Introduction and Agenda Setting

• Greet the client and introduce yourself
  • “Hi there, my name is ___ and I’m a registered dietitian who’ll be working with you today.”
• Describe the role of the RD in their diabetes care
  • “My role is to help you figure out your food and nutrition needs based on your lifestyle, medication, and health goals, like managing your blood sugars or lowering your cholesterol.”
• Invite the client to the conversation and build rapport
  • “How are you doing today?”
• Set the agenda for the appointment with the client
  • “What brings you in today?”
  • “How might I help?”
  • “What part of managing your diabetes would you like to discuss with me today?

Gathering Data for an Assessment

1. Clinical Data - Medical Hx and Social Hx
2. Anthropometric Data
3. Biochemical Data
4. Dietary Data

Medical Hx

• Diagnosis
  • Do they have prediabetes, type 2 diabetes, or gestational diabetes? Are they at risk of developing diabetes? Duration of Dx?
• PMHx
  • Do they have other medical conditions (hypertension, dyslipidemia, cardiovascular disease, schizophrenia, depression, bipolar disorder, PCOS, sleep apnea)?

• Family Hx
  • Did members of their family have diabetes or other medical conditions?

• Diabetes symptoms
  • Do they experience any complications of poor diabetes management (polydipsia, polyuria, neuropathy, nephropathy, sexual dysfunction, or problems with their vision, feet, or gums)?

• Medications
  • Are they on any oral anti-hyperglycemic agents, non-insulin injectables, and/or insulin? Blood pressure or cholesterol medications? Are they taking any supplements?

Medications

Insulin

Social Hx

• Housing and Income
  • What is their living situation? Do they live with others/have a support system?
  • Are they currently working? What is their main source of income? Do they have medical coverage?

• Substance Use
  • Smoking? Etoh? Any other substances?

• Food Security
  • Ask the question "Have you or anyone in your household gone without food in the past month because you couldn't afford it?"

• Physical Activity?
  • Do they have an injury or live in an unsafe area making it difficult to get outside to exercise?

Case Study

In the case study used throughout this module, you are a Registered Dietitian at a Family Health Team in the Diabetes Program. The client you are assessing is a 58 year old female named Penelope.

Anthropometric Data

Biochemical Data - Diagnostic Criteria

Biochemical Data - Target Ranges

Biochemical Data - Lipids

Biochemical Data - Urinalysis and Renal Function

Diabetes Management **NOTE: HYPERLINKS NEEDED UNDER CHOLESTEROL/DRUGS**

Creating a Nutrition Care Plan for Diabetes

1. Hypoglycemia
2. Hyperglycemia
3. Medication and Insulin
4. Carbohydrate Intake
5. Macronutrient Distribution
6. Meal Timing
7. Cholesterol
8. Physical Activity

Common PES Statement Terminology

• 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

Hypoglycemia

• Signs and Symptoms
  • Shaking/trembling, fast heartbeat, sweating, dizziness, hunger, blurred vision, headache, confusion, weakness/fatigue, anxiousness or irritability
  • Nocturnal hypoglycemia may cause: vivid dreams or nightmares, restless sleep, morning headache, or night sweats
• Treatment
  • If BG less than 4.0 mmol/L follow the 15:15 rule:
    • Take 15g Simple CHO (¾ cup juice or regular pop; 3-4 glucose tablets; 3 packets of sugar)
    • Recheck BG after 15 minutes
    • If above 4.0 have a balanced snack or meal
    • If below 4.0 retreat with 15g CHO
• Causes
  • More physical activity than usual, taking too much medication, not eating on time or eating less than usual, or drinking alcohol

Hyperglycemia

• Signs and Symptoms
  • Dry mouth, thirst, frequent urination, blurred vision, drowsiness/tiredness
• Treatment
  • If BG frequently more than 11.0 mmol/L:
    • Adjust medication and/or insulin
    • Adjust dietary patterns
    • Increase physical activity
  • If BG more than 20.0 mmol/L:
    • Seek immediate medical attention
• Causes
  • Occurs when food, physical activity, and medications are not balanced
• Long Term Complications
  • Eye damage (diabetic retinopathy), heart disease, stroke, hypertension, kidney disease, nerve damage and amputation, gastroparesis, or erectile dysfunction

Medication and Insulin

• 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?

Carbohydrate Intake

• 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

Carbohydrate Counting **NOTE: NEED IMAGE OF LABEL FROM DIABETES CANADA**

Macronutrient Distribution

• 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)

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

Plate Model **NOTEL: NEED PLATE MODEL IMAGE FROM DIABETES CANADA**

Meal Timing

Cholesterol

• 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
• Take cholesterol medications as prescribed

Physical Activity

Summary of Nutrition Care Plan Recommendations

Penelope's Nutrition Care Plan 

Interdisciplinary Team

• Endocrinologist: Doctors who specialize in treating problems with the endocrine system including the pancreas and insulin production in diabetes
• Physician or Nurse Practitioner: Assess patient needs, order and interpret lab work, diagnose diabetes, and prescribe treatment plans
• Diabetes Nurse Educator: Registered nurses who have specialized experience in the care of patients with diabetes
• Social Worker: Provide counselling and identify sources of emotional support for patients and their families to cope with diabetes
• Physiotherapist: Provide manual therapy and education related to movement and exercise to help people with diabetes engage in physical activity
• Chiropodist: Specializes in foot care and provides treatment of the foot

Education

• Individualize the education as much as possible
  • Discuss high-risk topics (like hypoglycemia) first since they are priority Connect the client’s goals to your plan and focus on what they want to learn
• Find out if client has had previous education
  • Ask the client if any one else has talked to them about their diet and diabetes, and adjust your education accordingly
• Focus on a few key messages
  • If the client is newly diagnosed or doesn’t know much about diabetes, try not to overwhelm them with too much information during your first couple of interactions
  • Use visuals, like props and resources, to convey your message whenever possible

Supporting Change

• Motivational Interviewing
  • Collect their story
  • Listen reflectively
  • Collaborate rather than convince
• SMART Goal Setting ○ Part of creating a nutrition care plan with the client ○ Help to identify barriers to change
• Referral to Social Worker
  • Ongoing management of a chronic disease can lead to burnout
  • Clients may need someone to talk to about coping with this extra burden

SMART Goals

• Use the 15:15 rule to treat hypoglycemia
• Use the Plate Method to create balanced meals, with high fibre CHO at each snack and meal, like whole grain bread or brown rice
• Have diet pop instead of apple juice at dinner time
• Include CHO at HS snack if BG are ~4-5 mmol/L
• Continue to test BGs 2x/day (FBG in the morning and BG at HS before she takes her insulin) using glucometer

Evaluating the Nutrition Care Plan

• Clinical Data (both Medical Hx and Social Hx)
• Anthropometric Data
• Biochemical Data
• Dietary Data

Clinical Data

• CKD
  • What stage? What is the cause?
• Dialysis prescription
  • Are they on dialysis? If so, what type and what prescription?
• Comorbidities
  • Ex/ Diabetes, hypertension, cardiovascular disease, hyperlipidemia, metabolic syndrome
• Fluid Status
  • How much urine are they producing? Are they retaining fluid? Edema present?
• GI symptoms
  • Constipation, nausea, vomiting, poor appetite, meat aversion, taste changes are common symptoms of uremia in advanced CKD
• Medications
  • Replavite (Vit C & B complex, if on dialysis), Phosphate Binders (Tums/Calcium Carbonate, Sevelamer, Lanthanum), Calcitriol (Active Vitamin D), Iron

Case Study: Meet Jacob

In the case study for this module, you are a Registered Dietitian in cardiology. The patient you are assessing is a 55 year old male named Jacob.

Anthropometric Data

• Body weight
• Weight Hx
  • Usual body weight
• Dry weight
  • Weight without any excess fluid, if on dialysis
• Inter-dialytic weight gains (if on hemodialysis)
  • Fluid weight gained between dialysis sessions; this should be no more than 5% of body weight
• Height
• BMI
• SGA

Biochemical Data

Dietary Data

• Current Diet
  • Diet order for inpatients
  • How much are they drinking?
• Diet Hx
  • FFQ, 24 hour recall, 3-day food record (Note: A food frequency questionnaire might be useful if trying to determine a specific dietary cause of a high serum potassium or phosphorus)
  • Details on protein intake and fluid intake
• Eating behaviours
  • How many meals/day?
  • Eating at home or eating out?
• Factors affecting intake
  • Social Hx (Do they have a support system? Housing? Income?)
  • Food access & preparation (Do they cook?)

1. Energy
2. Protein
3. Potassium
4. Phosphorus
5. Sodium
6. Fluid
7. Vitamins

Common PES Statement Terminology

• Inadequate energy / protein intake
• Excessive phosphorus / potassium intake
• Excessive fluid / sodium intake
• Increased nutrient needs
• Inadequate vitamin intake (B&C)
• Altered nutrition-related laboratory values
• Involuntary weight loss
• Food and nutrition related knowledge deficit

Energy

• Use weight loss or weight gain to determine if patient is meeting energy requirements on their current diet
• Try to use edema-free weight to calculate energy requirements
• If a patient is experiencing unintended weight loss or is consuming inadequate calories
  • Consider increasing caloric intake via energy-dense foods
  • Consider an Oral Nutrition Supplement (ONS)

Choosing an ONS for Renal Nutrition

Protein

Potassium

Reducing Potassium in the Diet

• Aim for less than 6 servings/day (less than 200 mg per ½ cup serving) of foods with a high amount of potassiumThis includes some specific vegetables, fruit, fruit juice, beans, legumes, and nuts
• Double boil root vegetables
  • This includes potatoes, sweet potatoes, squash
• Limit consumption of dairy products
  • This includes milk and yogurt
• Avoid potassium salt substitutes
  • No salt© or Half Salt©

Phosphorus

Reducing Phosphorus in the Diet

• Dairy products to ½ -1 cup/day
• Legumes, nuts, whole grain products
• Processed foods with phosphate additives, like ‘phosphoric acid’ or ‘sodium phosphate’ in the ingredients list (this includes commercial baked goods, processed deli meats, processed cheese, cola, frozen meats)

Consider Phosphorus Binders

Sodium

• Lower blood pressure
• Maintain fluid balance
• Control thirst

• Choose homemade foods more often
• Limit consumption of processed foods, which contribute > 75% of sodium in the diet

Fluid

• The amount of urine output vs. fluid intake
• The amount of IDWG
• Blood Pressure (BP)
• Shortness of Breath (SOB)
• Edema

Vitamins

• Replace vitamins lost by taking Replavite® after dialysis once daily
• Avoid regular multi-vitamins in dialysis patients, as toxicity of vitamin A is possible

• Vitamin B1 (Thiamine Mononitrate) 1.5 mg
• Vitamin B12 (Cyanocobalamin) 6 mcg
• Vitamin B2 (Riboflavin) 1.7 mg
• Vitamin B6 (Pyridoxine Hydrochloride) 10 mg
• Vitamin C (Ascorbic Acid) 100 mg
• Biotin 300 mcg
• D-Pantothenic Acid (Calcium D-Pantothenate) 10 mg
• Folic Acid 1 mg
• Nicotinamide 20 mg

Summary of Nutrition Care Plan Recommendations

Creating a Nutrition Care Plan for Diabetes

• Eat at regular times throughout the day, no more than six hours apart
• Eat the same amount of carbohydrate-containing foods at each meal
• Limit simple sugars and sweets such as regular pop/soda/soft drinks, fruit juices, sweet desserts, candies, jam, honey, and sugar
• Control blood sugar to help control thirst and fluid gains
• Avoid salt substitutes and processed foods high in sodium
• Choose lean protein foods prepared with little added fat
• Choose low phosphorus and low potassium foods, if necessary (limit whole wheat foods last)
• Do some physical activity each day

• Nephrologist: Doctors who have advanced training in treating kidney disease
• Nurse Practitioner: Collaborate with the doctors in caring for kidney patients
• Nephrology Nurse: Registered nurses who have specialized experience in the care of patients with chronic kidney disease
• Social Worker: Provide counselling  and identify sources of emotional support for patients and their families cope with kidney disease
• Pharmacist: Review the patient’s medication orders for appropriateness and ensure that the right medication and the right dose is administered
• Patient Care Technician and/or Renal Technologist: Directly involved with starting, monitoring, and ending the patient’s dialysis treatment

Education

• Individualize the education as much as possible based on their stage of kidney disease and labs
  • If the patient’s potassium and phosphorus is not elevated, then no K/PO4 intervention is required at that time, and you can continue to monitor
• Find out if patient has had previous education
  • Ask the patient if any one else has talked to them about their diet and kidney disease
  • If the patient is followed by another renal dietitian, it might be worthwhile to reach out to them to gain additional information about the patient’s situation
• Focus on a few key messages
  • If the patient is newly diagnosed or doesn’t know much about kidney disease, try not to overwhelm them with too much information during your first couple of interactions

Jacob's Education

Before implementing the diet order, you need to meet with Jacob to go over the plan with him. In your meeting with him, you can explain the reasons for the dietary changes and what that means in terms of the types of foods he will be receiving while he is in the hospital. When you ask him if he has been told to make diet changes before, he tells you the only thing he remembers that his family doctor has told him many times to cut back on the amount of salt he is eating because of his history of high blood pressure. You decide to talk to him about 3 key messages related to the changes to his diet:

1. Your kidneys are not able to filter enough fluid and salt from your blood. So when you drink a lot of fluid and eat too much salt, the fluid builds up in your ankles, making them swollen. To try to reduce the swelling, you will get foods that are lower in salt and only get about 6 cups of fluid to drink in a day.
2. Some foods, like multigrain bread, beans, cheese, and milk contain higher amounts of phosphorus. You won’t get these foods very often on your tray at the hospital because your kidneys cannot process a large amount of phosphorus.
3. Your kidneys are also not able to process high amounts of protein, which is why you may receive smaller portions of meat in your meals than you are used to having.

Practice explaining the three key messages in plain language. It can be helpful to use simple analogies, for example, in our bodies, the kidneys’ role is to clean and filter our blood, kind of like how cars need filters to clean the oil that moves throughout the engine to keep it running. Sometimes when filters get old or they break they are not able to filter the oil properly, - this is what happens when you have kidney disease since your kidneys can no longer clean the blood the way they used to, so we need to make some changes to ensure your body can still function.    

Supporting Change

• Motivational Interviewing
  • Collect their story
  • Listen reflectively
  • Collaborate rather than convince
• SMART Goal Setting
  • Part of discharge planning
  • Help to identify barriers to change
• Referral to Social Worker
  • Ongoing management of a chronic disease can lead to burnout
  • Patients may need someone to talk to about coping with this extra burden

Discharge Planning and SMART Goals

• Limit consumption of processed foods with phosphate additives and salt (like bacon, frozen french fries, and pop)
• Choose more fresh, homemade, and unprocessed foods (like fresh or frozen vegetables and unprocessed meat, poultry, and fish)
• Reduce the amount of meat, poultry, and fish consumed at each meal (like having 3 oz of chicken breast instead of 8 oz)
• Drink a maximum of 6 cups of fluid per day, including coffee/tea, pop, water, milk, and anything that melts at room temperature

What is the role of the cardiovascular system?

• Regulates blood flow to tissues
• Delivers oxygenated blood and nutrients
• Retrieves waste products
• Thermoregulation
• Hormone transport
• Maintenance of fluid volume
• Regulation of pH
• Gas exchange

What is Cardiovascular Disease?

• Coronary artery disease (CAD)
• Hypertension
• Heart failure
• Ischemic heart disease or coronary heart disease (CHD)
• Peripheral arterial disease (PAD)
• Dyslipidemia

Hypertension

• Cardiac output
• Sympathetic nervous system
• Renin angiotensin aldosterone system (RAAS)
• Renal function

Dyslipidemia

• Low-density lipoprotein (LDL)
• High-density lipoprotein (HDL)
• Triglycerides (TG)

• Hyperlipidemia: abnormally high levels of TC, LDL-C or TG
• Hypercholesterolemia: elevated TC and/or LDL-C

• Dyslipidemia can also mean that HDL cholesterol levels are too low.

Atherosclerosis and Coronary Artery Disease

• Coronary arteries (CAD),
• Heart (myocardial infarction),
• Brain (stroke),
• Legs (PAD)

1. Start out by greeting them and introducing yourself. “Hi there, my name is ___ and I’m a registered dietitian who will be working with you today.”
2. Describe the role of a registered dietitian in terms of their health care.
   “My role is to help you figure out your food and nutrition needs based on your lifestyle, medication, and health goals, like managing your blood pressure or lowering your cholesterol.”
3. Invite them to the conversation to build rapport.
   “How are you doing today?”
4. Set the agenda for the appointment by asking about what brings them in and how you can help with the management of their blood pressure or cholesterol.
   “What brings you in today?”
   “How might I help?”
   “What part of managing your blood pressure or cholesterol would you like to discuss with me today?”