Medical Nutrition Therapy Part 2 for Diabetes

Carbohydrate intake is adjusted for other circumstances, such as increased physical activity and lower blood glucose levels before the evening snack to reduce the risk of low blood glucose levels.

•         For increased physical activity beyond the usual routine: Eat or drink 15 g carbohydrate for every hour of extra activity before the activity. For longer, more strenuous exercise (>1 hour), include protein with the carbohydrate. These guidelines may be individualized depending on the insulin regimen, blood glucose level before exercise, and training intensity (Table 8).

•         For lower blood glucose levels before the evening snack: If blood glucose levels are 70-100 mg/dl, eat or drink an additional 15 grams of carbohydrate with the regular evening snack. If blood glucose levels are < 70 mg/dl, treat the low blood glucose first with 15 g carbohydrate or glucose; wait 15 minutes and retest; eat or drink another 15 g carbohydrate if the blood glucose level is still

< 70 mg/dl. Otherwise, have the regular evening snack with an additional 15 g carbohydrate.

TABLE 8

Guidelines for Exercise

For most people, the safe pre-exercise blood glucose (BG) range is from 100-250 mg/dl.

If BG is less or close to 100 mg/dl, have a snack to raise it before exercising, as shown below.

When BG is 100-150 mg/dl, many people do not require a snack unless exercise is intense. However, test during exercise and be prepared to snack to keep BG up if necessary.

For every hour of exercise, be ready to consume 10-15 grams of carbohydrate. A BG 151-250 mg/dl is optimal for safe exercise.

Avoid exercise if fasting BG is >350 mg/dl or >250 mg/dl and ketones are present. Identify usual BG response to exercise to determine if insulin must be reduced

Be prepared to test in the middle of the night if the exercise is intense or of long duration. Have carbohydrate (CHO) foods available at all times – before, during and after exercise.

Examples of regimens tailored to intensity of exercise

  Intensity of Exercise    Examples                                       Suggested Snack                                             

Mild/moderate (<30 minutes)

Walking, cycling                              15g CHO - 1 granola bar or 4 oz juice

Moderate (1 hour)

Tennis, swimming, jogging, golfing, or leisurely cycling

30g CHO* - Large banana or 16 oz sports drink

Intense                        Football, hockey, racquetball, basketball, strenuous cycling, swimming, shoveling snow

45g CHO* - Sandwich and 8 oz sports drink

*  Some guidelines suggest adding a protein serving with moderate or intense exercise

Adapted From: Orr, DP. Contemporary management of adolescents with diabetes mellitus. Part 1: Type 1 diabetes. Adolescent Health Update 2000;12(2), Table 7, p 10.

Nutritional recommendations for teens are similar to those for other young people. Macronutrient distribution should be approximately 50-60% carbohydrate, 10-20% protein and 30% fat. Saturated fat should be limited to < 10% of total calories and dietary cholesterol to < 300 mg/day to help reduce the risk of cardiovascular disease. Further adjustments in fat intake may be required with elevated lipid levels and/or unhealthy weight gain. Guidelines for dietary fiber and sodium are the same as for the general population.

Scientific evidence no longer supports the need to restrict sucrose and sucrose-containing foods to reduce hyperglycemia. Therefore, teens can continue to eat many common foods, such as sweetened cereal, cookies, brownies, and ice cream, in the context of a healthy eating plan as long as they estimate the amount of carbohydrate eaten and make appropriate adjustments.

Special Considerations

Hypoglycemia (a blood glucose level < 70 mg/dl). (See Table 9.)

•         Also called low blood sugar, insulin reaction or insulin shock.

•         Usually caused by too little food, too much insulin, extra physical activity or delayed meals and snacks.

•         May occur at any time, but is most likely before meals, during peak action time of insulin and during or after exercise.

•         Frequent or severe hypoglycemia is unpleasant and many teens will tolerate higher blood glucose levels and not increase insulin doses as recommended in order to avoid these episodes. The diabetes team should be sensitive to this and work with the teen to promote gradual improvements in blood glucose levels.

•         Teens with limited cognitive ability, those who skip or delay meals, those lacking awareness of hypoglycemia (increasingly common after having diabetes for 10 years) and those who are starting intensive insulin therapy are at risk for increased hypoglycemia. If this persists, higher blood glucose levels may be acceptable.

TABLE 9 Hypoglycemia  Guidelines
	Mild	Moderate	Severe
SYMPTOMS	Hungry             Dizzy Shaky              Sweaty Headache        Weak Pale                 Irritable Nervous           Unusual behavior	Confusion Poor coordination Restlessness Double vision Combativeness	Unconsciousness Seizures
TREATMENT	Eat or drink 15 g carbohydrate: –        1/2 c orange juice –        1/2 c regular pop –        5 Lifesavers® –        1 fruit roll-up –        3 glucose tablets Wait 15 minutes and retest. If no better, repeat. If more than 1 hour before the next meal, eat or drink 1 serving of starch/bread item or 1 c milk.	If alert: Give 15 g carbohydrate If confused and unable to swallow: –        Apply glucose gel or Cake Mate® gel to inside of gum. –        If no better in 15 minutes, repeat. If more than 1 hour before the next meal, eat or drink 1 serving of starch/bread item or 1 c milk.	Administer glucagon: –        Mix according to instructions. –        Inject 1 vial. Check blood glucose levels every 15-30 minutes. Upon arousal, encourage small amounts of regular pop and crackers. When tolerating pop well, give 30 g carbohydrate. May sleep if blood glucose >100 mg/dl.

TO BE CONTINEU


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