Patient Food Log
Diabetes Medications
Insulin Therapy:
Describe mechanism of action (how does this drug work?):
After a meal, blood glucose is elevated and insulin acts as the key to open up the cells to allow glucose into the cells in order for them to make energy.
| |Onset of action (time) |Peak (time) |Duration of action (hours) |
|Short acting (regular) |15-60 min |4 hours |5-8 hours |
|Rapid acting (lispro) |Within 15 minutes |60-90 minutes |3-5 hours |
|Intermediate (NPH) |1 ½ hours |6-10 hours |Cloudy |
|Long acting (ultralente) |3-4 hours |Peakless |24 hours |
Biguanides
Describe mechanism of action (how does this drug work?):
These types of drugs work by suppressing the production of hepatic glucose.
| |Onset (hr) |Duration (hrs) |Max dose per day |
|Metformin |1-3 hours |24-48 hours |850 mg tid or 1000 mg bid |
|Metformin XL |4-8 hours |24-48 hours |2000 mg once a day |
Sulfonylureas
Describe mechanism of action (how does this drug work?):
These drugs act by stimulating beta cells in the pancreas to release insulin. They also block ATP-sensitive potassium channels on beta cells in order to allow calcium channels to open.
| |Onset (hr) |Duration (hrs) |Max dose per day |
|Glimiperide (Amaryl) |1 hour |24 hours |8 mg/day |
|Glipizide (Glucoatrol) |30 minutes |12 hours |20 mg/day |
|Glyburide (DiBeta) |30 minutes |18-24 hours |12 mg/day |
Alpha-Glucosidase Inhibitors
Describe mechanism of action (how does this drug work?):
This delays the absorption of carbohydrates after a meal.
| |Usual starting dose |Max dose/day |
|Acarbose |25 mg |100 mg up to 3 times a day taken with meals |
TZDs
Describe mechanism of action (how does this drug work?):
These drugs work by improving the peripheral insulin sensitivity in adipose tissue and muscle.
| |Usual starting dose |Max dose/day |
|Rosiglitazone (Avandia) |4 mg |8 mg |
|Pioglitazone (Actos) |15 mg |45 mg/day |
Dipeptidyl Peptidase (DPP-4) Inhibitor
Describe mechanism of action (how does this drug work?):
This drug enhances the effect of GLP-1 an GIP by preventing degradation.
| |Usual starting dose |Max dose/day |
|Sitagliptin (Januvia) |100 mg | |
Glucagon-like peptide (GLP-1)
Describe mechanism of action (how does this drug work?):
This drug enhances insulin secretion from the beta cells, slows down gastric emptying, and suppresses elevated glucagon secretion.
| |Duration (hr) |Usual starting dose |Max dose/day |
|Exenatide (byetta) |24 hours |5 mcg twice daily |10 mcg twice daily |
|Liraglutide (Victoza) |24 hours |0.6 mg |1.8 mg |
Synthetic Analog of Human Amylin
Describe mechanism of action (how does this drug work?):
This drug inhibits the production of glucagon and slows down gastric emptying.
| |Usual starting dose |Max dose/day |
|Pramlintide Injection |60 mcg |120 mcg |
Diet History
Name ______Allison Doriot_____________ MD ___________________________ Age __21___ Date __10-29-13_
Occupation ______student___________ Dx _Type 1 DM______________ Sx _______female_________________
Diet Order _____diabetic______________ Diets previously followed ______normal_______________________________
Prior instruction? __________________ Social hx __________________________________________________________
Height __5’4”____ Weight _130____ IBW __120_____ % IBW __108%___ Desired wt 120_____ BEE ______ TDE ______
Wt hx ________________________________________________________________________________________________
Medications ___________________________________________________ Side effects? _____________________________
do you take insulin? what kinds? Yes, short-acting (regular)
where do you store your insulin when you are not suing it? The refrigerator
Do you exercise? What type? duration? Yes, jogging for 30 min 3-4x per week
do you use diabetes oral medications? No
do you test your blood sugars? what is your testing schedule? Yes, when I wake up, before meals, and before bed (5x per day)
Pertinent labs:
FBS __150 mg/dL__ 1 hr ppd __140 mg/dL____ 2 hr ppd _120 mg/dL___ 3 hr ppd __100 mg/dL____ HgA1C__6.8%__ Cholesterol __175__ HDL ___55___ LDL _85____ TG __125___ BP __125/80___
Medical History:
MI ____N/A_______ cancer ____N/A_______ diverticulosis, arthritis, hypertension, renal disease, hiatal hernia _N/A_______
CVA __________N/A_____ COPD ______N/A__________ other ______________________________________________
Family History:
Heart disease ____yes________ NIDDM or IDDM ___No________ cancer, diverticulosis, arthritis, hypertension __HTN___
Hypoglycemia _______No________
Coffee or tea _coffee____ Smoking no Packs/day ______ Quit ____ Alcohol ________ Water __yes__ Pop __diet_____
Difficulty chewing or swallowing ________no______________ Constipation _______no________
Recent changes in eating habits __frequent snacking, more coffee____________
Food allergies or intolerances __none_____________________ Supplements ______none___________________________
Dining out frequency ____1-2x per week__________ Typical meal ___sandwich with fries_____________________
Fast food meal __chipotle burrito bowls, no other fast foods______________________
Exercise history __jogging for about 4 years______________________________________________________________
Meals at usual times? ____Most days, eats late at night frequently___________________________ Shift work? __N/A_____
24 hour diet recall:
½ cup old fashioned oats, artificial sweetener packet
- ½ cup almond milk
- Banana
- Coffee with 2 T sugar free coffee creamer
- 2 slices whole wheat bread
- 2 T PB
- Apple
- Hard boiled egg
- 1.5 chicken tortilla soup
- 1 serving tortilla chips
- 1 bottle diet coke
Energy Estimate, Insulin Dosage
Patient Ht _5’4”____ cm__162.56__ Wt _59.1__ kg; IBW _120 lbs____; %IBW __108%_____
Determine estimated caloric needs. Show your calculations and consideration of activity level, %IBW, and any other considerations you used in your estimation.
10(59.1) + 6.25(162.56) – 5(21) – 161 = 1341 kcal (REE)
1340 kcal x 1.6 x 1.0 = 2145 kcal/day
_2145 ______ kcal per day
Coordination with Insulin. Use a “flexible insulin regimen” as outlined in Mahan Chapter 33
This is a combination of rapid-acting insulin (e.g. lispro) at meals and long-acting or basal in the evening before bed (e.g.glargine) as a basline insulin at bedtime.
Fill out the schematic below to represent the time your “patient” will eat meals and snacks and when the insulins will be injected – and their peak actions (your graph should list specific times for meals – that fit your patient’s schedule, injection times/types of insulin). You also need to incorporate strenuous exercise – and coordinate it with snacks and meals. This template should then show how the diet (i.e. meals and snacks) and exercise will be coordinated with the insulin regimen. This is the pattern your “patient” is to follow for 3 days.
Type(s) of insulin Times administered
________Lispro (Rapid-Acting)___________ Before breakfast: 8:30 am; Before lunch: 11:30 am; before dinner: 6:30 pm
______Long-acting______________________ Before bed (after night-time snack)________
Any considerations due to strenuous exercise? (describe) – for example you may need to have an extra snack or adjust timing of meals to accommodate when someone works-out.
Allison currently exercises for 30 min 3-4 times per week. If she were to increase the exercise intensity or time, she would need to readjust her schedule for insulin and snacks. I would recommend that she eat another snack directly after her workout and take another dose of insulin. For now, she does not need to be taking any additional insulin or eating any additional snacks.
Draw in insulin curve: for Rapid _ _ _ _ _ Intermediate/Longer acting ____________
Indicate when meals and snacks will be consumed. Adjust this to when the “patient” typically gets up. There is no way to skip breakfast. If someone has strenuous exercise – read the handout on the web – you need to be sure that the insulin is not peaking then, and you may need to add a snack.
[pic]
Meal or____ ____ ____ ____ ____ ____ ____ ____ ____ ___ ____ ___
Snack:
Insulin injection (indicate with an arrow)
Exchange System
|Food Group |Breakfast |Snack |Lunc|Snack |
| | | |h | |
|Breakfast | 2 Slices | Whole wheat toast (2 CHO) | |2 Starch |160 kcal | |
| |4 tsp |Strawberry Jam (1 fruit) | |1 Fruit |60 kcal | |
| | 1 Cup |Flavored yogurt (1 milk) | |1 Milk |90 kcal | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | 130 kcal |
|Snack | ¾ oz | Pretzels (1 CHO) | |1 starch |80 kcal | |
| | 1 ½ T | Peanut Butter (1 FAT) | |1 fat |45 kcal | |
| | | | | | | 125 kcal |
|Lunch | 2 Slices | Whole Wheat Bread (2 CHO) | |2 starch |160 kcal | |
| | 2 oz | Shaved Turkey Breast (2 PRO) | |2 meats |105 kcal | |
| | 1 small | Apple (1 FRUIT) | |1 fruit |60 kcal | |
| | 1 cup | Raw carrots (1 veg) | |1 veg |25 kcal | |
| | ¼ of one smashed | Avocado (on the sandwich) (2 fats) | |2 fats |90 kcal | |
| | 1 cup | Salad Greens (on sandwich) (1 veg) | |1 veg |25 kcal | |
| | 1 cup | Skim milk (1 milk) | |1 milk |90 kcal | |
| | 6 | Crackers (1 starch) | |1 starch | 80 kcal | 635 kcal |
|Snack | ½ of one | English Muffin | |1 starch |80 kcal | |
| | 1 T | Cream cheese | |2 fats |90 kcal | |
| | | | | | | 170 kcal |
|Dinner | 4 oz | Grilled Chicken Breast (4 meats) | |4 meats |220 kcal | |
| | 1 C | Brown Rice (3 starches) | |3 starch |240 kcal | |
| | 2 t | Butter (2 fats) | |2 fats |90 kcal | |
| | 1 C | Skim milk | |1 milk |90 kcal | |
| | ½ C | Steamed Broccoli | |1 veg |25 kcal | |
| | 1 | Kiwi | |1 fruit |60 kcal | |
| | | | | | | |
| | | | | | | |
| | | | | | | 725 kcal |
|Snack | 1 Medium |Peach | |1 fruit |60 kcal | |
| | 3 C |Popcorn | |1 starch |80 kcal | |
| | | | | | | 140 kcal |
| | |TOTAL | | | | 1925 kcal |
Patient Food Record - Day 1
The “Patient” will record everything eaten, amount, and time of day. Try to be honest about what you actually consumed. Then evaluate food eaten with respect to food groups and calculate total macronutrients and calories consumed for that day. The “RD” is then responsible for checking the calculations and evaluating whether appropriate amounts and types of foods were eaten at appropriate times.
| | | |Food Groups |Carbohydrate Counts |
|Time |Food Item and Method of Preparation |Amount Eaten |Starch |Fruit |
|Time |Food Item and Method of Preparation |Amount Eaten |Starch |Fruit |
Time |Food Item and Method of Preparation |Amount Eaten |Starch |Fruit |Milk |Veg |Meat |Fat |15 g Cho = 1 choice | |9 am |Special K |¾ cup |1 | | | | | |15 g | | |Strawberries |½ cup | |1 | | | | |15 g | | |Skim milk |1 cup | | |1 | | | |12 g | |11:30 |Wheat Bread |2 slices |2 | | | | | |30 g | | |Almond Butter |1 ½ t | | | | | |1 |0 g | | |Jelly |4 tsp | |1 | | | | |15 g | | |Banana |1 | |1 | | | | |15 g | | |Carrots |½ cup | | | |1 | | |5 g | | |Skim milk |8 oz | | |1 | | | |12 g | |3:00 |Pretzels |¾ oz |1 | | | | | |15 g | | |Almond butter |1 ½ t | | | | | |1 |0 g | |6:00 |Chicken Breast |4 oz | | | | |1 | |0 g | | |Broccoli |½ cup | | | |1 | | |5 g | | |Rice |1/3 cup |1 | | | | | |15 g | | |Apple |1 | |1 | | | | |15 g | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Totals |5 |4 |2 |2 |1 |2 |169 | |
Daily Totals: __169____ g CHO ___53_____ g protein ___48_____ g fat _1691_____ total Kcalories
RD Evaluation of Patient - Follow-up
From the "patient's" food record, check that food groups and calculation of CHO, fat, protein and total calories is correct. Look at all 3 days of records and make a general evaluation of the following:
1. diet was followed as instructed (i.e. appropriate number of exchanges, and/or carbohydrate counts consumed)
Day 1:
- Pt ate 59% of the recommended calories (1275 kcal /2145 kcal)
- 39% of the calories were from fat; 15% of the calories were from protein; 46% of the calories were from CHO
- Pt ate three meals and no snacks
- The pt did not eat as much as she should have on the first day, however her macronutrient distributions were acceptable. Fat intake was a little high. The pt also should have been eating snacks throughout the day to keep her blood sugar stabilized.
Day 2:
- Pt ate 82% of recommended calories
- 36% of calories were from fat; 21% of calories were from protein; 42% of calories were from CHO
- Pt ate three meals and two snacks throughout the day
- Pt ate more of the recommended calorie intake on this day and her macronutrient distributions were still acceptable, but again fat was slightly high. The incorporation of snacks in between her meals was good.
Day 3:
- Pt ate 65% of recommended intake.
- 27% of calories were from fat; 18% of calories were from protein; 53% of calories were from CHO
- Pt ate three meals and snacks throughout the day and her macronutrient distribution was acceptable.
2. all snacks and meals were consumed at appropriate times
All meals were consumed at appropriate times and breakfast was never skipped.
3. meals and/or snacks were not skipped
The patient did not always eat the snacks she should have but she always ate all meals.
4. Compared to the calculated diet – how closely did actual intake compare in terms of total calories,
total carbohydrate, and the distribution of CHO, fat, and protein? Using the carbohydrate counting method, do you reach the same conclusions?
See distributions above. Each day was slightly different, but the macronutrient distributions were acceptable each day. However, she did not eat enough calories per day based on her calculated energy requirement. On day 1 she ate about 10 CHO choices, on day 2 she ate 12 CHO choices, and on day 3 she ate 12.5 CHO choices.
Patient __Allison Doriot____________________
RD _____Haley Bremkamp________________________
Follow the Nutrition Care Process (ADIME) and evaluate the patient
A:
- Type 1 diabetes; 21 yo; diabetic diet order
- Insulin: lispro (rapid-acting) and long-acting
- 5’4” 130 lbs
- IBW: 120 lbs %IBW= 108%
- BMI: 22.5 normal
- Family history of hypertension
- Jogs 3-4x week for 30 minutes
- Eats out 1-2 times per week
- Eats BLD at normal times
- Biochemical: FBS: 150 mg/dL HgbA1c: 6.8% TG: 125 HDL: 55
D:
Inadequate energy intake related to food and nutrition knowledge deficit as evidenced by consuming less than 80% of recommended intake on a 3-day food record.
I:
Education: Will educate the patient on the importance of eating the recommended amount of calories based on her height and weight in order to make sure her blood sugar stays stable.
Goals:
Pt will increase energy intake
Pt will eat 2-3 small snacks per day
Pt will keep track of blood sugar levels each day in a journal
M: Monitor weight and blood sugar levels to make sure levels are staying stable
E: In one month, evaluate another 3-day food record and blood sugar journal
Now, write a progress note (not the initial note) for your “Patient” using the following format.
S: Eats late at night and tends to snack on unhealthy foods
O: 5’4”, 130 lbs, 108% IBW, 21 yo, Diabetic, 2145 kcal/day: 50% CHO, 20% protein, 30% fat
A: Meals were eaten at appropriate times, but sometimes patient went to long without eating a snack and blood sugar could have dropped to a low level. This is dangerous and could cause serious problems if it is not monitored and taken care of.
P: Short-term goals include making sure to incorporate snacks throughout the day and to eat the recommended amount of calories for her height and weight. Patient has expressed the desire to loose weight and be closer to her IBW, so long-term goals would include loosing weight in a healthy manor that would not compromise her blood sugar level. This may include adding extra to workouts but always making sure to compensate with a snack or insulin dose if working out at an intense level.
“Patient” Reaction
As your role as “Patient” – Briefly summarize your experience.
Following a diabetic diet was much more difficult than I thought it would be. The main difference for me was feeling like I was eating much more than I would normally eat to try and get to my recommended calorie requirement. The food choices were not much different from the foods I normally eat. I eat a lot of fruits and vegetables and not a lot of junk or fast food. I thought this was a good experience to have to understand what a patient with diabetes goes through on a daily basis.
What was the most challenging aspect of following the diet and insulin injections?
I did not give myself injections or check my blood sugar, but the most challenging aspect of this diet was being strict with what times I ate my meals and snacks. I normally do not think about what time I eat and when I need to be getting my next meal, but while following this diet I had to be very aware of that.
Compared to your experience, what adaptations would be required if you were counseling a patient who wasn’t knowledgeable in nutrition, aware of the content of foods or portion sizes, and was generally anxious about being a newly diagnosed diabetic.
I think the most important topic to cover with a patient who was not knowledgeable about nutrition would be the exchange system and proper food choices. I would have to work with this patient for a while to make sure they understand what to do and it would take time for them to get the hang of it. I would go over portion sizes and the process of counting carbohydrates to match insulin injections. This is a complete lifestyle change and it is very overwhelming to someone who knows nothing about nutrition or diabetes, however, it is so important to care of yourself because it could be life or death.
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