Nutritional
Management of
Diabetes at School
Betsy Smith, MS, RD
Children’s Hospital
January 11, 2007
Nutrition Objectives
• To provide nutrition guidelines for the
school nurse working with children with
diabetes
• To describe the most popular methods
of diabetes medical nutrition therapy
• To describe and educate on the use of
carbohydrate counting
Outline
• Professional guidelines
• 2 Main types of MNT with pediatrics
• Carbohydrate Counting
• Making adjustments for exercise
• Questions
Goals of Medical
Nutrition Therapy
• To provide adequate energy to ensure
normal growth & development
• To facilitate changes in eating &
physical activity habits to reduce insulin
resistance
• Attain & maintain optimal metabolic
outcomes
• Prevent & treat the chronic
complications of diabetes
Goals of Medical
Nutrition Therapy
• Improve health through healthy food
choices & physical activity
• Address individual nutritional needs
• To provide self-management education
for treatment of acute complications
• To decrease diabetes risk by
encouraging physical activity & promoting
healthy food choices
Medical Nutrition Therapy
• Goal to achieve blood glucose goals
without excessive hypoglycemia
• Based on requirements for all healthy
children & adolescents
• Ensure adequate intake of essential
vitamins & minerals
Diabetes Classification
Type 1 Diabetes
•
•
•
•
•
Idiopathic
Autoimmune
Beta cell destruction
Autoantibodies
Insulin dependent
Clinical Presentation
Type 1 Diabetes
•
•
•
•
•
•
•
Hyperglycemia
Ketoacidosis
Dehydration
The “Polys”
Nausea & vomiting
Ill appearing
Weight loss
Diabetes Classification
•
•
•
•
•
Type 2 Diabetes
Insulin resistance
Deficient insulin secretion
Obesity or increased body fat
Elevated insulin levels
Initially treated with diet, exercise,
medications
Clinical Presentation
•
•
•
•
•
•
•
Type 2 Diabetes
Increased weight gain
Ketonuria
The “Polys”
Hyperglycemia
Elevated serum insulin
Acanthosis nigricans
Infections
Medical Treatment
of Diabetes
• Target blood sugar range
• Use of insulin
Subcutaneous (SQ) injections
Continuous SQ insulin infusion
• Use of oral hypoglycemic agents
• Weight management
• Exercise
• Medical nutrition therapy
Weight Management for
Type 2 Diabetes
• Exercise can decrease insulin resistance &
help with weight management
• Weight loss can also improve lipid levels
• Decrease risk for more immediate health
risks
• Slow rate of weight gain
Weight Management for
Type 2 Diabetes
• 3 meals + 2-3 snacks a day should be
encouraged
• Consumption of more fruits & vegetables, whole
grain products, lowfat dairy products
• Facilitate behavior change
• Identify barriers to success & help eliminate
them
ADA Exchange List
• Developed in 1950, revised by ADA in
1995
• Lists of groups of measured foods that
equal an “exchange”
• Can be used for Type 1 & Type 2
• Alerts patient to fiber & sodium
• Divides foods into 3 food groups
• Carbohydrate
• Meat & Meat Substitutes
• Fat
ADA Exchange List
Advantages
• Provides a framework for grouping foods
• Emphasizes important nutritional
management concepts
• Can use nutrient values from food labels
Not appropriate for use if the family
cannot understand “exchanging”
Carbohydrate Counting
• Been around since 1920’s
• Specifically focused on techniques to
optimize blood glucose control
• Used to match pre-meal insulin doses to
the demand created by food
• Other nutrition aspects must be
addressed separately
Carbohydrate Counting
•Easier to learn than exchanges
•Offers more variety in food
choices
•Provides a more accurate
prediction of rises in blood
sugar following a meal or snack
•Allows utilization of food labels
to make meal planning easier
Carbohydrate Counting
Three Levels
•Basic - learn carbohydrate
exchanges & consistent intake
•Intermediate - learn to identify
patterns in blood glucose levels
that are related to food eaten,
diabetes medications used, &/or
physical activity and how to make
adjustments
Carbohydrate Counting
• Advanced - learn how to adjust
short-acting insulin to the
carbohydrate content of meals
(carbohydrate to insulin ratios)
SO HOW DO YOU
COUNT
CARBOHYDRATES?
IDENTIFY
CARBOHYDRATE
FOOD SOURCES
MILK
FRUITS
STARCHES &
STARCHY
VEGETABLES
The Fruit Group
• Fresh fruit
• Canned fruit
(packed
in lite syrup, juice or
water)
• 100% fruit juice
(Labeled on container)
• Dried fruit
(raisins)
The Starch Group
• Starches (bread,
pasta, rice, crackers,
cereals, snack foods)
• Starchy
vegetables (corn,
potatoes, dried beans,
peas)
The Milk Group
• Milk
•
•
•
•
(whole, 2%, 1%, skim,
buttermilk)
Yogurt
Pudding
Ice cream
NOT CHEESE !
WHAT TO CONSIDER
WITH CARBOHYDRATE
• Used terms: sugars, starch, fiber
• Factors that influence glycemic
responses to foods:
Amount of Carbohydrate
Type of sugar
Nature of the starch
Cooking & food processing
Food form
BE FAMILIAR WITH
HOW MUCH FOOD
COUNTS AS A
SERVING
1 CARBOHYDRATE
SERVING =
15 GRAMS
CARBOHYDRATE
The Fruit Group
• Fresh fruit
1 cup, 1/2 banana, 15
grapes, 1/8
cantaloupe, tennis-ball
size piece
• Canned fruit
1/2 cup
• 100% fruit juice
4 ounces
• Dried fruit
2 Tablespoons
The Starch Group
• Starches
1 slice bread, 1/3 cup
rice, 1/2 cup pasta,
1/2 cup cereal, 1 small
roll, 1/2 bun
• Starchy
vegetables
1/2 cup corn,
potatoes, dried beans,
peas
The Milk Group
• Milk
8 ounces
• Yogurt
1 cup
• Pudding & ice
cream
1/3 - 1/2 cup
READ THE
NUTRITION FACTS
LABELS!
3 THINGS TO READ ON
A LABEL
• Serving Size
• Total Carbohydrate
• Total Fat
How Meal Plan Developed
for Each Child
• Based on age & ideal body weight in
kilograms
• Pattern of growth & weight gain
• Typical food intake at home
• Food history & activity patterns
• Time & place of all meals & snacks
• Home & school schedule during week
Carbohydrate Counting:
Suggested Education
Progression
• Initial session
Diet goals and rationale
Healthy nutrition
Balanced meals
Timing/consistency of meals
Carbohydrate, protein, fat sources & effects on blood
sugar levels
Concentrated sweets/free foods
Basic level of carbohydrate counting
Carbohydrate Counting:
Suggested Education
Progression
• Follow-up (initial 1 to 2 months, at 6 months,
yearly full nutrition assessment)
Individualized meal plan based on clinical
goals and patient/family readiness &
motivation
Meal Plans at School
• Prescribed carbohydrate grams for
meals and snacks
• Not every child with diabetes will have a
meal plan
• Usually prescribed at diagnosis or clinic
visit, cannot be prescribed over the
phone
• Sent to nutritionist of Child Nutrition
Program, who sends it to the school
Exercise Guidelines for
Type 1 Diabetes
• Blood glucose
monitoring
• Precautions to
avoid hypoglycemia
• Food intake may
need to be
increased
• Fluid intake is
essential
Exercise Guidelines for
Type 1 Diabetes
• Carry adequate ID & a source of fastacting carbohydrate
• May require a decrease in insulin
• Continue monitoring blood glucose after
exercise is completed
General Guidelines For Making
Food Adjustments
Types of Exercise
If Blood Sugar
Is:
Less than 80
Increase Food
Intake By:
10-15 g CHO/hour
Above 80
Not needed
Jogging, swimming,
golf
Less than 80
25-50 g CHO/hour
80-170
10-15 g CHO/hour
Football, soccer,
basketball,
cheerleading
Less than 80
45 g CHO/hour
80-170
20-45 g CHO/hour
Walking, leisure
bike
Parties at School
• Can still participate and eat food at
parties!
• Communicate with parent ahead of time
– Can plan to change insulin dose to
cover party food
– Plan to have party around time of
snack
• Encourage teacher or parents to provide
healthy snacks at parties, sugar-free
hard candy and lollipops
• Use fat-free whipped topping as icing on
cakes or cookies
Questions