MEDICAL NUTRITION THERAPY FOR DIABETES MELLITUS
Fifth Edition
Marion J. Franz, MS, RD, LD, CDE
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Copyright 2006 Wolf Rinke Associates, Inc. All rights reserved for this self-directed, accredited learning program. Reproduction in whole or part without written permission from the publisher is prohibited.
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OVERVIEW AND INSTRUCTIONS
Diabetes is a serious chronic disease affecting approximately seven out of
every 100 Americans. It is costly in both economic terms and its impact on an
individual's quality of life. Evidence exists that Medical Nutrition Therapy
(MNT) for diabetes as provided by dietitians can have a major impact on medical
and clinical outcomes and quality of life of persons with diabetes (Pastor,
2003). However, for nutrition professionals to be effective clinicians and educators
knowledge about diabetes nutrition is not enough; we also must be knowledgeable
and skilled in the overall management of diabetes and effective diabetes education.
By developing these competencies, nutrition therapy can be integrated effectively
into diabetes management. For the person with diabetes, this will allow flexibility
in lifestyle and improved quality of life while still being able to maintain
excellent metabolic control. The goal of this continuing education program is
to provide the information needed by dietetics professionals to develop these
competencies.
Chapter 1 discusses the classifications, diagnosis, and screening of diabetes.
Chapter 2 outlines lifestyle strategies for the prevention of diabetes. Chapter
3 reviews the management of diabetes. It begins by reviewing how monitoring
of diabetes management outcomes is done and used to achieve treatment goals.
Medical Nutrition Therapy reviews the goals and expected outcomes of nutrition
therapy and the nutrition-related strategies that have been shown to contribute
to improved glycemic control in both type 1 and type 2 diabetes. The 2002 and
2006 American Diabetes Association nutrition principles and recommendations
are classified based on the level of supporting evidence and thus in clinical
practice, priority can be given to the recommendations with the strongest supporting
evidence. Also summarized are the roles of physical activity and medications,
both oral-glucose lowering medications and insulin. Chapter 4 provides an overview
of the acute complications of diabetes-hypo- and hyperglycemia-and the role
of nutrition therapy in treatment and prevention. The long-term complications
of diabetes and nutrition therapy for dyslipidemia, hypertension, and nephropathy
are discussed in chapter 5. Issues related to nutrition therapy for preexisting
diabetes and pregnancy and for gestational diabetes are covered in chapter 6.
The implementation of medical nutrition therapy for diabetes is a primary responsibility
for dietetics professionals and is addressed in chapter 7. Implementation steps
as outlined in the Nutrition Care Process include nutrition assessment, nutrition
diagnosis, nutrition intervention (planning and implementations), nutrition
monitoring and evaluation (Lacey and Pritchett, 2003). Chapter 7 also includes
a brief discussion of how the American Diabetes Association diabetes nutrition
recommendations are implemented by health care facilities. A case study provides
the opportunity to apply the overall information gained from the learning program
to life situations and is included after the final chapter.
This learning program is a level 2 Continuing Professional Education (CPE) program
approved for 15 continuing education units (CPEUs). That means that the reader
has little or no prior knowledge of the literature and professional practice
within the area covered. The focus of the program is to enhance knowledge and
application.
To get the most benefit from this program, we suggest you adhere to the following
four steps:
Step 1: Review the objectives for the learning program.
Step 2: Study each chapter. As you read, think of patients from your own practice
who fit the situation described.
Step 3: Assess what you have learned by completing the self assessment instrument
at the end of this learning program.
Step 4: Compare your answers to the answer key that has been provided. If you
score at least 80% correct, you are ready to transfer your answers to the CONTINUING
PROFESSIONAL EDUCATION REPORTING FORM. If you scored less than 80% correct,
re-read this learning program until you score at least 80% correct.
After you have successfully completed this program, mail or fax the completed
CONTINUING PROFESSIONAL EDUCATION REPORTING FORM to:
Wolf Rinke Associates, Inc.
P.O. Box 350
Clarksville, MD 21029
Fax (410)531-9282
Upon receipt of your successfully completed CONTINUING PROFESSIONAL EDUCATION
REPORTING FORM, 15 CEs will be reported to the accrediting agency of your association.
HAPPY LEARNING!
Marion J. Franz, MS, RD, LD, CDE
OBJECTIVES
Upon completion of this accredited, self-directed learning program, the nutrition
professional should be able to:
" Recognize the types of glucose intolerance, screening recommendations,
and diagnosis criteria.
" Assess symptoms and etiologies of type 1 and type 2 diabetes.
" Identify recommended blood glucose, lipid, and blood pressure goals.
" Describe expected outcomes from medical nutrition therapy for diabetes
and when to evaluate outcomes.
" Identify lifestyle factors with research support for the prevention of
diabetes.
" Recognize two types of monitoring for glucose.
" Identify four goals of medical nutrition therapy.
" Apply strategies for attaining and maintaining blood glucose control
in type 1 diabetes.
" Implement four strategies to achieve the primary nutrition goals for
persons with type 2 diabetes.
" Recommend guidelines for total and types of carbohydrate in diabetes
food and meal planning.
" Define acceptable daily intake for nonnutritive sweeteners.
" Identify the role of protein in overall diabetes management.
" Specify guidelines for types and amounts of fat in diabetes meal planning.
" Specify guidelines for the use of alcoholic beverages.
" Recommend guidelines that allow a person with diabetes to exercise safely.
" Recognize classes of glucose-lowering medications and their primary mode
of action.
" Identify types, peak effect, and usual duration for human insulin.
" Identify new injectable medications for diabetes.
" Recognize the causes and treatment for hypoglycemia, hyperglycemia, and
ketoacidosis.
" Identify five long-term complications of diabetes.
" Implement nutrition therapy for nephropathy, dyslipidemia, and hypertension.
" Recommend blood glucose goals for pregnancy with preexisting diabetes
and gestational diabetes.
" Recognize the four components of the nutrition care process and their
application to diabetes medical nutrition therapy.
" Specify areas of assessment needed in order to provide Medical Nutrition
Therapy.
" Plan and implement nutrition interventions for persons with diabetes.
" Apply food/meal planning approaches for diabetes.
" Recognize the five stages of intentional behavior change as outlined
by the transtheoretical model of change.
" Assess factors to be addressed in nutrition care monitoring and evaluation.
" Provide follow-up and ongoing nutrition care for persons with diabetes.
" Discuss use of a consistent-carbohydrate diabetes meal planning system
for acute and long-term care health care facilities.
TABLE OF CONTENTS
Chapter 1. Classification, Screening, and Diagnosis of Diabetes 1
CLASSIFICATION CRITERIA 5
Type 1 Diabetes 7
Type 2 Diabetes 9
Pre-Diabetes 11
Gestational Diabetes Mellitus 12
Other Types of Diabetes 12
SCREENING FOR DIABETES 13
DIAGNOSTIC CRITERIA FOR DIABETES 14
Chapter 2. Prevention of Diabetes 17
DIABETES PREVENTION RESEARCH STUDIES 19
MEDICAL NUTRITION THERAPY FOR PRE-DIABETES 21
Chapter 3. Management of Diabetes 25
MONITORING 29
Self-Monitoring of Blood Glucose 29
MEDICAL NUTRITION THERAPY 32
Goals and Outcomes of Medical Nutrition Therapy for Diabetes 34
Nutrition Interventions for Type 1 Diabetes 38
Nutrition Interventions for Type 2 Diabetes 39
Nutrient Recommendations 41
Carbohydrate 41
Protein 46
Dietary Fat 47
Alcohol 48
Micronutrients 50
PHYSICAL ACTIVITY/EXERCISE 52
Benefits 52
Potential Problems with Exercise 54
Exercise Guidelines 56
Carbohydrate Adjustments 56
Insulin Adjustments 57
Precautions for Persons with Type 2 Diabetes 58
Exercise Prescription 59
MEDICATIONS 60
Glucose-Lowering Medications for Type 2 Diabetes 61
Injectable Glucose Lowering Medications 66
Insulin 67
SELF-MANAGEMENT EDUCATION 72
.
Chapter 4. Nutrition Therapy and the Acute Complications of Diabetes 75
HYPOGLYCEMIA 75
HYPERGLYCEMIA/DIABETIC KETOACIDOSIS 79
Fasting Hyperglycemia 81
HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS) 82
Chapter 5. Nutrition Therapy and the Long-Term Complications of Diabetes 85
MICROVASCULAR DISEASE 85
Retinopathy 85
Nephropathy 87
Medical Nutrition Therapy for Nephropathy 89
NEUROPATHY 90
MACROVASCULAR DISEASE 92
Dyslipidemia 92
Medical Nutrition Therapy for Dyslipidemia 93
Hypertension 94
Medical Nutrition Therapy for Hypertension 94
Chapter 6. Nutrition Therapy for Diabetes and Pregnancy 97
PREEXISTING DIABETES AND PREGNANCY 99
Nutrition Therapy for Preexisting Diabetes and Pregnancy 100
GESTATIONAL DIABETES MELLITUS 101
Nutrition Therapy for Gestational Diabetes Mellitus 105
Lactation 107
Chapter 7. Putting It All Together: Implementing the Nutrition
Care Process 109
IMPLEMENTING THE NUTRITION CARE PROCESS 109
Nutrition Assessment 110
Nutrition Diagnosis 115
Nutrition Interventions 116
Planning Nutrition Interventions 116
Nutrition Education 122
Nutrition Counseling 125
Nutrition Monitoring and Evaluation 127
Follow-up Encounters 129
Reimbursement 131
IMPLEMENTING DIABETES NUTRITION INTERVENTIONS
INTO HOSPITALS AND LONG-TERM CARE FACILITIES 132
SUMMARY 134
Case Study 137
References 143
For Your Continuing Education 153
List of Abbreviations 155
Glossary 157
Resources 163
Self Assessment Questions 165
Answer Key 175
Explanation to Questions 177
About the Author 181
About Wolf Rinke Associates 182
ABOUT THE AUTHOR
Marion J. Franz is a registered dietitian and a certified diabetes educator
with a master's degree in nutrition from the University of Minnesota. She is
a nutrition/health consultant with Nutrition Concepts by Franz, Inc. For over
20 years she was the Director of Nutrition and Health Professional Education
at the International Diabetes Center, Minneapolis. She has authored books, numerous
articles in professional and lay journals, and chapters in texts and manuals
for professionals and the lay public. She lectures frequently in the United
States and internationally on nutrition, exercise, and diabetes. She co-chaired
the task force to write the American Diabetes Association 1994 and 2002 nutrition
principles and recommendations for diabetes technical reviews and position statements
and was editor of the American Association of Diabetes Educators Core Curriculum
for Diabetes Education, 4th and 5th editions. She received the 2001 American
Diabetes Association Charles H. Best Medal for Distinguished Service in the
Cause of Diabetes, the American Dietetic Association 2006 Medallion Award, and
was the American Dietetic Association 2002 Lenna Frances Cooper Memorial Lecturer.
In addition, she has received the American Diabetes Association Award for Outstanding
Health Professional Educator, The American Dietetic Association Award for Excellence
in the Practice of Clinical Nutrition, the Park Nicollet Medical Center's Community
Service Award for Outstanding Service to the Community and the Park Nicollet
Medical Center's Educator Award, the University of Minnesota College of Human
Ecology Centennial 100 Honoree, and the Minnesota Dietetic Association Medallion
Award 2006.