overeating.
• Teach “menu creativity” with restaurant menus. People don’t automatically need to order a main course. They can order a soup and salad, an appetizer and soup, or a half portion. Encourage people to eat “family style” in a variety of restaurants—from American to ethnic (where it’s more common). This type of “family style” eating encourages people to eat less by ordering fewer dishes than the number of people at the table and share the fewer menu items between diners. (This style of eating is in contrast to the portion control suggestion for eating at home that encourages people not to put large bowls of food on the table for sharing, or what’s typically thought of as “family-style” service.)
• Encourage people and let them know it is okay to split, share, and mix and match menu items to get the foods they want in the portions they need.
• Show people how they can use the estimating capabilities they have gained as they have used their measuring and portion control equipment at home. Encourage the use of hand guides and well-trained eyes.
• Encourage assertiveness to ask for take-home containers, ideally at the start of the meal so the “second serving” can be put away before eating.
For further portion control education, use some of the following ideas and resources:
• Have samples of the type of measuring equipment people should have and use at home.
• Have plenty of Nutrition Facts panels from commonly eaten foods. Use these to help people determine proper portions.
• Have commonly sized bowls, plates, and cups that people have in their kitchens to show them how smaller quantities of foods look on dishes with which they are familiar.
• Use the above serving items to have people demonstrate their ability to measure foods accurately. Ask them to measure a nonperishable food, such as nuts or dry cereal, in a serving item and pour it into a measuring cup. Use a food model as an example for weighing meat or cheese.
• Use food models of fruit to demonstrate proper portions; people regularly don’t count the amount of carbohydrate in fruit correctly.
• Consider purchasing and/or gathering additional portion control resources from the following sources (all websites as of the writing of this book):
Continually stress portion control
Educators need to continually reinforce the importance of eating proper portions and using measuring equipment and portion control tools. It is well known that people underestimate the amount of food they eat, whether they record this information or not. It is also easy to see how a person who is making many behavior changes and is eating healthier overall believes that eating larger portions of healthy foods will not make much difference. The reality is that slightly larger portions consumed every day do matter, especially for people who have minimal caloric needs. At the end of any day, extra grams of carbohydrate and calories can be the difference between achieving diabetes and nutrition goals or not.
Know how to interpret postprandial blood glucose levels
Checking and reviewing postprandial blood glucose levels regularly can provide healthcare providers and people with diabetes valuable insights into their glucose control. Postprandial levels often go unchecked and unanalyzed, usually because healthcare providers do not request them or because individuals already check so many fasting and mealtime levels that they don’t want to check more. Educators need to emphasize the value of postprandial monitoring, especially if A1C values are higher than expected, which could indicate people are likely missing high blood glucose levels after meals. Table I-1 on page 2 provides the goal for postprandial blood glucose and a note that postprandial levels should be checked 1–2 hours after the beginning of the meal.
If people who aren’t on MDI or CSII therapy aren’t willing to add more glucose checks, educators can encourage them to substitute a fasting or preprandial check for a postprandial check. People on MDI or CSII therapy, however, will need to add postprandial checks to their fasting and mealtime checks because they need this information for insulin dosing.
Encourage people to check postprandial blood glucose levels to accomplish the following:
• Gain more insights into blood glucose control after eating and before the next food intake
• Learn the impact of both the types of foods eaten and the amounts and make changes as needed
• Gain insights about the effectiveness of mealtime insulin dosing or other blood glucose—lowering medication and use the information to make changes in ICRs as needed
• Determine the duration of rapid-acting insulin action in order to individualize the bolus-on-board setting on insulin pumps or improve correction dosing using MDI
CHAPTER FIVE
Basic Carbohydrate
Counting
Case Studies
CASE STUDY #1: BENITA
Situation: Benita is a 47-year-old woman who owns her own health care consulting business. She is married and has one 10-year-old child. She was diagnosed with type 2 diabetes recently and was referred to a local diabetes education program. Benita had gestational diabetes in her only pregnancy and has struggled with her weight most of her adult life. She has gained 50 pounds over the years since her pregnancy. She has been on a host of diets over the years with little success. However, during her pregnancy, she did follow a meal plan to manage her gestational diabetes successfully.
Physical and Lab Data: Ht: 5′0″; Wt: 175 lb; BMI: 34; A1C: 7.4%; Hypertension is not under control; Total Cholesterol (TC): 225 mg/dl, HDL-C: 27 mg/dl, LDL-C: 132 mg/dl; Triglycerides (TG): 153 mg/dl
Blood Glucose—Lowering Medication(s): None
Food Habits/Daily Schedule:
Workdays:
• Wakes: 6 AM
• Breakfast: 7:30 AM: One whole banana and one bagel with cream cheese (eaten in her car on the way to work) or she skips breakfast. She drinks several cups of coffee with half and half and sugar throughout
