TYPE 2 DIABETES MASTER DECISIONPATH 103 • Laboratory data: HbA 1c , plasma glucose level, fasting lipid profile, blood pressure, renal function and liver function tests (ALT) • Goals for patient care: target blood glucose, target HbA 1c , method and frequency of blood glucose monitoring and weight management • Medical clearance for patient to exercise and/or other pertinent information related to daily activities Assess obesity. To determine the appropriate nutrition intervention, include an assessment of body mass index (BMI – divide weight measured in kilograms by the square of the height mea- sured in meters – kg/m 2 ). Recently, the National Heart, Lung, and Blood Institute identified over- weight as a BMI of 25–29.9 kg/m 2 and obesity as ≥30 kg/m 2 . See the BMI chart in the Appendix (Figure A.5) to calculate the BMI. Body mass index correlates well with body fat as a clinical measure of obesity. A loss of two units of BMI corresponds to a decrease in body weight of about 5–6 kg (11 to 13.2 lb). Once the BMI has been determined, obtain this additional information: • Thorough diet history including past experi- ence with meal planning • Dietary restrictions due to allergies, religion, culture, finances, and preferences • Weight history including any significant loss or gain in weight over the past five years • Weight goals • Current appetite, recent loss of appetite • Eating or digestion problems • Eating schedule • Meal preparation practices • Typical day’s food intake (to be evaluated for approximate calories and nutrient compo- sition, other nutritional concerns, frequency, and timing of meals) • Frequency and choices in restaurant meals • Alcohol intake • Use of vitamins or nutritional supplements Obtain data related to physical activity and exercise: 1. What type of activity does the patient cur- rently do? 2. Does the patient exercise regularly? 3. What limitation does the patient have that would hinder or prevent exercise? 4. Is the patient willing or interested in becom- ing more physically active? Assess psychosocial/economic issues (see the “Behavioral Issues and Assessment” section). During the visit, include a review of the liv- ing situation, cooking facilities, finances, ed- ucational background, employment, ethnicity, religious background, and belief considerations. Next, develop a plan that includes a combination of patient and healthcare team goals related to di- abetes management, such as target HbA 1c .The food plan prescription should be individualized to the patient based on diet history, food patterns and preferences, and other collected data, as well as socioeconomic issues, ethnic/cultural issues, reli- gious practices, and lifestyle. Medical nutritional interventions are behavioral in their approach. Begin by establishing a blood glucose target and the period of time it should take to reach this goal. This decision needs to be made by the patient and the physician. Next, determine the degree to which the individual is ready to alter caloric intake as part of a strategy for controlling blood glucose. Sometimes readiness to change is a function of knowledge. Individuals with diabetes must first understand the disease, treatment options, and long-term prognosis before they are ready to accept a therapeutic choice. The SDM section on patient education addresses this point and provides details regarding the approach to education. SDM uses three principles in the development of a food plan: replace, reduce, and restrict. 104 TYPE 2 DIABETES The fi rst step in designing an effective food plan is to replace high caloric and high carbohydrate foods and drinks with substitutes that are simi- lar in volume and taste. Replacing regular soda pop with diet soda is one example: the same size portion and a similar taste. Replacing full fat ice cream with a low fat, low sugar substitute is an- other example. In general, patients are willing to do this as it causes the least inconvenience and is easy to fit into their current lifestyle. If this fails to adequately lower blood glucose (expect a drop of 20–30 mg/dL (1.2–1.7 mmol/L) within the first week, consider more aggressive caloric reductions and restrictions. If, over a period of two t o three weeks, the trend does not continue, then move to the second principle. Reduction of caloric in- take is accomplished by reducing the portion size of key foods and drinks. Begin with a total re- duction of approximately 10 per cent. The easiest way to accomplish this is to reduce all caloric intake during meals and snacks. Keep slowly re- ducing t otal calories (5 per cent/week) until total caloric intake reaches 75 per cent of the original intake or a reduction by 500 kcal/day. This should result in a weight reduction of approximately 1 pound weekly. Blood glucose should continue to improve. If this fails, significant restrictions need to be placed on intake of certain food or drinks, for example, total omission of regular soda pop, high- fat milk, cheese, butter, ice cream, salad dressing, and sweetened syrups may be required. The replace, reduce, restrict approach is one strategy. A far more comprehensive approach is usually needed. If medical nutrition therapy is to work for a long period of time, then the plan must target blood glucose and weight maintenance or reduction simultaneously. Begin with a calcu- lation of t arget weight (assuming that the blood glucose has already been agreed upon). The tar- get weight can be determined by finding the upper limit of the normal range of the BMI for the patient. Next, plan to move towards this goal in in- crements of 1 to 2 points. For example, if the cur- rent BMI of a 5 ft. 8 in. male patient is 32 kg/m 2 his long term goal would be a BMI of 24 kg/m 2 , requiring a weight loss of at least 50 lb (23 kg). The initial target would be a weight loss of 5 lb. (2 kg). This could be accomplished by a net reduc- tion in daily caloric intake of 500 kcal/day for a period of five weeks. To reach the long-term goal, the patient would continue on the new dietary reg- imen for approximately one year. Although this seems to be a long period of time, it has been found that the changes in lifestyle, that lead to the weight loss will be more likely to be sustained. The regimen can be modified for both daily activity level and age. Persons with a sedentary lifestyle generally need fewer calories to main- tain their metabolic rate. Typically, an obese and sedentary individual requires one-third fewer calo- ries to maintain the same body weight than an active leaner person. See Table 4.6. Harris–Benedict equation. The Harris– Benedict equation is another way to determine caloric requirements. 32 It is a close estimation of basal energy expenditure (BEE), shown in Table 4.7. Adjustment in body weight for obese patients. The BEE should be modified for obese individuals, since it assumes a certain metabolic rate for all tissues. An obese person has a greater percentage of body fat, which is much less metabolically active. Thus, caloric needs cal- culated on the basis of an obese person’s actual body weight would be skewed very high. Obese Table 4.6 Estimation of calorie requirements for adults kcal per lb kcal per kg DBW DBW Men and physically active women ∼15 ∼30 Most women, sedentary men, adults over age 55 ∼13 ∼28 Sedentary women, obese adults, sedentary adults over age 55 ∼10 ∼20 TYPE 2 DIABETES MASTER DECISIONPATH 105 Table 4.7 Basal energy expenditure (BEE) Female BEE 655 + (9.6 × W ) + (1.8 × H ) − (4.7 × A) Male BEE 66 + (13.7 × W ) + (5 × H ) − (6.8 × A) W = actual weight in kg; H = height in cm; A = age in years BEE × activity factor = total caloric requirement Activity Factors very sedentary = 1.1 sedentary/most people = 1.2 aerobic exercise 3 times/week = 1.3 aerobic exercise 5 times/week = 1.5 daily aerobic exercise = 1.6 persons do, however, have an increased caloric expenditure required for walking and moving ex- cess weight or the increase in body protein for structural support of extra fat tissue. Because of these concerns, the following formula is suggested for obese patients. This formula is based on phys- iologic theory, rather than direct clinical research. Use the adjusted body weight obtained through this calculation in place of actual weight in the formula for BEE. Adjusted weight (kg) = (ABW - DBW) × 0.25 + DBW ABW = actual body weight DBW = desirable body weight 0.25 = percentage of metabolically active body fat tissue Macronutrient composition. Although re- duction in total caloric intake is effective, yet an- other approach evaluates the macronutrient com- position of the food plan. Staged Diabetes Man- agement recommends plans are individualized ac- cording to a person’s lifestyle, eating habits, and concurrent medical conditions. For example, i f weight is a concern, total fat should be reduced; if elevated cholesterol is a concern, saturated fat should be reduced to less than 10 per cent of to- tal fat; and if hypertension is a concern, sodium intake should be reduced to <2400 mg/day. Educating individuals about food planning in- volves teaching basic concepts of nutrition, dia- betes nutrition guidelines, and discussing ideas for altering current food plans to meet these guide- lines. Points of focus include the following: 1. When and how much to eat. Space food throughout the day to avoid long times be- tween meals and snacks. Choose smaller por- tions. Eat smaller meals and snacks. Avoid skipping meals and snacks (if part of food plan). 2. What to eat. Choose a variety of foods each day. Choose foods lower in fat. Avoid foods high in added sweeteners such as soda pop, syrup, candy, and desserts. 3. How to make food choices. Include a simple definition of carbohydrate, protein, and fat, with examples of food sources of each; dis- cuss nutrition guidelines, such as eating less fat and carbohydrates, using less added sweet- ener, eating more fiber, and reducing total caloric (fat) intake for weight loss if appro- priate; and suggest grocery shopping tips for making these changes in their current eating pattern. 4. Changes in food plan when taking medi- cations. Since patients may eventually be placed on oral agent or insulin therapy, it is appropriate to indicate that some changes in the food plan may take place when these therapies are initiated. Additional attention to food and eating awareness is recommended for obese individuals. This can be achieved by discussing the connection between por- tion size and carbohydrates; the calorie and fat content of foods; and the importance of self-monitoring behaviours, such as food records designed to increase awareness of to- tal food consumption and stimuli that promote overeating. Carbohydrate counting and the exchange lists. Carbohydrates are quickly broken down to glucose in the digestive track and thus have the greatest immediate impact on blood glucose 106 TYPE 2 DIABETES levels. Therefore, accounting for the amount of carbohydrate intake is of particular concern when generating a food plan for the individual with di- abetes. One approach, called carbohydrate count- ing, has patients consume a specific number of carbohydrate choices (15 g carbohydrate/choice) at each meal or snack. Carbohydrate counting al- lows for synchronization of pharmacologic ther- apy to the glucose patterns that emerge from following an established food plan (see the Ap- pendix, Figure A.14). Patients using pre-meal rapid-acting insulin or rapid-acting meglitinides can be taught to adjust the pre-meal dose based on the number of carbohydrates they plan to in- gest at the next meal. After experimentation, many patients can become adept at these adjustments (often with excellent results). This approach is best when packaged foods are used with the nu- tritional labels that contain the amount of calories coming from carbohydrates. The approach is least effective when portion sizes are hard to estimate and the composition of the food or drink is un- known. Foods are divided into three categories: carbo- hydrates, meats and meat substitutes, and added fat. For each category, each unit contains a rel- atively fixed range of calories ( see Table 4.8). The exchange lists, which group foods into six lists with all foods on any one list containing approximately the same proportion of carbohy- drate, fat, and protein, can be used to select foods from the three categories. The six lists are starch, meat and meat substitutes, vegetables, fruit, milk, and fat. Because foods can be exchanged within one list it allows greater variety in food choices while maintaining consistency in nutrient con- tent. A food plan would include choices in the three categories for each meal and snack. For example, a typical breakfast might include three carbohydrate choices (banana, milk, and toast), one meat choice (ham), and one fat choice (but- ter). The total calories would be 270 (CHO) + 100 (meat) + 45 (fat) = 415 kcal. Reinforcement, doctor/patient relationship. In order to support and sustain medical nutrition interventions there are many areas that need to be addressed by the patient and the health care provider. Some of these are listed here: • Agreement on short-term goals. Short-term goals should be specific, “reasonable and re- alistic,” and achievable in 1–2 weeks. Goals should address eating, exercise, and blood glucose monitoring behaviours. The focus should be to change one or two specific be- haviours at a time in each area, e.g. eat breakfast and use less margarine, walk for 15 minutes twice a week, test blood glucose be- fore and after the main meal three times a week. • Collection of important clinical data. Provide instructions on how to record food intake (actual food eaten and quantities, times of meals), exercise habits (type, frequency, and duration), and blood testing results. • Documentation. Include in the patient’s per- manent record the assessment and interven- tion. The report should include a summary of assessment information, long-term goals, edu- cation intervention, short-term goals, specific actions recommended, and plans for further follow-up, including additional education top- ics to be reviewed. Coordinated exercise/activity plan. Medi- cal nutrition therapy incorporates a food plan with exercise or activity designed to optimize glucose Table 4.8 Calories and food exchanges Type of Food Calories (kcal/kg) Exchange List Carbohydrates 60–90 Starch, fruit, milk Meat and meat substitutes 50–100 Meat Added fat 45 Fat TYPE 2 DIABETES MASTER DECISIONPATH 107 uptake and insulin utilization. The approach to exercise and activity is detailed in this chapter. Glucose monitoring. Although the patient may be started on a regimen based solely on MNT to improve glycemic control, it is espe- cially important not to omit SMBG. In general, SMBG is used too infrequently with such pa- tients. This places the patient and health care pro- fessional at an enormous disadvantage. Lacking SMBG data, it is almost impossible for the patient or professional to have adequate data to deter- mine how well the nutrition therapy is working. Patient knowledge of target blood glucose ranges and blood glucose testing technique need to be assessed. During the start treatment phase, when data are being collected to determine whether medical nutrition therapy and increased exercise are reasonable choices, SMBG must occur at least 2–4 times each day. The testing schedule of fast- ing, before meals, 2 hours after the start of the meal, and before bedtime should be used in or- der to develop patterns of blood glucose levels throughout the day. This should be combined with testing before and after exercise (at least twice during the initial treatment phase). Testing using an SMBG meter with memory is the only cer- tain way to ensure accurate data. Do not employ SMBG as a punitive measure. Patients are likely to fabricate results to please the healthcare team if SMBG is used punitively. HbA 1c should be used in association w ith SMBG, but not as a replacement (see Table 4.4). Since several assays for glycosylated hemoglobin exist, one way to standardize the HbA 1c is to re- port the difference between the reported value and the upper limit of normal. Thus, when the upper limit of normal is 6 per cent, an HbA 1c of 10.5 per cent is 4.5 per cent above normal. The average SMBG value for a period of at least 1 month with two to four tests per day should correlate with the HbA 1c level. Minimally, the SMBG values and HbA 1c should move in the same direction. If this is not the case, suspect error in SMBG. During the start phase (1–2 weeks), all SMBG data should be reviewed weekly. Examine blood glucose records for the incidence of hyper- glycemia, hypoglycemia, and number of blood glucose values in target range. If several values exceed 300 mg/dL (16.7 mmol/L), consider ini- tiating an oral agent (see the oral agent section that follows). A follow-up contact within 2 weeks of the initial visit should be made. At that time, review baseline data (SMBG). A 5 per cent re- duction in mean blood glucose should have been possible by this time. If this level is reached, a second appointment 2 weeks later should show continued reduction. If, after the second follow- up, blood glucose levels (based on verified data) do not show at least 15 mg/dL (0.8 mmol/L) improvement, adjust the food plan, reassess the exercise prescription, and consider starting an oral agent. Medical nutrition therapy/adjust Evaluate progress. Optimally, patients should be seen two weeks after the start of MNT to re- view their progress. At this visit, weigh the patient and determine whether there have been changes in diet, alterations in medication, and changes in exercise habits. Review SMBG records f or fre- quency of testing, time of testing, and results. Assess blood pressure and obtain any pertinent laboratory data. As it is too early to uncover a change in HbA 1c , measure blood glucose by re- flectance meter during the visit. Obtain the pa- tient’s food records completed since initial visit or take a 24 hour food recall (see Figure 4.8). To determine whether the therapy is effective, examine the SMBG records for patterns of re- duced blood glucose levels. Patterns are three consecutive days in which there is little change in blood glucose at a particular time of the day (within 1–2 hour intervals). To corroborate the blood glucose values check the glucose meter’s memory. This can be accomplished by either downloading the stored glucose data or scrolling though the device. If there is a pattern of higher blood glucose, then alterations in the food plan are necessary. If it is lower blood glucose, the regimen is working. However, these values must be corroborated by HbA 1c . Since only two weeks have passed, the HbA 1c will not change to any 108 TYPE 2 DIABETES YES YES Patient enters Medical Nutrition Therapy/Maintain Continue current therapy; use this DecisionPath for follow-up Follow-up Medical: every 3–4 months Education: every 6–12 months (minimum) Nutrition: every 6–12 months (minimum) See Medical Visit, Nutrition Education and Diabetes Education Patient remains in Medical Nutrition Therapy/Adjust Continue current therapy; use this DecisionPath for follow-up Follow-up Medical: every 1–2 months Patient in Medical Nutrition Therapy Stage NO NO YES Has patient been in medical nutrition therapy stage more than 3 months? See Self Management Adherence to assess day-to-day management Interim History and Physical • Current medications • SMBG and HbA 1c • Medical history (HTN, lipids, albuminuria) • • • Adherence to treatment plan Intercurrent illness Weight change • • • Hypoglycemia/hyperglycemia Laboratory HbA 1c every 3–4 months Lipid profile/albuminuria screening annually See Medical Visit Assess Monthly Improvement Has average SMBG improved by 15–30 mg/dL (0.8–1.7 mmol/L) and/or HbA 1c by 0.5–1.0 percentage points? NO SMBG and/or HbA 1c within target range? Start oral agent; move to Oral Agent Selection Medical Nutrition Therapy Adjustments Food Plan • Adjust carbohydrate intake Reduce fat intake • • Adjust portion size and meal spacing Physical Activity Increase activity frequency and duration • • Suggest alternative forms of exercise Follow-up Medical: monthly; use this DecisionPath for follow-up Figure 4.8 Type 2 diabetes Medical Nutrition Therapy/Adjust appreciable degree. In this case wait another 2–4 weeks before a second HbA 1c assay is performed. If there have been episodes of hypoglycemia, they are related to exercise or skipped meals. If there is a pattern of hyperglycemia, gener- ally it will appear as post-prandial blood glucose values> 160 mg/dL (8.9 mmol/L). Alterations in food plan should continue for up to three months. Staged Diabetes Management provides the gen- eral guideline of between 0.5 and 1 percentage point improvement in HbA 1c and a parallel low- ering of average blood glucose of 15–30 mg/dL TYPE 2 DIABETES MASTER DECISIONPATH 109 (0.8–1.7 mmol/L) monthly. If this target has not been achieved in at most three months, then the food plan should be supplemented by oral medi- cations. Corrective measures. • Changes in exercise and/or activity lev- els. Patient should have gradually increased physical activity with a minimum goal of 10–15 minutes of physical activity three to four times a week. Is the patient willing or able to do more? • Change in food habits. Patient eats meals and snacks on a regular basis and makes appropriate food choices in reasonable por- tions. If caloric intake has been excessive, can the patient reduce calorie intake by moderate amounts (approximately 250–500 calories per day)? Can the patient make further improve- ments in the overall quality of the diet? • Change in weight. Weight maintenance or modest weight loss would be an appropri- ate outcome. If the patient’s weight increases, have positive changes in food selection and/or exercise been made? Or is weight gain re- lated to rehydration as a result of improved glycemic control? • Achievement of short-term goals. Determine whether the patient has achieved short- term goals established in previous visits and whether they are willing to set new goals. • Intervention. Identify and recommend the changes in food and exercise that can improve the outcome, such as meal spacing; appro- priate portions and choices; meal and snack schedule; and exercise frequency/duration/ type/timing, including exercise after meals to reduce post-prandial hyperglycemia. Adjust food plan if necessary based on patient feed- back. Reset short-term goals based on recom- mendations. Self-management skill review. Do any sur- vival self-management skills need to be reviewed (e.g. hypoglycemia prevention, illness manage- ment)? Are continuing self-management skills needed (e.g. use of alcohol, restaurant food choices, label reading, handling special occasions, and other information to promote self-care and flexibility)? Set follow-up plans. A second follow-up visit is recommended if: 1. patient is newly diagnosed 2. patient is having difficulty making lifestyle changes 3. additional support and encouragement is re- quired 4. major goal is weight loss If no immediate follow-up is needed, schedule the next appointment within 3–4 months. Communication/summary to referral so- urce. A written documentation of t he nutrition assessment and intervention should be completed and placed in the patient’s medical record. This documentation should include summary of assess- ment information, education intervention, short- term goals, specific actions recommended, and plans for further follow-up, including additional education topics to be reviewed. Follow-up visits. All follow-up visits should include weight in light clothing without shoes; changes in medication; and changes in exercise habits. Review SMBG records, including fre- quency of testing, time of testing and results. Exam current blood pressure level and HbA 1c value. Complete a 24 hour food recall, and check for food plan problems and/or concerns. Again, evaluate whether therapy is working or if change is needed, based on the following: • Improvement in HbA 1c or at target. • Changes in blood glucose values – is there a downward trend in blood glucose values? 110 TYPE 2 DIABETES Have there been episodes of hypoglycemia? Is it related to exercise or skipped meals? Is there a pattern of hyperglycemia? Are post-prandial blood glucose values less than 160 mg/dL (8.9 mmol/L)? What percent of blood glucose values are within the target range? An overall decrease in blood glucose values of 15–30 mg/dL (0.8 to 1.7 mmol/L) per month should be obtained. • Changes in exercise and/or activity levels – patient has gradually increased physical activ- ity with a minimum goal of 15–20 minutes of physical activity three to four times a week. Is the patient willing or able to do more? • Change in food habits – patient eats meals and snacks on a regular basis and makes appro- priate food choices in reasonable portions. If calorie intake has been excessive, can patient reduce calorie intake by moderate amounts (approximately 250–500 calories per day)? Can the patient make further improvements in the overall quality of the diet? • Weight maintenance or modest weight loss would be an appropriate outcome. If patient’s weight has increased, have positive changes in food selection and/or exercise been made? • Determine whether patient has achieved short- and l ong-term goals. Do these goals remain appropriate for the patient, or should new ones be established? • During the adjust phase, therapy is modified to accelerate reaching the target blood glucose level. Increase in exercise levels, decrease in caloric intake, and other strategies may be en- listed to ensure further glucose reduction at an accelerated rate. The period of experimen- tation with steps to reduce blood glucose re- quires SMBG four times per day and monthly visits. HbA 1c levels should begin to respond to the overall lower blood glucose during the first month. However, not until the end of the second month will the impact of the initial therapy be fully reflected in the HbA 1c levels. From there on, reduction by at least 0.5 per- centage points in HbA 1c per month should continue until targets (HbA 1c within 1.0 per- centage point of the upper limit of normal) are achieved. Follow-up intervention. Too often members of the healthcare team other than the physician are reluctant to recommend changes in therapy. This leads to both reduced efficiency and need- less error in treatment. If any of the following are uncovered by any team member (especially di- etitian or nurse), consider contacting provider for immediate alteration in therapy: • blood glucose levels (average SMBG) have not shown a downward trend • blood glucose levels (average SMBG) have not reached the target range by 3–6 months • HbA 1c has not shown a downward trend • HbA 1c has not reached target range by 3–6 months • Hypertension (blood pressure >130/80 mmHg) has not responded to dietary changes, weight loss, and/or exercise changes • Lipids outside target range after 4–6 months of nutrition intervention (see Chapter 8) Note: If laboratory data show no improvement and/or the patient is not willing to make food and exercise behaviour changes, a change in therapy will be required. If the patient is treated with an oral agent, consider a combination of oral agents, combination oral agent-insulin, or insulin ther- apy. Otherwise, consider referral to a specialty team. If medical nutrition therapy fails, be cer- tain that long-term goals, ongoing care, weight maintenance or loss, and overall glucose and lipid control are discussed. Reset short-term goals and review self-management skills. Determine whether any survival or continuing level self-management skills need to be addressed or reviewed. Additional follow-up visits are recommended if the patient needs and/or desires assistance with additional lifestyle changes, weight loss, and/or further self- management skill training. Written documentation TYPE 2 DIABETES MASTER DECISIONPATH 111 of the intervention should include a summary of outcomes of nutrition intervention (medical out- comes, food and exercise behaviour changes), self- management skill instruction/review provided, rec- ommendations based upon outcomes, and plans for follow-up. Medical nutrition therapy/maintain This may prove to be the most difficult phase to sustain. During this phase, blood glucose and HbA 1c target levels have been achieved. Patients often reduce SMBG testing and abandon their food and exercise plans. If at any time the patient exceeds the SMBG or HbA 1c levels, return the patient to the adjust treatment phase. Consider referral for diabetes and nutrition education every 6–12 months. Ongoing education that reinforces the importance of a food and exercise/activity plan is a critical factor in helping patients maintain glycemic control. Exercise assessment The importance of exercise in restoring a balance between food intake and energy expenditure is paramount in diabetes management. Increased ac- tivity level improves insulin sensitivity, which has a direct impact on glycemic control. Some stud- ies have been able to quantify this relationship by showing that 6 weeks of regular exercise will re- sult in an average drop in mean blood glucose of between 30 and 45 mg/dL (1.7–2.5 mmol/L). 33 This is equivalent to a drop of 1–1.5 percentage points HbA 1c . Developing an exercise prescription begins with assessing the patient’s cardiovascular fitness and making appropriate adjustments based on age, weight, and medical history. (see Figure 4.9). As shown in Photo 4.1, one option for assessing a patient’s overall fitness level is to measure the amount of oxygen that can be delivered to the body (VO 2 max). Often a registered dietitian or exercise specialist can be very helpful. In his or her absence, common sense plays a major role. Exercises should be comfortable, frequent, Photo 4.1 Exercise assessment: Determining VO 2 max consistent, and reasonable. They should be based on the patient’s ability and motivation. Fitting exercise into the lifestyle of most patients requires some innovative thinking. Some exercises can be done sitting, standing, and even lying down. Most are not stressful and are designed for the older patient. Aerobic (walking, swimming) and anaerobic (lifting) exercises are both important. Setting the long-term goal between 50 and 75 per cent maximal heart capacity adjusted for age is a safe and efficacious plan. Exercise may need to vary with the seasons. While walking outdoors is fine in good weather, walking indoors in shopping centers is best for inclement weather. Exercise must be combined with lower caloric intake. (Walking to the bakery is not good exercise if it results in increased caloric intake.) Start the exercise prescription with intermediate goals using low-intensity warm-up and cool-down exercises. Begin with walking and lifting exercises using the daily routine as the 112 TYPE 2 DIABETES Exercise assessment indicated Obtain Medical Clearance Avoid strenuous exercise if BP Ͼ180/100 mmHg; if active proliferative retinopathy or recent laser therapy; if recent foot disease or no feeling in extremities (neuropathy) If HbA 1c Ͼ6 percentage points above upper limit of normal, measure change in BG during test exercise Perform stress EKG if pre-existing CHD; over age 40; or over age 30 with Ͼ10 years duration of diabetes YES NO Medical clearance obtained? Obtain Fitness Clearance Strength: Flexibility: Endurance: If micro- or macro-vascular disease, refer accordingly If BG control problem, adjust medical nutrition therapy and/or medication to optimize control, then reassess for exercise Educate patient about benefits of exercise See Exercise Education Topics Refer to Exercise Specialist to improve fitness for exercise YES NO Fitness clearance obtained? YES NO Does patient understand the role of exercise in diabetes? Move to Exercise/Plan Obtain Referral Data Type of diabetes Diabetes treatment regimen (medications, medical nutrition therapy) Medical history (HTN, lipids, complications) HbA 1c /ketones SMBG/HbA 1c targets • • • • • • • • lift 5–10 lbs overhead stretch to reach feet step test Figure 4.9 Exercise Assessment DecisionPath guide (e.g. walking instead of driving, carrying items). During the start period, maintain weekly contact until a pattern has been achieved. The use of exercise to reduce blood glucose level is less likely to occur initially unless the food plan has changed as well. See Appendix A.16 through A.18 for a detailed outline of exercise plan goals, follow-up and ed- ucation topics. If the exercise prescription is ineffective, con- sider resetting the goals. Determine the patient’s readiness to do exercise, re-educate as to the [...]... flexibility regarding timing of meals Staged Diabetes Management encourages providers to discuss the advantages of Stage 4 with their patients, especially those starting insulin at diagnosis or after oral agents have failed Insulin stage 4 (basal/bolus)/start: at diagnosis R–R–R–N or LA or RA–RA–RA–N or LA If starting Stage 4 at diagnosis, ask the patient to do SMBG four times/day (before each meal and at bedtime... imperative to maintain glucose levels at a point that will avoid both hypoglycemia and hyperglycemia Additionally, co -management with the various health professionals who will be involved in diabetes care must be established The nurse educator and dietitian are vital components of the healthcare team and should be incorporated into care as soon as feasible This is especially important in ambulatory management. .. forms of information would be helpful at the point of diagnosis: fasting plasma glucose, HbA1c , and plasma insulin level Generally, only a casual or fasting plasma glucose is available In that case, follow the Type 2 Diabetes Master DecisionPath using the glucose criteria from the diagnostic tests If at diagnosis a baseline HbA1c and fasting plasma glucose are available, use these values to guide... the appropriate oral agent has become a very critical part of good diabetes management Oral agent selection and contraindications Before considering initiation of an oral agent, certain factors must be addressed: Step 1 The first step should be a review of the contraindications, regulations and other factors that might remove an agent for consideration In the United States, the Food and Drug Administration... hypoglycemia as well as hyperglycemia Insulin stage 3 (Mixed)/start: at diagnosis R/N–0–R–N or RA/N–0–RA–N Morning insulin start If the patient starts this therapy in the morning, the total daily dose is calculated as 0 .3 U/kg (see Figure 4.16) The total daily dose is divided into three periods associated with breakfast, the evening meal (approximately 10 hours apart) and bedtime (at least 3 hours after... This therapy is temporary Have the patient return the next morning to initiate daily insulin administration (see previous section) 133 During the first several days it is imperative to maintain glucose levels at a point that will avoid both hypoglycemia and hyperglycemia Have the patient SMBG at least four times per day (before meals and at bedtime) Additionally, co- management with the various health professionals... cause mid-afternoon hypoglycemia TYPE 2 DIABETES MASTER DECISIONPATH At Diagnosis Fasting plasma glucose 30 0 mg/dL (16.7 mmol/L) or casual plasma glucose 35 0 mg/dL (19.4 mmol/L) Start insulin within 1 week; hospitalize if outpatient education not available If acute illness, hospitalize and start insulin immediately 129 From Oral Agent or Combination Therapy If unable to achieve targets after 2–4... of the patient’s weight Oral agents are generally given before breakfast and/or the evening meal The meglitinides are rapid acting and meant to be given before each meal The code for all oral agent administration is provided above The first OA (without parenthesis) denotes the most popular time (pre-breakfast) for OA administration The OA in parenthesis denotes optional or alternate times Two factors... avoided or used cautiously Scientifically, alphaglucosidase inhibitors make the most sense if the defect can be isolated to an elevated post-prandial rise in blood glucose levels .34 Since each of these is a starting therapy at diagnosis, patients should be told that it is likely to be changed once additional information from SMBG and serial HbA1c is available The food plan and exercise program for an... SMBG data Most oral agents Oral agent/maintain OA–(OA)–(OA)–0 If the patient has reached the therapeutic goal on the oral agent, treatment now turns to maintenance SMBG testing schedules and frequency of contact with the health care professional are individualized Insufficient contact (especially for 118 TYPE 2 DIABETES the elderly) may cause the patient to lose interest in intensified treatment and become . post-prandial hyperglycemia. Adjust food plan if necessary based on patient feed- back. Reset short-term goals based on recom- mendations. Self -management skill review. Do any sur- vival self -management. Therapy Stage NO NO YES Has patient been in medical nutrition therapy stage more than 3 months? See Self Management Adherence to assess day-to-day management Interim History and Physical •. tissue Macronutrient composition. Although re- duction in total caloric intake is effective, yet an- other approach evaluates the macronutrient com- position of the food plan. Staged Diabetes Man- agement