Beverly A Benes, PhD, RD Nutrition Services, NE Dept of Education bev'benesnde'ne'gov

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Beverly A Benes, PhD, RDNutrition Services, NE
Dept of Educationbev.benes_at_nde.ne.gov
Diabetes in the School and Carbohydrate Control
Some slides adapted from the the University of
Georgia Cooperative Extension Service
http//www.fcs.uga.edu/pubs/ppt/PPT-26.ppt
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Objectives

• Describe the prevalence of diabetes
• Describe the legal considerations for schools
• Describe the responsibilities of school personnel
• Discuss the role of carbohydrates in the diabetic
  diet
• Q A

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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1990
1990
Source Mokdad et al., Diabetes Care
2000231278-83 J Am Med Assoc
200128610 retrieved from http//www.cdc.gov/dia
betes/statistics/maps/
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1990
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1991 - 92
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1993 - 94
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1995 - 1996
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1995
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1997 - 1998
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 1999
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 2000
Source Mokdad et al., J Am Med Assoc 200128610.
Source Mokdad et al., Diabetes Care
2000231278-83.
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Diabetes Trends Among Adults in the U.S. (incl.
Gestational Diabetes) BRFSS 2001
Source Mokdad et al., J Am Med Assoc 200128610.
Source Mokdad et al., Diabetes Care
2000231278-83.
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All the pieces must fit.

Legal Rights
Health Learning
http//www.diabetes.org/advocacy-and-legalresource
s/discrimination/school/schooltraining.jsp Retriev
ed 1-31-06 Diabetes Care Tasks At School What
Key Personnel Need To Know
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All the pieces must fit.
http//www.diabetes.org/advocacy-and-legalresource
s/discrimination/school/schooltraining.jsp Retriev
ed 1-31-06 Diabetes Care Tasks At School What
Key Personnel Need To Know
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Its the law.Legal Considerations

• Federal laws that protect students with diabetes
• Impact of state laws upon diabetes care in the
  school setting
• Recommendations for 504 Plan or IEP

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Legal Considerations Needs of children with
diabetes in school setting . . .

• Eliminate discrimination
• Equal access to educational and school related
  opportunities
• Secure care
• A medically safe environment for students with
  diabetes

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Legal Considerations Federal Laws Equal
Access

• Section 504 - section 504 of the Rehabilitation
  Act of 1973
• ADA Americans with Disabilities Act
• IDEA Individuals with Disabilities Education Act

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Legal Considerations Federal Protection

• Prohibits discrimination against people with
  disabilities by public schools and most private
  schools that receive federal funds
• Students must be given equal opportunity
• Related aids and services are required to meet
  the individual needs of a student with disability

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Legal Considerations Written Plans

• Educational needs
• 504 Plan
• IEP
• Health care needs
• Diabetes Medical Management Plan (DMMP)

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Legal Considerations Needs addressed by 504
Plan/IEP Plan

• Location and timing of blood glucose monitoring
• Identity of trained diabetes personnel
• Location of diabetes supplies
• Free access to water and restroom
• Nutritional needs, meals and snacks
• Full participation in all school-sponsored
  activities
• Alternative times for academic exams if student
  is experiencing hypoglycemia or hyperglycemia
• Absences without penalty for doctors
  appointments and diabetes-related
  illness
• Maintenance of confidentiality and students
  right to privacy

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Legal Considerations State Laws and
Regulations

• State and local laws and regulations vary
  regarding who may perform various aspects of
  diabetes care
• Become familiar with state and local laws that
  impact school diabetes care
• Regardless of state and local law, the
  requirements of federal laws must be met

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http//www.ndep.nih.gov/diabetes/pubs/Youth_School
Guide.pdf
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Blood Glucose Goals for Children
From ADA, 2005
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Carbohydrate CountingAdvantages

• Easier - only count carbohydrate
• Allows more flexibility in food choices
• Virtually any food can be worked into a meal plan

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What is Carbohydrate Counting?

• Keeping track of the amount of carbohydrate eaten
  at meals and snacks
• Keeping carbohydrate intake consistent at meals
  from day to day
• Matching insulin injections to
• carbohydrate intake (for some)

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Why Count Carbohydrate?

• Amount of carbohydrate eaten determines how high
  blood glucose will rise after a meal
• Carbohydrate begins to raise blood
  glucose within 15 minutes of
  eating

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Nutrients in Foods

• Carbohydrate
• Protein
• Fat
• (Vitamins, minerals, water)

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Why Count Carbohydrate?
Carbohydrate is the nutrient in food that raises
blood glucose the most
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Carbohydrate is Healthy

• Most foods containing carbohydrate are among the
  healthiest foods to eat
• grains, fruits, vegetables, low-fat milk and
  yogurt
• Carbohydrates are the foundation of a healthy
  eating plan
• contain many essential vitamins, minerals, and
  fiber

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Other Factors to Consider

• Fat
• Slows down time your stomach takes to empty
• Delays rise in blood glucose
• High in calories

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Other Factors to Consider

• Protein
• Very little effect
• on blood glucose
• Usually combined
• with fat

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What are Carbohydrates?

• fruit, milk, regular sodas, candy, juices
• bread, rice, cereal, potatoes, pasta, corn,
  peas, butter beans
• oats, barley, fruits and vegetables

Sugars
Starches
Fiber
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Mixed Foods Containing Carbohydrate

• Macaroni Cheese
• Soups
• Casseroles
• Lasagna

• Subs/sandwiches
• Beef Stew
• Spaghetti and Meatballs

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Which Contain Significant Carbohydrate?

• Brunswick stew
• Brussels sprouts
• Sugar-free jello
• Skim milk
• Fat-free frozen yogurt

• Baked chicken
• Rice
• Orange juice
• Diet soda
• Oreos

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Which Contain Significant Carbohydrate?

• Brunswick stew
• Brussels sprouts
• Sugar-free jello
• Skim milk
• Fat-free frozen yogurt

• Baked chicken
• Rice
• Orange juice
• Diet soda
• Oreos

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Does the Type of Carbohydrate Matter?
Glycemic Index

• Various carbohydrates have slightly different
  effects on blood glucose
• Processing
• Cooking
• Fiber
• Mixed meals with with fat or protein

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The amount of Carbohydrate is more important than
the type

• 1 frosted brownie 2 slices bread
• 1 cup ice-cream 1 cup cereal
• (30 grams carbohydrate)

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2 Ways to Count Carbohydrate

• Carbohydrate Choices
• Food Exchanges or Servings
• Carbohydrate Grams
• Specific number of grams of carbohydrate per
  meal or snack

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Carbs in food - an eg from the grains and veges
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15
5
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Carbohydrate Choices(servings)

• Each food in fruit or starch group contains about
  15 grams carbohydrate
• White milk contains 12-15 grams carbohydrate
• A vegetable has about 5 grams carbohydrate
• One carbohydrate choice 15 grams carbohydrate

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Meal Plan carbohydrate gram counting
Basic Carbohydrate Counting 2003 American
Diabetes Association
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Carbohydrate Choices

• Lunch
• Exchanges Carbohydrate Choices
• 2 starch 2 carb choices
• 1 fruit 1 carb choice
• 1 milk 1 carb choice
• 3 meat 0 carb choices
• 2 fat 0 carb choices

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Each Carbohydrate Choice 15 grams Carb

• Example
• Breakfast 3 carb choices 45 grams
• Lunch 2 carb choices 30 grams
• Snack 1 carb choice 15 grams
• Dinner 3 carb choices 45 grams
• Evening
• Snack 1 carb choice 15 grams

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How Much Carbohydrate?

• Depends on
• calorie needs
• height
• weight
• physical activity
• level of fat in blood (triglycerides)
• usual food habits and schedule

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Carbohydrate Needs (Example)

• 1500 Calories 188 grams/day
• 3 carb choices at breakfast
• 4 carb choices at lunch
• 4 carb choices at dinner
• 1 carb choice at bedtime

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Resources for Counting Carbohydrate

• Food package labels
• Carbohydrate counting
• books
• Food Exchange
• booklets

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Nutrition Facts Label

• Best resource for
• carbohydrate counting
• Pay attention to
• Serving Size
• Total Carbohydrate

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Fiber and Carbohydrate Counting

• Included in total carbohydrate
• Does not convert to glucose
• For more than 5 grams insoluble fiber per
  serving subtract amount of fiber from the Total
  Carbohydrate

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Fiber and Carbohydrate Counting

• For example
• 1 cup 30 gm Total Carbohydrate
• cereal - 7 grams insoluble dietary fiber
  23 grams
• Count as 23 grams carbohydrate

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Dietary Fiber on the Nutrition Facts Food Label
How many carbohydrate grams are in 1 serving?
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Dietary Fiber on the Nutrition Facts Food Label
How many carbohydrate grams are in 1 serving?
1 slice 10 grams Total Carb - 0
grams dietary fiber 10 grams Total
Carb Count as 10 grams carbohydrate NOTE the
DV for Dietary Fiber is 20 this food would be
an excellent source of dietary fiber.
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Read the Nutrition Facts labelfor total sugars
Plain Yogurt
Fruit Yogurt
Fruit Yogurt
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Substituting sweets for starches
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Other carbohydrates????

• Terms no federal standards for these terms or
  low carb
• Net carbs
• Net impact carbs
• Effective carbs
• Digestible carbs
• Sugar alcohols required to be listed by name in
  ingredients
• Manitol
• Sorbitol
• Xylitol
• Lactitol
• Hydrogenated starch hydrolysates

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Sugar Alcohols on Food Labels
Total Carbohydrate 21 grams 1 gram dietary
fiber lt 1 gram sugar 18 grams
sugar alcohol 2 grams other carb
Note the sugar alcohol is not deducted from
the total carbohydrates
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Food Label (Example 1)

• Bedtime Meal Plan
• 2 carb choices (30 grams carb)
• Food label for ice-cream
• Serving size 1/2 cup
• Total carbohydrate 15 grams
• How much ice-cream could you have?

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Food Label (Example 1)

• Bedtime Meal Plan
• 2 carb choices (30 grams carb)
• Food label for ice-cream
• Serving size 1/2 cup
• Total carbohydrate 15 grams
• How much ice-cream could you have? 1 cup

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Food Label (Example 2)

• Breakfast Meal Plan 45 grams carb
• Food label Cereal Milk
• Serving size 1/2 cup 1 cup
• Total Carb 15 grams 12 grams
• How much cereal and milk should you have?

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Food Label (Example 2)

• Breakfast Meal Plan 45 grams carb
• Food label Cereal Milk
• Serving size 1/2 cup 1 cup
• Total Carb 15 grams 12 grams
• How much cereal and milk should you have?
• 1 cup cereal 1 cup milk

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Carbohydrate Counting Books

• Use for foods without a
• Nutrition Facts Label
• Fresh fruits
• Fresh vegetables
• Breads from a bakery or farmers market
• Restaurant foods

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Carbohydrates in Commodity Foodshttp//www.nde.st
ate.ne.us/ns/forms/nslpforms/nutrition.htm
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Sample Elementary School Lunch Menu
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Sample Elementary School Lunch Menu
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Sample Elementary School Lunch Menu
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Sample Elementary School Lunch Menu
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Sample Elementary School Lunch Menu
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Sample Elementary School Lunch Menu
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What Else Affects Blood Glucose?

• Portions sizes
• Large portions of carbohydrate
• increase blood glucose

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What Else Affects Blood Glucose?

• Timing of food intake
• Space food throughout day
• Eat at regular times
• Dont skip meals

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Fast Foods

• Get carbohydrate information from
• Web site or toll-free number for chain
  restaurants - i.e. www.mcdonalds.com
• Carbohydrate counting books

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http//www.diabetesnet.com/diabetes_food_diet/fast
_foods.php
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http//www.diabetes.org or call 800-232-6733
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http//www.lowcarbfriends.com/carbcounter.shtml
http//www.ars.usda.gov/main/site_main.htm?modecod
e12354500
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http//www.lowcarbfriends.com/carbcounter/meat.sht
ml
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http//www.ndep.nih.gov/resources/SchoolNurseNews.
htm
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Activity
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http//www.mayoclinic.com/health/diabetes-diet/DA0
0077
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http//www.mayoclinic.com/health/diabetes-diet/DA0
0077
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http//diabetes.niddk.nih.gov/dm/pubs/eating_ez/
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http//www.fda.gov/diabetes/food.html
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http//0-www.nlm.nih.gov.csulib.ctstateu.edu/medli
neplus/tutorials/diabetesmealplanning/htm/index.ht
m
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http//www.joslin.org/managing_your_diabetes_707.a
sp
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http//www.diabetes.org/all-about-diabetes/chan_en
g/i3/i3p4.htm
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Any questions?http//www.nde.state.ne.us/ns/slide
_shows.htm