia

If you identified hypoglycemia as a problem from your assessment, then this needs to be prioritized in your care plan as it presents a high risk.

Make sure clients know the signs and symptoms of hypoglycemia, which can include: shaking/trembling, fast heartbeat, sweating, dizziness, hunger, blurred vision, headache, confusion, weakness/fatigue, anxiousness or irritability. In addition, nocturnal hypoglycemia may cause: vivid dreams or nightmares, restless sleep, morning headache, or night sweats.

Make sure clients know how treat hypoglycemia using the 15:15 rule. If their BG is less than 4.0 mmol/L, they can follow these steps:

1. Take 15g of simple CHO (carbohydrate): For example ¾ cup juice or regular pop; 3-4 glucose tablets; 3 packets of sugar
2. Recheck BG after 15 minutes
   • If above 4.0: have a balanced snack or meal
   • If below 4.0: re-treat with 15g CHO

You also need to think about the potential causes of the hypoglycemia and advise the client on measures they can take to prevent low blood sugars from happening in the first place. Causes include: more physical activity than usual, taking too much medication, not eating on time or eating less than usual, and drinking alcohol.

Impaired awareness of hypoglycemia (IAH) also poses a risk to patients living with diabetes. IAH occurs when a person does not experience the symptoms typically associated with hypoglycemia. In these cases, the first symptom is often more serious such as confusion or loss of consciousness. IAH is more likely to occur in patients who experience hypoglycemia often, have had diabetes for a long time, or who suffer from diabetic neuropathy. IAH is reversible through improved glycemic control and avoidance of hypoglycemia. As a dietitian it is important to be aware of IAH as your patient may not identify these symptoms for you. Encouraging self-monitoring of blood glucose can be a helpful tool to identify and treat hypoglycemia.

Hyperglycemia

If you identified frequent hyperglycemia as a problem from your assessment, then this needs to be prioritized in your care plan as it presents a risk for developing long-term complications  (e.g. eye damage or diabetic retinopathy, heart disease, stroke, hypertension, kidney disease, nerve damage and amputation, gastroparesis, erectile dysfunction).

Make sure clients know the signs and symptoms of hyperglycemia, which can include: dry mouth, thirst, frequent urination, and blurred vision.

Think about the potential causes of the hyperglycemia (e.g imbalance of food, certain medical conditions, stress, and some medications) and advise the client on measures they can take to prevent high blood sugars.

When treating hyperglycemia, consider the BG:

• If BG is frequently more than 11 mmol/L: adjust medication and/or insulin, adjust dietary patterns, and increase physical activity
• If BG is more than 20 mmol/L: seek immediate medical attention

Medication and Insulin

If a client is experiencing hypo- or hyperglycemia that you think may be related to medication and insulin, check the following:

• Are they taking their medication and insulin at the times prescribed?
• Does the type of medication commonly cause hypoglycemia?
• Where are they injecting?
• Are they rotating their insulin injection sites? How often?
• Are they changing the needle/pen tip every time?
• Are they waiting 10 seconds before removing the needle from the skin?
• Do they see any insulin leaking out of the injection site?

Liaise with the client’s Primary Care Provider (PCP) regarding medication or insulin education, or changes, if needed. This is especially important If a client is experiencing hypo- or hyperglycemia that you think may be related to medication and insulin.

Carbohydrate Intake

To maintain optimal blood sugar control throughout the day clients can be encouraged to try to:

• Choose carbohydrate foods with low glycemic index (beans, lentils, whole grains, most vegetables and fruits) as they contain fibre which slows the absorption of sugar into the blood.
• Limit simple sugars (regular pop, desserts, candies, jam, and honey) as they raise blood sugars rapidly.
• Check food labels for hidden sugars (agave, corn syrup, dextrose, fructose, glucose, maltose, maple syrup, molasses, raw sugar, sucrose, etc.).
• Use the Nutrition Facts table when Carb Counting to determine the amount of carbohydrate in 1 serving.

Carb Counting is a great method to recommend for keeping portions equal throughout the day. Carb Counting is more appropriate for a client who has a high literacy level and is committed to spending time planning their diet as a part of their diabetes management.

For more information, read Diabetes Canada’s “Basic Carbohydrate Counting” (PDF) resource.

Macronutrient Distribution

To maintain optimal blood sugar control throughout the day clients can be encouraged to try to:

• Eat around the same amount of carbohydrate-containing foods at each meal.
• Include protein and unsaturated fats with carbohydrates at meals and snacks to slow the absorption of sugar into the blood.
• Use the plate method (½ vegetables, ¼ grains and starches, ¼ protein).

A suggested pattern for meals and snacks could consist of:

• Breakfast: 1-2 servings CHO + protein
• Lunch/Dinner: 2-3 servings of CHO + protein + 1-2 cups vegetables
• Snacks: 1 serving CHO + protein

When working with those with diabetes, the plate method  is commonly used when helping clients to balance their meals and snacks.  Clients who require a simpler explanation of carbohydrate portioning can benefit from using the plate method to help manage their diabetes with their diet.

For more information, read Diabetes Canada’s “Just the Basics” (PDF) resource.

Meal Timing

Cholesterol

To lower LDL cholesterol, clients can be encouraged to try to:

• Choose unsaturated fats (olive oil, canola oil, nuts and seeds, fatty fish, soft non-hydrogenated margarine) more often than saturated fats (fatty meats, cream, butter).
• Avoid trans fats (found in some highly processed foods).
• Choose foods high in soluble fibre (beans, oats, fruit, some vegetables).
• Consider adding psyllium husk (like Metamucil) to meals or snacks, once per day.

Physical Activity

Nutrition Care Plan Summary

Recommendations

Now that we have gone through all 8 of the key areas to investigate when creating a nutrition care plan, here is a summary of the recommendations. You can refer to this summary when working with clients living with diabetes in your placement and add to this list as you expand your knowledge in this clinical area of practice.