Counseling the New Diabetes Patient on Nutrition

The diagnosis of diabetes can be overwhelming for anyone. It is a disease with associated risks, new medications, a new lifestyle. Eating a healthier diet is among the most important lifestyle components of managing the disease, and it is very important that new diabetes patients understand how diet can help control diabetes and prevent its complications. Although the 2003 American Diabetes Association (ADA) guidelines offer evidence-based recommendations on nutrition and diabetes, there is no cookie-cutter approach to teaching patients with diabetes how and what to eat. Knowing healthy eating recommendations that can apply to many patients with diabetes and then tailoring these to individual lifestyles is essential for providing the best nutrition education. The ADA identifies pharmacists as key contacts to provide medical nutrition therapy (MNT). The ADA?s goals of MNT for patients with diabetes are intended to serve as guidelines for educating patients on the best food choices.

The guidelines are as follows:

? Attain and maintain optimal metabolic outcomes (blood glucose, lipids, blood pressure)

? Modify nutrient intake and lifestyle as appropriate for the prevention and treatment of obesity, dyslipidemia, cardiovascular disease, hypertension, and nephropathy

? Improve health through healthy food choices and physical activity

? Address individual nutritional needs, taking into consideration personal and cultural preferences and lifestyle, while respecting the individual?s wishes and willingness to change1

So, how are we as pharmacists to teach people with diabetes to meet these goals? Here are a few suggestions to give your patients.

1. Limit carbohydrate servings.

Carbohydrates include sugars, starch, and fiber, and 1 serving is about 15 g. People with or without diabetes should eat a diet that includes carbohydrate, particularly from whole grains, fruits, vegetables, and low-fat milk. Several studies show that carbohydrate, no matter its source (eg, cakes, corn, cereal, candy), produces about the same response in blood sugar; therefore, it is the total amount of carbohydrate in meals and snacks that is most important, not the type of carbohydrate^.1

2. Maintain approximately the same number of carbohydrate servings at each meal each day.

This is especially important if the patient is taking a fixed dose of insulin. Many people using insulin can base their dose on the amount of carbohydrate that is to be consumed along with their current blood sugar. This takes training, so patients should not do this without education and coaching.

3. Lose weight.

Weight loss reduces blood sugar and A1c levels2 and can be so effective that, after reaching weight-loss goals, some patients no longer need their diabetes medications. Calorie restriction is necessary for losing weight, but the very low-calorie diets (< 800 calories/day) are not effective for long-term weight loss. Most people need 1200 to 2000 calories/day, depending on metabolic needs and activity level. It is helpful to get an idea of what a patient?s typical daily caloric intake is and then work with that patient on ways to cut back on calories. This might include substituting low-fat dressings for regular, using mustard instead of mayonnaise, eating lean meats instead of fatty ones. Also, nonnutritive sweeteners, which have few or no calories, are safe when consumed within the acceptable daily intake levels established by the FDA.

Low-carbohydrate diets promote weight loss by replacing carbohydrates with monounsaturated fat. This does reduce postprandial blood sugars and triglycerides; however, there is some concern that the increased fat consumption may promote weight gain.¹ The ADA does not make any recommendations on using one of these popular diets over another (eg, Atkins, the Zone), but evidence suggests that these diets are beneficial in helping people lose weight.³ More research needs to be done, however, to assess long-term success and potential risks.

The best weight-loss program involves routine exercise, which is defined as exercising on most days of the week for at least 30 minutes. All diabetes patients should discuss exercise programs with their physician before beginning.

4. Restrict protein in the presence of renal dysfunction.

For people with diabetes, there is no evidence to suggest that usual protein intake (15%?20% of total daily energy) should be modified if renal function is normal. If there is renal dysfunction, however, protein should be restricted to 8 mg/kg/day.¹

5. Limit sodium.

Hypertension increases the risk for heart attack and stroke as well as nephropathy in people with diabetes. Limiting sodium can help decrease blood pressure.⁴ The goal should be to reduce sodium intake to 2400 mg or salt to 6000 mg/day^.1

6. Limit saturated fats and dietary cholesterol.

Dyslipidemia, as well as diabetes, increase a person?s risk for cardiovascular complications such as heart attack and stroke. Saturated fats should make up <10% of daily intake. Cholesterol intake should be <300 mg/dL/day.¹ (If LDL is >100 mg/dL, limit saturated fats to <7% and dietary cholesterol to < 200 mg/dL/day.)

7. Limit alcohol consumption.

It is important to tell those patients with diabetes who would like to drink alcohol when and how much it is safe to drink and still keep their diabetes under control. Alcohol can cause serious fluctuations in blood sugar levels, particularly when combined with oral diabetes medications or insulin. The liver normally keeps a person?s blood sugar from going too low by releasing glucose into the blood. When a person drinks, the liver is not able to maintain this action because it is breaking down the alcohol. Therefore, if a diabetes patient is taking insulin or a secretagogue and consumes alcohol, his or her blood sugar may become too low.

On the other hand, alcohol does contain calories and carbohydrates, which can cause the blood sugar to rise. These 2 things must be factored into the patient?s eating plan to keep blood sugar under control and to maintain or lose weight. Alcohol also raises triglyceride levels.

Pharmacists are essential in educating diabetes patients about proper eating habits to reduce blood sugar and ultimately prevent the long-term complications of diabetes. Take time with your patients and have educational materials in your pharmacy or practice site to hand out on healthy eating habits. We can make a difference.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. D. Ryan, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: dryan@mwc.com.