5/16/2018. It is easier to change a man s religion than to change his diet. Nilda Benmaor, M.S.,R.D.N.,C.D.E. Margaret Mead, Anthropologist

Transcription

1 Nilda Benmaor, M.S.,R.D.N.,C.D.E. It is easier to change a man s religion than to change his diet. Margaret Mead, Anthropologist MEDICAL NUTRITION THERAPY Recommendations MACRONUTRIENT DISTRIBUTION Distribution of calories among Carbohydrates, Protein and Fat. Carbohydrates Protein Fat 45% 50% of total calories 18% 22% of total calories 30% 35% of total calories calories/day Total CHO = grams Carbohydrate intake from whole grains, vegetables, fruits, legumes and dairy products with emphasis on foods higher in fiber and lower in glycemic load, should be advised over other sources, especially those containing sugars. It s not the amount of carbohydrate you eat alone. If the body has sufficient insulin around when CHO are consumed, the body can control blood glucose levels. 1

2 RATIONAL FOR CARBOHYDRATE COUNTING It is important to control the intake of carbohydrates by eating the same amount of carbohydrates, along with some protein and fat at each meal. Offers flexibility in food choices. It is used for pattern management to determine medication doses. Helps understand that foods that contain carbohydrates should not be significantly limit or avoided as a means to achieve glycemic control. Helps understand how much carbohydrates to eat per meal or snack. CARBOHYDRATES THE TOTAL AMOUNT OF CARBOHYDRATES MAKES THE BIGGEST DIFFERENCE IN BLOOD SUGAR LEVELS. Once the carbohydrate in food is broken down to glucose and is in the blood the cells do not know whether that glucose came from jelly beans or a piece of fruit. Simple Carbs: are shorter chains and turn into glucose faster. Complex Carbs : are longer chains and usually turn into glucose slower. AMERICAN DIABETES ASSOCIATION AND ACADEMY OF NUTRITION AND DIETETICS RECOMMENDATIONS 1 carbohydrate choice= 15 grams (g) of carbs Most Women Need Most Man Need Each Meal 3 4 carbs choices = g of carbs/meal Snacks 1 carb choice= (if needed) 15 g of carbs/snack 4 5 carb choices= g of carbs/meal 1 2 carb choices= g of carbs/snack 2

3 Counting Carbohydrates STARCH GROUP (measured after cooking) 15 grams of carbohydrates, 2 3 grams of protein /serving 1 slice of bread (weighing 1 ounce) 1/4 large bagel 1/2 hamburger bun, hot dog bun, pita bread, English muffin 1/3 cup rice, pasta, millet, couscous 1/2 cup beans (pinto, kidney, garbanzo, lentils) 1/2 cup starchy vegetable (potato, corn, peas, sweet potato, yam) 1/2 cup oatmeal, kasha, grits, bulgur 1 small tortilla (flour or corn, 6 inch size) 6 saltine crackers 3 graham cracker squares 3 cups popcorn Counting Carbohydrates FRUIT GROUP 15 grams of carbs, 0 grams of protein 1 small apple, orange, peach, pear or nectarine (1/2 if large fruit) 1 small banana (1/2 of average banana) 1/2 grapefruit 1/2 cup unsweetened applesauce 3/4 cup fresh pineapple chunks, blueberries, or blackberries 17 grapes 3 prunes 1 1/4 cups strawberries, or watermelon 1 cup cantaloupe, honeydew, or papaya 1 large kiwi 2 tablespoons raisins 1/2 cup orange juice, apple juice, or grapefruit juice Counting Carbohydrates MILK GROUP 15 grams of carbohydrate,6 8 grams of protein/serving 1 cup of milk 1 cup of soy milk 1 cup of buttermilk 2/3 cup of plain yogurt 2/3 cup of aspartame sweetened yogurt 1 cup = 8 fluid ounces 3

4 Counting Carbohydrates NON STARCHY VEGETABLES 5 grams of carbohydrate per 1/2 cup cooked, or 1 cup raw. Artichokes, asparagus, green beans, beets, broccoli, Brussels sprouts, cabbage, carrots, cauliflower, eggplant, greens, kohlrabi, leeks, okra, onions, pea pods, peppers, spinach, summer squash, tomato, tomato sauce, turnips, and zucchini. Diabetic Meal Plans Be consistent with carbohydrate portions per meal. Ex: Breakfast = 45grams= 3 CHO choices. GRAMS OF CARBOHYDRATES CARBOHYDRATE CHOICES / / / / / Estimating Amount of Carbohydrates Reading food labels. Serving sizes such as cups, spoons and ounces in foods that do not have labels. Apps such as My Fitness Pal, Calorie King,My Calorie Counter ADA Food Exchanges Publications. 4

5 Nutrition Facts Labels Whole Wheat Bread Serving Size: 2 Calories: 110 Total Fat: 1.5 g Carbohydrates: 20 g Sugar: 2g Dietary Fiber: 3g Protein: 5 g Sodium: 230 mg Corn Tortillas Serving Size:2 Calories:100 Total Fat: 1.5g Carbohydrates: 20g Sugar:2g Dietary Fiber: 3g Protein: 2g Sodium: 10 mg Nutrition Facts Labels DIET RECALLS Avoid negative comments or facial expressions because you could impact the accuracy of the diet recall. Be non judgmental! Be familiar with typical foods from country of origin. Ask, do not assume! What time did you eat this meal? Record times of food eaten. When did you eat next? Was there a special occasion on this day? What did you drink with your meals? How many glasses? 5

6 Cultural Appropriate Strategies For Menu Planning Consider the following: Age Language Ability to prepare meals Budget Food preferences & habits Cooking facilities ( kitchen, oven, microwave, stove, sink, etc.) Storage facilities Include : My Plate as a guide (25% Protein,25%Grains & Starchy Foods, 50% Non Starchy Vegetables) + Fruit + Drink. Clip art, color, pictures Large font Breakfast, Lunch, Dinner & 1 2 snacks. Ethnic and traditional foods Foods that have positive health consequences should be encouraged ( Ex: nopales) Carbohydrates/meal Comparisons TYPICAL Breakfast #1 7:00 8:00 am HISPANIC FOODS Breakfast #1 at 10:00 11:00 am Food Amount Grams of Carbs Food Amount Grams of Carb Oatmeal cooked 1 cup 30 Milk, skim 1 cup 12 Blueberries 3/4 cup 15 Bread ( whole wheat) 1slice 15 Total Grams: 72 grams Breakfast #2 Tortillas corn 2 20 Milk, skim 1 cup 12 Egg Cheese 1 slice 0 Beans boiled ½ cup 15 Total Grams: 47grams Grams of Breakfast #2 Food Amount Carb Grams of Bagel 1 bagel (4 oz.) 60 Food Amount Carb Low sugar jelly 1 Tbsp Milk, skim 1 cup Burrito ( wheat tortilla) (4 oz.) 30 beans 1/2cup 15 cheese 1 slice 0 apple 1 15 Total Grams: 78 grams Total Grams: 60 grams Healthier choices Mexican foods Estimated CHO > 120 grams Estimated CHO = 75 grams 6

7 Sample Menus English & Spanish FOOD MENU 1 MENU 2 GROUP BREAKFAST BREAKFAST 1 fruit serving 1 small apple ½ banana 1 protein serving 1 scrambled egg 1 slice of string cheese 1 bread/starch 1 slices whole wheat bread 1/2 cup cereal servings 1 milk serving 8 ounces soy milk or low fat 8 ounces soy milk or low fat milk milk 1 fat serving 1 teaspoon margarine 6 almonds GRUPO DE MENú 1 MENú 2 ALIMENTO DESAYUNO DESAYUNO 1 porción de fruta 1 manzana pequeña ½ banana 1 porción de proteína 1 huevo revuelto 1 rodaja de queso (bajo en grasa) 1 porciones de pan 1 rodajas de pan de trigo 1/2 taza de cereal /almidón 1 porción de leche 8 onzas de leche ó leche 8 onzas de leche ó leche de de soya soya 1 porción de grasa 1 cucharita de margarina 6 almendras LUNCH LUNCH LUNCH/ALMUERZO LUNCH/ALMUERZO 1 fruit serving 1 small orange grapes 1 porción de fruta 1 naranja pequeña uvas 3 protein servings 3 ounces roast turkey 3 ounces of chicken 3 porciones de 3 onzas de pollo (tacos de pollo) 3 onzas de carne de res sin grasa 2 bread/starch 2 slices of whole wheat bread 1 cup boiled beans proteína servings 2 porciones de 2 tortillas de maíz 1 taza de frijoles de la olla pan/almidón 1 fat serving 1 tsp light mayonnaise 1/8 Avocado 1 porción de grasa 1 cucharita de aceite para 1/8 Aguacate con limón Free foods Lettuce/tomato salad Lettuce/tomato salad cocinar celery and cucumbers Celery and cucumbers Alimentos Libres Ensalada :Lechuga, tomates, Ensalada: lechuga, tomates, apio y pepinos apio y pepinos AFTERNOON SNACK AFTERNOON SNACK BOCADILLO BOCADILLO 1 protein serving 1 string cheese 1 tbsp. peanut butter 1 porción de proteína 1 rodaja de queso (quesadilla) 2 cucharadas de mantequilla de cacahuate 1 bread /starch ¾ ounces pretzels 1 rice cake 1 porción de pan/ 1 tortilla de maíz 4 5 galletas de trigo serving almidón 1 milk serving 1 yogurt light 8 ounces milk 1 porción de leche 1 yogurt bajo en grasa. 8 onzas de leche o leche de soya 1 fruit serving 1 cup strawberries 1 tangerine 1 porción de fruta 1 taza de fresas 1 mandarina DINNER DINNER CENA CENA 3 protein servings 3 ounces fish (cooked) 3 ounces of turkey ground 3 porciones de 3 onzas pollo sin piel (cocido) 3 onzas carne de pavo molida 2 bread / starch 1 small baked potato 1 cup whole wheat pasta( cooked) proteína servings 2 porciones de ½ taza de frijoles de la olla 1 taza de pasta de trigo( cocida) 2 vegetable servings 1 cup green beans 1 cup broccoli pan/almidón ½ taza de arroz moreno 1 fat serving 1 tbsp. light sour cream 1 teaspoon oil 2 porciones de 1 taza de ejotes 1 taza de brocoli Free foods Lettuce tomato salad Tomatoes, onion ( sauce) vegetales 1 porción de grasa 1 cucharita de aceite para 1 cucharita de aceite para cocinar cocinar Alimentos libres Ensalada de lechuga y tomates Salsa de tomate BEDTIME SNACK BEDTIME SNACK 1 bread /starch 4 graham crackers squares 4 6 whole wheat crackers. BOCADILLO BOCADILLO serving 1 porción de pan / 4 galletas graham ( cuadrados) ¾ taza de pretzels 1 protein serving 2 tbsps. peanut butter ¼ cup low fat cottage cheese almidón 1 porción de proteína 2 cucharadas de mantequilla de ¼ taza de requesón cacahuate. DESAYUNO (#1) COMIDA (#2) CENA (#3) BOCADILLO 1 rodaja de pan de trigo 2 claras de huevo revuelto 1 naranja 1 vaso ( 8 onzas) leche Tacos de Pollo 2 tortillas de maíz 3 4 onzas de pollo 1 cucharita avocados Ensalada con limón 1 pera Caldo de Pollo con Verduras 3 4 onzas de pollo Verduras y elote 1 tortilla de maíz 1 durazno Quesadilla 1 tortilla de maíz 1 rodaja de queso 1 yogurt Case Study 48 year old Mexican woman with type II DM, HT= 5 1, WT = 180# and A1C= 9.5 was referred by PCP for nutrition & diabetes education. Patient reported FBS s, does not check BS after meals and sometimes has symptoms of low blood sugar at night. She stated taking metformin in the morning with coffee and at night with water or tea. Patient was scheduled for a 30 minute appointment. DIET RECALL 5:00 am coffee with creamer and pan dulce. (at home) 10:00 am 1 egg, ½ cup refried beans, 1 sausage, 2 3 corn tortillas. 8oz lemonade. ( at work) Noon 1 cup of watermelon with a 1 small bag of chips ( at work) 3:00 4:00 pm 4 6 oz. chicken, 1 cup refried beans, 1 cup rice & 4 corn tortillas. 8 oz. of horchata or agua frescas. ( at home) 7:00 pm 1 cup of cereal with 4 oz. milk 9:00 pm 1 glass of water or green tea ( no sugar) 7

8 Case Study Action Plan Medication : reviewed PCP instructions. Take metformin with 5 am & 4 pm with meals. SMBG= FBS daily & HS( 3x/week). Avoid lemonade, horchata or agua frescas. Try to eat 3 balanced meals a day. Limit snacks in between meals. Try 1 corn tortilla with cheese or 1 slice of whole grain bread with peanut butter instead of pan dulce. Choose boiled beans ( de la olla) instead of rice. Reduce tortillas 1 2 per meal. Add nopales and salad. Add protein to 7 9 pm snack. Walk around the block. Summary Diabetes management requires individualized, patientcentered, and culturally appropriate strategies. Integrate, language, religion, literacy skills, and traditional foods from country of origin to improve blood sugar levels. Educate patients that controlling after meals blood sugar levels takes time and effort. Adapt expectations of patients to keep accurate records of their blood sugars, food, and physical activity, based on their literacy skills and education levels. With the release of the new Delicioso Forever stamps, the U.S. Postal Service celebrates the influence of Central and South American, Mexican, and Caribbean foods and flavors on American cuisine. 8

9 9