![\"Step](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-1024x132.png\")
\r\nCreating a Nutrition Care Plan for Diabetes<\/h2>\r\nMake sure to review the following 8 key areas:\r\n\r\n \t- Hypoglycemia<\/li>\r\n \t
- Hyperglycemia<\/li>\r\n \t
- Medication and Insulin<\/li>\r\n \t
- Carbohydrate (CHO) Intake<\/li>\r\n \t
- Macronutrient Distribution<\/li>\r\n \t
- Meal Timing<\/li>\r\n \t
- Cholesterol<\/li>\r\n \t
- Physical Activity<\/li>\r\n<\/ul>\r\n
Common PES Statement Terminology<\/h2>\r\nAs 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<\/a>.\r\n\r\nHere are some common nutrition problems that patients with diabetes experience.\r\n\r\n \t- Excessive energy intake<\/li>\r\n \t
- Less than optimal intake of types of carbohydrate (specify)<\/li>\r\n \t
- Food- and nutrition-related knowledge deficit<\/li>\r\n \t
- Not ready for diet\/lifestyle change<\/li>\r\n \t
- Physical inactivity<\/li>\r\n \t
- Unintended weight loss<\/li>\r\n \t
- Altered nutrition-related laboratory values (specify)<\/li>\r\n \t
- Inconsistent carbohydrate intake<\/li>\r\n \t
- Less than optimal intake of types of fats (specify)<\/li>\r\n \t
- Disordered eating pattern<\/li>\r\n \t
- Inability to manage self-care<\/li>\r\n \t
- Impaired ability to prepare foods\/meals<\/li>\r\n<\/ul>\r\nYou can create a PES statement for Penelope as we go through each of the 8 key areas.\r\n\r\n \r\n\r\nHere is Penelope\u2019s biochemical data from the assessment section. It may be helpful to refer to when creating your PES statements.\r\n
Penelope's Lab Results<\/caption>\r\n \r\n\r\nLab Test<\/th>\r\n Lab Result<\/th>\r\n Target Range<\/th>\r\n<\/tr>\r\n<\/thead>\r\n \r\n\r\nA1C<\/th>\r\n 7.5%<\/td>\r\n \u2264 7.0%<\/td>\r\n<\/tr>\r\n \r\nRandom BG<\/th>\r\n 11.0 mmol\/L<\/td>\r\n 5.0 - 10.0 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nTC<\/th>\r\n 3.6 mmol\/L<\/td>\r\n \u2264 4.0 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nLDL<\/th>\r\n 1.45 mmol\/L<\/td>\r\n \u2264 2.0 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nHDL<\/th>\r\n 1.9 mmol\/L<\/td>\r\n \u2265 1.3 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nTG<\/th>\r\n 1.2 mmol\/L<\/td>\r\n \u2264 1.7 mmol\/L<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nHypoglycemia<\/h1>\r\nIf 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.\r\n\r\nMake sure clients know the signs and symptoms<\/strong> 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.\r\n\r\nMake sure clients know how treat hypoglycemia using the 15:15 rule<\/strong>. If their BG is less than 4.0 mmol\/L, they can follow these steps:\r\n\r\n \t- Take 15g of simple CHO (carbohydrate): For example \u00be cup juice or regular pop; 3-4 glucose tablets; 3 packets of sugar<\/li>\r\n \t
- Recheck BG after 15 minutes\r\n
\r\n \t- If above 4.0: have a balanced snack or meal<\/li>\r\n \t
- If below 4.0: re-treat with 15g CHO<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ol>\r\nYou also need to think about the potential causes<\/strong> 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:\u00a0more physical activity than usual, taking too much medication, not eating on time or eating less than usual, and drinking alcohol.<\/span>\r\n\r\nImpaired 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.\r\n\r\n \r\n\r\n[h5p id=\"25\"]\r\n
\r\nPenelope's Hypoglycemia<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Hypoglycemia related to inconsistent carbohydrate intake, as evidenced by feelings of hunger and shaking\/trembling before lunch.<\/div>\r\n\r\n \t- Treat: use the 15:15 rule<\/li>\r\n \t
- Prevent: encourage Penelope to include CHO at all meals, especially breakfast<\/li>\r\n<\/ul>\r\nHer lows before lunch are likely related to her lack of carbohydrates at breakfast, which is evidenced in her 24-hour recall.\r\n\r\nMake sure Penelope recognizes the signs and symptoms of low blood sugar and has a plan in place for treating it if it happens again. For example, if she wakes up and has a BG of 3.5 mmol\/L, she should have \u00be cup of juice and follow the 15:15 rule before having breakfast.\r\n\r\nYou also want to try to prevent her hypos in the morning and before lunch by encouraging Penelope to include carbs at all meals, especially breakfast.\r\n\r\n<\/div>\r\n<\/div>\r\n
Hyperglycemia<\/h1>\r\nIf 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<\/strong>\u00a0 (e.g. eye damage or diabetic retinopathy, heart disease, stroke, hypertension, kidney disease, nerve damage and amputation, gastroparesis, erectile dysfunction).\r\n\r\nMake sure clients know the\u00a0signs\u00a0<\/strong>and symptoms <\/strong>of hyperglycemia,\u00a0<\/strong>which can include: dry mouth, thirst, frequent urination, and blurred vision.\r\n\r\nThink about the potential causes<\/strong> 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.\r\n\r\nWhen treating<\/strong> hyperglycemia, consider the BG:\r\n\r\n \t- If BG is frequently more than 11 mmol\/L: adjust medication and\/or insulin, adjust dietary patterns, and increase physical activity<\/li>\r\n \t
- If BG is more than 20 mmol\/L: seek immediate medical attention<\/li>\r\n<\/ul>\r\n \r\n\r\n[h5p id=\"26\"]\r\n
\r\n \t- <\/li>\r\n<\/ul>\r\n\r\n
\r\nPenelope's Hyperglycemia<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Hyperglycemia related to excessive carbohydrate intake at dinner, as evidenced by BG > 11 mmol\/L 2 hours after dinner and diet history.<\/div>\r\nTo prevent hyperglycemia, encourage Penelope to include CHO at all meals, and reduce the portion size of CHO at dinner.\r\n\r\nPenelope\u2019s hyperglycemia in the evening is likely related to her excessive carbohydrate intake at dinner. The most effective plan to reduce Penelope\u2019s high blood sugars in the evening and help to keep them controlled throughout the day, is to encourage her to include carbs at all meals and reduce the portion size of carbs at dinner.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\nMedication and Insulin<\/h1>\r\nIf a client is experiencing hypo- or hyperglycemia that you think may be related to medication and insulin, check the following:\r\n\r\n \t- Are they taking their medication and insulin at the times prescribed?<\/li>\r\n \t
- Does the type of medication commonly cause hypoglycemia?<\/li>\r\n \t
- Where are they injecting?<\/li>\r\n \t
- Are they rotating their insulin injection sites? How often?<\/li>\r\n \t
- Are they changing the needle\/pen tip every time?<\/li>\r\n \t
- Are they waiting 10 seconds before removing the needle from the skin?<\/li>\r\n \t
- Do they see any insulin leaking out of the injection site?<\/li>\r\n<\/ul>\r\n[caption id=\"attachment_1112\" align=\"aligncenter\" width=\"431\"]
![\"Diabetes](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2021\/08\/pexels-nataliya-vaitkevich-6941099-300x200.jpg\")
Photo by Nataliya Yaitkevich<\/a> on Pexels<\/a>[\/caption]\r\n\r\nLiaise 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.\r\nCarbohydrate Intake<\/h1>\r\nTo maintain optimal blood sugar control throughout the day clients can be encouraged to try to:\r\n\r\n \t- 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.<\/li>\r\n \t
- Limit simple sugars (regular pop, desserts, candies, jam, and honey) as they raise blood sugars rapidly.<\/li>\r\n \t
- Check food labels for hidden sugars (agave, corn syrup, dextrose, fructose, glucose, maltose, maple syrup, molasses, raw sugar, sucrose, etc.).<\/li>\r\n \t
- Use the Nutrition Facts table when Carb Counting to determine the amount of carbohydrate in 1 serving.<\/li>\r\n<\/ul>\r\nCarb 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.\r\n\r\nFor more information, read Diabetes Canada's \"Basic Carbohydrate Counting\" (PDF)<\/a> resource.\r\n
Macronutrient Distribution<\/h1>\r\nTo maintain optimal blood sugar control throughout the day clients can be encouraged to try to:\r\n
Common PES Statement Terminology<\/h2>\r\nAs 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<\/a>.\r\n\r\nHere are some common nutrition problems that patients with diabetes experience.\r\n\r\n \t- Excessive energy intake<\/li>\r\n \t
- Less than optimal intake of types of carbohydrate (specify)<\/li>\r\n \t
- Food- and nutrition-related knowledge deficit<\/li>\r\n \t
- Not ready for diet\/lifestyle change<\/li>\r\n \t
- Physical inactivity<\/li>\r\n \t
- Unintended weight loss<\/li>\r\n \t
- Altered nutrition-related laboratory values (specify)<\/li>\r\n \t
- Inconsistent carbohydrate intake<\/li>\r\n \t
- Less than optimal intake of types of fats (specify)<\/li>\r\n \t
- Disordered eating pattern<\/li>\r\n \t
- Inability to manage self-care<\/li>\r\n \t
- Impaired ability to prepare foods\/meals<\/li>\r\n<\/ul>\r\nYou can create a PES statement for Penelope as we go through each of the 8 key areas.\r\n\r\n \r\n\r\nHere is Penelope\u2019s biochemical data from the assessment section. It may be helpful to refer to when creating your PES statements.\r\n
Penelope's Lab Results<\/caption>\r\n \r\n\r\nLab Test<\/th>\r\n Lab Result<\/th>\r\n Target Range<\/th>\r\n<\/tr>\r\n<\/thead>\r\n \r\n\r\nA1C<\/th>\r\n 7.5%<\/td>\r\n \u2264 7.0%<\/td>\r\n<\/tr>\r\n \r\nRandom BG<\/th>\r\n 11.0 mmol\/L<\/td>\r\n 5.0 - 10.0 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nTC<\/th>\r\n 3.6 mmol\/L<\/td>\r\n \u2264 4.0 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nLDL<\/th>\r\n 1.45 mmol\/L<\/td>\r\n \u2264 2.0 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nHDL<\/th>\r\n 1.9 mmol\/L<\/td>\r\n \u2265 1.3 mmol\/L<\/td>\r\n<\/tr>\r\n \r\nTG<\/th>\r\n 1.2 mmol\/L<\/td>\r\n \u2264 1.7 mmol\/L<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nHypoglycemia<\/h1>\r\nIf 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.\r\n\r\nMake sure clients know the signs and symptoms<\/strong> 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.\r\n\r\nMake sure clients know how treat hypoglycemia using the 15:15 rule<\/strong>. If their BG is less than 4.0 mmol\/L, they can follow these steps:\r\n\r\n \t- Take 15g of simple CHO (carbohydrate): For example \u00be cup juice or regular pop; 3-4 glucose tablets; 3 packets of sugar<\/li>\r\n \t
- Recheck BG after 15 minutes\r\n
\r\n \t- If above 4.0: have a balanced snack or meal<\/li>\r\n \t
- If below 4.0: re-treat with 15g CHO<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ol>\r\nYou also need to think about the potential causes<\/strong> 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:\u00a0more physical activity than usual, taking too much medication, not eating on time or eating less than usual, and drinking alcohol.<\/span>\r\n\r\nImpaired 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.\r\n\r\n \r\n\r\n[h5p id=\"25\"]\r\n
\r\nPenelope's Hypoglycemia<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Hypoglycemia related to inconsistent carbohydrate intake, as evidenced by feelings of hunger and shaking\/trembling before lunch.<\/div>\r\n\r\n \t- Treat: use the 15:15 rule<\/li>\r\n \t
- Prevent: encourage Penelope to include CHO at all meals, especially breakfast<\/li>\r\n<\/ul>\r\nHer lows before lunch are likely related to her lack of carbohydrates at breakfast, which is evidenced in her 24-hour recall.\r\n\r\nMake sure Penelope recognizes the signs and symptoms of low blood sugar and has a plan in place for treating it if it happens again. For example, if she wakes up and has a BG of 3.5 mmol\/L, she should have \u00be cup of juice and follow the 15:15 rule before having breakfast.\r\n\r\nYou also want to try to prevent her hypos in the morning and before lunch by encouraging Penelope to include carbs at all meals, especially breakfast.\r\n\r\n<\/div>\r\n<\/div>\r\n
Hyperglycemia<\/h1>\r\nIf 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<\/strong>\u00a0 (e.g. eye damage or diabetic retinopathy, heart disease, stroke, hypertension, kidney disease, nerve damage and amputation, gastroparesis, erectile dysfunction).\r\n\r\nMake sure clients know the\u00a0signs\u00a0<\/strong>and symptoms <\/strong>of hyperglycemia,\u00a0<\/strong>which can include: dry mouth, thirst, frequent urination, and blurred vision.\r\n\r\nThink about the potential causes<\/strong> 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.\r\n\r\nWhen treating<\/strong> hyperglycemia, consider the BG:\r\n\r\n \t- If BG is frequently more than 11 mmol\/L: adjust medication and\/or insulin, adjust dietary patterns, and increase physical activity<\/li>\r\n \t
- If BG is more than 20 mmol\/L: seek immediate medical attention<\/li>\r\n<\/ul>\r\n \r\n\r\n[h5p id=\"26\"]\r\n
\r\n \t- <\/li>\r\n<\/ul>\r\n\r\n
\r\nPenelope's Hyperglycemia<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Hyperglycemia related to excessive carbohydrate intake at dinner, as evidenced by BG > 11 mmol\/L 2 hours after dinner and diet history.<\/div>\r\nTo prevent hyperglycemia, encourage Penelope to include CHO at all meals, and reduce the portion size of CHO at dinner.\r\n\r\nPenelope\u2019s hyperglycemia in the evening is likely related to her excessive carbohydrate intake at dinner. The most effective plan to reduce Penelope\u2019s high blood sugars in the evening and help to keep them controlled throughout the day, is to encourage her to include carbs at all meals and reduce the portion size of carbs at dinner.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\nMedication and Insulin<\/h1>\r\nIf a client is experiencing hypo- or hyperglycemia that you think may be related to medication and insulin, check the following:\r\n\r\n \t- Are they taking their medication and insulin at the times prescribed?<\/li>\r\n \t
- Does the type of medication commonly cause hypoglycemia?<\/li>\r\n \t
- Where are they injecting?<\/li>\r\n \t
- Are they rotating their insulin injection sites? How often?<\/li>\r\n \t
- Are they changing the needle\/pen tip every time?<\/li>\r\n \t
- Are they waiting 10 seconds before removing the needle from the skin?<\/li>\r\n \t
- Do they see any insulin leaking out of the injection site?<\/li>\r\n<\/ul>\r\n[caption id=\"attachment_1112\" align=\"aligncenter\" width=\"431\"] Photo by Nataliya Yaitkevich<\/a> on Pexels<\/a>[\/caption]\r\n\r\nLiaise 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.\r\n
Carbohydrate Intake<\/h1>\r\nTo maintain optimal blood sugar control throughout the day clients can be encouraged to try to:\r\n\r\n \t- 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.<\/li>\r\n \t
- Limit simple sugars (regular pop, desserts, candies, jam, and honey) as they raise blood sugars rapidly.<\/li>\r\n \t
- Check food labels for hidden sugars (agave, corn syrup, dextrose, fructose, glucose, maltose, maple syrup, molasses, raw sugar, sucrose, etc.).<\/li>\r\n \t
- Use the Nutrition Facts table when Carb Counting to determine the amount of carbohydrate in 1 serving.<\/li>\r\n<\/ul>\r\nCarb 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.\r\n\r\nFor more information, read Diabetes Canada's \"Basic Carbohydrate Counting\" (PDF)<\/a> resource.\r\n
Macronutrient Distribution<\/h1>\r\nTo maintain optimal blood sugar control throughout the day clients can be encouraged to try to:\r\n
| Lab Test<\/th>\r\n | Lab Result<\/th>\r\n | Target Range<\/th>\r\n<\/tr>\r\n<\/thead>\r\n |
|---|---|---|
| A1C<\/th>\r\n | 7.5%<\/td>\r\n | \u2264 7.0%<\/td>\r\n<\/tr>\r\n |
| Random BG<\/th>\r\n | 11.0 mmol\/L<\/td>\r\n | 5.0 - 10.0 mmol\/L<\/td>\r\n<\/tr>\r\n |
| TC<\/th>\r\n | 3.6 mmol\/L<\/td>\r\n | \u2264 4.0 mmol\/L<\/td>\r\n<\/tr>\r\n |
| LDL<\/th>\r\n | 1.45 mmol\/L<\/td>\r\n | \u2264 2.0 mmol\/L<\/td>\r\n<\/tr>\r\n |
| HDL<\/th>\r\n | 1.9 mmol\/L<\/td>\r\n | \u2265 1.3 mmol\/L<\/td>\r\n<\/tr>\r\n |
| TG<\/th>\r\n | 1.2 mmol\/L<\/td>\r\n | \u2264 1.7 mmol\/L<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nHypoglycemia<\/h1>\r\nIf 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.\r\n\r\nMake sure clients know the signs and symptoms<\/strong> 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.\r\n\r\nMake sure clients know how treat hypoglycemia using the 15:15 rule<\/strong>. If their BG is less than 4.0 mmol\/L, they can follow these steps:\r\n
|