388
Tool Chest Meal Planning Approaches: Practical Application
Nutrition is
one key component in the management of diabetes and presents a
major challenge to diabetes educators. The challenge of modifying longstanding eating habits can be frustrating for both the client with diabetes and the educator. To facilitate changes in eating behavior, two points need to be considered: 1. Obtainable nutrition goals must be established to address identified nutrition problems. The goals need to be agreed upon by the client and educator. 2. Nutrition education is not a onetime visit to a registered dietitian. A number of follow-up visits are necessary to help the client meet the established goals. It is also important for all members of the diabetes care team to reinforce the nutrition education provided by the registered dietitian. In order to assist the client in accomplishing the established nutrition goals, the educator will need to have available a variety of meal planning approaches. ’.3 Some clients may need to utilize several different meal planning approaches to meet their diabetes nutrition goals. Therefore, it is important for all members of the diabetes care team to have some knowledge of the various
approaches. The
of various meal planning approaches is demonstrated in the following two case studies, which provide some insight into their practical application. Each case study utilizes several different meal planning approaches, based on a particular intervention period that was determined by the client’s
level of knowledge and skill, as well attitude and behavioral goals.
as
and 1 can of pop or lunch meat sandwich and 1 can of pop
Case Study #1- Newly-
diagnosed insulin-dependent diabetes mellitus (NIDDM) Patient Data Joey is an 1 I -year-old, is in the 5th grade, and lives with his mother. Parents are divorced. He is actively involved in sports at school. Medical Data Height: 60 in Weight: 89 lb (40.05 kg) Medium Frame 90th percentile for height and 75th percentile for weight on the growth grid. Information obtained during a sports
Dinner: casserole, 2 dinner rolls with butter, and 2 glasses of 2% milk
2 scoops of 3 cookies or pudding
Evening Snack: cream or
ice
Nutrient Intake: 3870 calories, 173 g fat (40% of calories from fat)
Estimated Calorie Needs: calories
2670-3204
physical: Urine glucose: 3+ Urine ketones: trace Plasma glucose: 450
Frequency For Eating Away From mg/dL (2
hr post
lunch)
Home:
No medications or allergies. Has experienced a 5 lb weight loss following the flu. Has had symptoms of excess thirst, hunger, and urination (five times a
day). Admitted to the medical center for initiation of insulin therapy and initial education. Nutrition Assessment Nutrition History (usual
intake):
2 large bowls of sweetened cereal with 2% milk, 12 oz glass fruit juice, and 2-3 slices toast with butter and jelly
Nutrition Problems Identified 1. Diet is high in total fat and saturated fat. 2. Diet is inadequate in fruits/
vegetables. 3. Diet is high in total calories. 4. Knowledge deficit of diabetes trition management.
Morning Snack:
2.
1 carton chocolate
milk
3. fish sandwich (with tarter
sauce), green beans, canned peaches,
nu-
Hospital Education Goals 1. Provide clientlfamily with informa-
Breakfast:
Lunch:
1-2 times/week in fast food
restaurants
use
Correspondence to Harold J. Holler, RD, CDE, Skemp Clinic, 800 West Avenue South, La Crosse, WI 54601.
Afternoon Snnck: potato chips (w/dip)
tion on normal nutrition and the nutrition goals for diabetes. Assist client/family with selecting meal planning approach to a provide adequate calories and nutrition. Provide information on making healthy food choices in fast food restaurants.
4.
oatmeal cookie, and 1 carton 2% milk
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
Discuss food exercise.
adjustments
and
389
Session 3 (2 months later) 1. Review guidelines for labels.
reading
Session 4 (3 months later) 1. Introduce concept of carbohydrate counting as an alternative to exchange lists (see Table). This approach may enhance the climeal ent/family’s planning activities and will allow the inclusion of some sweets.
Education Plan Day I I . Review nutrient content of food and impact on blood glucose levels. 2. Review nutrition goals for diabetes and establish client nutrition goals. 3. Review Basic Food Groups (see
Outpatient Education Goals 1. Adjust meal plan, if necessary. 2.
Provide
3.
information on of foods to include
more
types/amounts in a meal plan.
Provide information on how to admeal plan for various situations (late meals, special occasions,
just the
Table).
etc.). 1.
2.
Introduce the Healthy Food Choice guide (see Table). Discuss type of meal planning approach to be used (Basic Food Groups vs Healthy Food Choice Guide).
Day 3 1. ~
2.
Establish a meal plan using Healthy Food Choice Guide. Plan menus for several days including choices for school lunch and fast food restaurants.
Education Plan Session 1 (2 weeks post-hospitalization) 1. Answer questions and revise meal plan, if necessary. 2. Introduce Exchange Lists for Meal Planning to provide more variety in food choices (see Table). 3. Plan additional menu.
Session 2 ( 1 month later) 1.
Da 1, 4 1.
2. 3.
Discuss food adjustment necessary for increased activity. Plan several additional menus. Schedule appointment for followup outpatient nutrition counseling.
Review ways to adjust the meal for late meals, special occa-
plan
sions, etc. 2. Plan additional menu. 3. Review all basics discussed.
Case Study #2 Uncontrolled non-insulin dependent diabetes mellitus (NIDDM) -
Provide information on reading labels. 5. Review guidelines for meal planning during illness. 4.
Da» 2
In this case study, the dietitian has utilized four different meal planning approaches to assist the client/family in meeting their nutrition goals. First, the use of the Basic Four Food Groups helps to establish and reinforce the concept of food groupings and serving sizes. Next, the Healthy Food Choice Guide provides a simplified structure to meal planning that defines for the client/family the types and amounts of food to be included at meals and snacks. Later, the introduction of the Exchange Lists for Meal Planning provides the client/family with more food choices and more information about the nutrient composition of foods. Finally, the use of carbohydrate counting supplies the nutrient composition of foods to enhance the inclusion of all food items. This approach provides considerable flexibility to meal planning for busy families and may enhance the client’s personal management of diabetes.
previously
Patient Data Mary is a 59-year-old homemaker who provides day care in her home for seven children. She is a high school graduate. She lives with her husband and daughter, who is in college. She is actively involved in volunteer work for a local nursing home. Takes occasional walks, but not
regularly. Medical Data Height: 5’4&dquo; Weight: 192 lb (86.40 kg) Medium Frame Has had diabetes for 10 years. Glucotrol: 10 mg (AM) and 5 mg (PM) Has hypertension. Blood Pressure: 140/85 Serum Cholesterol: 257 mg/dL (HDL Cholesterol: 29 mg/dL, LDL Choles-
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
391
terol : 197 mg/dL) HgbA1c: 10.2% Blood Glucose Monitoring (once per
4. Provide information and alcohol use.
day):
Educational Plan Session I I . Review the nutrient content of foods and their impact on blood glucose, lipids, and weight. 2. Review ways to reduce the fat content of the diet by using the meal planning approach &dquo;Dietary Guidelines for Americans Avoid Too Much Fat, Saturated Fat, and Cholesterol&dquo; (see Table). 3. Establish goals for reducing fat content of diet.
Fasting: 180-245 mg/dL Before Dinner: 192-257 mg/dL Nutrition Assessment Nutrition Histoty (usual
intake):
2 slices toast with peanut
Breakfast:
butter, 8 oz fruit juice, coffee oz
fruit
Lunch:
Casserole (macaroni and cheese, spaghetti and meatballs, or ravraw
vegetables,
one
12
glass
oz
2% milk, I cookie
Afternoon Snack:
pudding plus
left-
Session 2 1. Review
previous accomplishments.
2.
Dinner: meat (1-2 pork chops, chicken breast w/skin, 1-2 hamburger patties, or bologna), fried or boiled potatoes, vegetable (corn, peas, or green beans), 1-2 slices bread with butter, diet
use
and
of the Basic Four Food
snack 3.
Nutrient Intake: 2475 calories, 125 g fat (45% of calories from fat)
Calorie Needs For Weight Loss: 1200-1300 calories.
Frequencyforeating mvayfrom home: 2-3 times/week, primarily evening
reducing
Session 3 1. Review 2.
or
Review
goals
3. Plan 1-2 menus. 4. Establish new goals for fat intake.
pop popcorn
out
Groups meal planning approach.
over cookies
Bedtime Snack: crackers
dining
-
Morning Snack: 1 cookie, 4 juice, V2 slice toast with butter
ioli),
on
previous goals and accomplishments. Discuss impact of physical activity on diabetes and establish a plan for activity. Have the client keep a food record.
Session 4 1. Review the food record for fat content, nutrient balance, and calories. 2. Review physical activity routine. 3. Establish new goals for changing diet; continue food records.
meal. Alcohol use: week.
lite
beer
2-3
times/
Session 5 1. Review food records and
previous
goals. 2. Discuss Fat
Nutrition Problems Identified 1. Diet is high in total fat, saturated fat, and calories. 2. Lack of routine physical activity. 3. Currently overweight. 4. Diet is poorly balanced. Education Goals 1. Provide client with information to lower fat content of diet. 2. Assist client in developing a routine of physical activity. 3. Provide client with a meal planning tool to enhance the nutrition quality of the diet.
3.
Counting meal planning approach (see Table). Review appropriate material and establish goal for fat intake.
4. Continue food records. Session 6 1. Review food records. 2. Answer questions 3.
about
Fat
Counting. Review guidelines dining out/alco-
hol use. 4. Establish
new
goals.
Session 7 1. Review food records and goals.
2.
Discuss support group activities and encourage enrollment.
In this case study, the dietitian has utilized three different meal planning approaches. The client has previously been taught the use of exchanges, which the client felt was not realistic for her family environment. Therefore, the dietitian looked at simpler ways of helping the client change her eating habits. Emphasis was placed on changing the fat content of the diet and eating a balanced diet through the use of the U.S. Dietary Guidelines and the Basic Four Food Groups. In order to help the client better understand the fat content of her diet, the use of fat counting was implemented, an approach that also would help with weight and lipid man-
agement. Diabetes nutrition education can be best accomplished by involving the client in the education process and by utilizing various meal planning approaches. A client may utilize one or more meal planning approaches over time in order to meet the nutrition goals in managing diabetes. The educator should not assume that one meal planning approach is all that will be necessary. The educator must be aware of the changing educational needs of each client, and thus the need for various meal planning approaches. No one meal planning approach will meet the needs of all clients. Each client must have an individualized meal plan that begins with selecting an approach that meets the client’s learning needs. References 1. Green J, Holler H. Meal planning approaches in the nutrition management of the person with diabetes. Chicago: The American Dietetic Associa-
tion,1987:9-19. 2. Holler H, Green Pastors J. Nutrition guidelines and meal planning. Diabetes Spectrum 1991;4:58. 3. Green Pastors J. Alternatives to the exchange system for teaching meal planning to persons with diabetes. Diabetes Educator 1992;18:57.
The purpose of this department is to provide a fornrrrt for sharing innovative educational strategies or tools for use in patient or profes.sional diabetes education. Author.B’ are invited to submit manuscripts that describe a strategy or tool and its implications for practice. Manuscripts should be limited to three to five double-spaced pages and sent to Tool Chest editor Kathryn Godley, MS, RN, CDE, 23 Harrison Avenue, Deiniar, NY 12054.
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
Tool Chest Meal Planning Approaches: Practical Application
Nutrition is
one key component in the management of diabetes and presents a
major challenge to diabetes educators. The challenge of modifying longstanding eating habits can be frustrating for both the client with diabetes and the educator. To facilitate changes in eating behavior, two points need to be considered: 1. Obtainable nutrition goals must be established to address identified nutrition problems. The goals need to be agreed upon by the client and educator. 2. Nutrition education is not a onetime visit to a registered dietitian. A number of follow-up visits are necessary to help the client meet the established goals. It is also important for all members of the diabetes care team to reinforce the nutrition education provided by the registered dietitian. In order to assist the client in accomplishing the established nutrition goals, the educator will need to have available a variety of meal planning approaches. ’.3 Some clients may need to utilize several different meal planning approaches to meet their diabetes nutrition goals. Therefore, it is important for all members of the diabetes care team to have some knowledge of the various
approaches. The
of various meal planning approaches is demonstrated in the following two case studies, which provide some insight into their practical application. Each case study utilizes several different meal planning approaches, based on a particular intervention period that was determined by the client’s
level of knowledge and skill, as well attitude and behavioral goals.
as
and 1 can of pop or lunch meat sandwich and 1 can of pop
Case Study #1- Newly-
diagnosed insulin-dependent diabetes mellitus (NIDDM) Patient Data Joey is an 1 I -year-old, is in the 5th grade, and lives with his mother. Parents are divorced. He is actively involved in sports at school. Medical Data Height: 60 in Weight: 89 lb (40.05 kg) Medium Frame 90th percentile for height and 75th percentile for weight on the growth grid. Information obtained during a sports
Dinner: casserole, 2 dinner rolls with butter, and 2 glasses of 2% milk
2 scoops of 3 cookies or pudding
Evening Snack: cream or
ice
Nutrient Intake: 3870 calories, 173 g fat (40% of calories from fat)
Estimated Calorie Needs: calories
2670-3204
physical: Urine glucose: 3+ Urine ketones: trace Plasma glucose: 450
Frequency For Eating Away From mg/dL (2
hr post
lunch)
Home:
No medications or allergies. Has experienced a 5 lb weight loss following the flu. Has had symptoms of excess thirst, hunger, and urination (five times a
day). Admitted to the medical center for initiation of insulin therapy and initial education. Nutrition Assessment Nutrition History (usual
intake):
2 large bowls of sweetened cereal with 2% milk, 12 oz glass fruit juice, and 2-3 slices toast with butter and jelly
Nutrition Problems Identified 1. Diet is high in total fat and saturated fat. 2. Diet is inadequate in fruits/
vegetables. 3. Diet is high in total calories. 4. Knowledge deficit of diabetes trition management.
Morning Snack:
2.
1 carton chocolate
milk
3. fish sandwich (with tarter
sauce), green beans, canned peaches,
nu-
Hospital Education Goals 1. Provide clientlfamily with informa-
Breakfast:
Lunch:
1-2 times/week in fast food
restaurants
use
Correspondence to Harold J. Holler, RD, CDE, Skemp Clinic, 800 West Avenue South, La Crosse, WI 54601.
Afternoon Snnck: potato chips (w/dip)
tion on normal nutrition and the nutrition goals for diabetes. Assist client/family with selecting meal planning approach to a provide adequate calories and nutrition. Provide information on making healthy food choices in fast food restaurants.
4.
oatmeal cookie, and 1 carton 2% milk
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
Discuss food exercise.
adjustments
and
389
Session 3 (2 months later) 1. Review guidelines for labels.
reading
Session 4 (3 months later) 1. Introduce concept of carbohydrate counting as an alternative to exchange lists (see Table). This approach may enhance the climeal ent/family’s planning activities and will allow the inclusion of some sweets.
Education Plan Day I I . Review nutrient content of food and impact on blood glucose levels. 2. Review nutrition goals for diabetes and establish client nutrition goals. 3. Review Basic Food Groups (see
Outpatient Education Goals 1. Adjust meal plan, if necessary. 2.
Provide
3.
information on of foods to include
more
types/amounts in a meal plan.
Provide information on how to admeal plan for various situations (late meals, special occasions,
just the
Table).
etc.). 1.
2.
Introduce the Healthy Food Choice guide (see Table). Discuss type of meal planning approach to be used (Basic Food Groups vs Healthy Food Choice Guide).
Day 3 1. ~
2.
Establish a meal plan using Healthy Food Choice Guide. Plan menus for several days including choices for school lunch and fast food restaurants.
Education Plan Session 1 (2 weeks post-hospitalization) 1. Answer questions and revise meal plan, if necessary. 2. Introduce Exchange Lists for Meal Planning to provide more variety in food choices (see Table). 3. Plan additional menu.
Session 2 ( 1 month later) 1.
Da 1, 4 1.
2. 3.
Discuss food adjustment necessary for increased activity. Plan several additional menus. Schedule appointment for followup outpatient nutrition counseling.
Review ways to adjust the meal for late meals, special occa-
plan
sions, etc. 2. Plan additional menu. 3. Review all basics discussed.
Case Study #2 Uncontrolled non-insulin dependent diabetes mellitus (NIDDM) -
Provide information on reading labels. 5. Review guidelines for meal planning during illness. 4.
Da» 2
In this case study, the dietitian has utilized four different meal planning approaches to assist the client/family in meeting their nutrition goals. First, the use of the Basic Four Food Groups helps to establish and reinforce the concept of food groupings and serving sizes. Next, the Healthy Food Choice Guide provides a simplified structure to meal planning that defines for the client/family the types and amounts of food to be included at meals and snacks. Later, the introduction of the Exchange Lists for Meal Planning provides the client/family with more food choices and more information about the nutrient composition of foods. Finally, the use of carbohydrate counting supplies the nutrient composition of foods to enhance the inclusion of all food items. This approach provides considerable flexibility to meal planning for busy families and may enhance the client’s personal management of diabetes.
previously
Patient Data Mary is a 59-year-old homemaker who provides day care in her home for seven children. She is a high school graduate. She lives with her husband and daughter, who is in college. She is actively involved in volunteer work for a local nursing home. Takes occasional walks, but not
regularly. Medical Data Height: 5’4&dquo; Weight: 192 lb (86.40 kg) Medium Frame Has had diabetes for 10 years. Glucotrol: 10 mg (AM) and 5 mg (PM) Has hypertension. Blood Pressure: 140/85 Serum Cholesterol: 257 mg/dL (HDL Cholesterol: 29 mg/dL, LDL Choles-
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
391
terol : 197 mg/dL) HgbA1c: 10.2% Blood Glucose Monitoring (once per
4. Provide information and alcohol use.
day):
Educational Plan Session I I . Review the nutrient content of foods and their impact on blood glucose, lipids, and weight. 2. Review ways to reduce the fat content of the diet by using the meal planning approach &dquo;Dietary Guidelines for Americans Avoid Too Much Fat, Saturated Fat, and Cholesterol&dquo; (see Table). 3. Establish goals for reducing fat content of diet.
Fasting: 180-245 mg/dL Before Dinner: 192-257 mg/dL Nutrition Assessment Nutrition Histoty (usual
intake):
2 slices toast with peanut
Breakfast:
butter, 8 oz fruit juice, coffee oz
fruit
Lunch:
Casserole (macaroni and cheese, spaghetti and meatballs, or ravraw
vegetables,
one
12
glass
oz
2% milk, I cookie
Afternoon Snack:
pudding plus
left-
Session 2 1. Review
previous accomplishments.
2.
Dinner: meat (1-2 pork chops, chicken breast w/skin, 1-2 hamburger patties, or bologna), fried or boiled potatoes, vegetable (corn, peas, or green beans), 1-2 slices bread with butter, diet
use
and
of the Basic Four Food
snack 3.
Nutrient Intake: 2475 calories, 125 g fat (45% of calories from fat)
Calorie Needs For Weight Loss: 1200-1300 calories.
Frequencyforeating mvayfrom home: 2-3 times/week, primarily evening
reducing
Session 3 1. Review 2.
or
Review
goals
3. Plan 1-2 menus. 4. Establish new goals for fat intake.
pop popcorn
out
Groups meal planning approach.
over cookies
Bedtime Snack: crackers
dining
-
Morning Snack: 1 cookie, 4 juice, V2 slice toast with butter
ioli),
on
previous goals and accomplishments. Discuss impact of physical activity on diabetes and establish a plan for activity. Have the client keep a food record.
Session 4 1. Review the food record for fat content, nutrient balance, and calories. 2. Review physical activity routine. 3. Establish new goals for changing diet; continue food records.
meal. Alcohol use: week.
lite
beer
2-3
times/
Session 5 1. Review food records and
previous
goals. 2. Discuss Fat
Nutrition Problems Identified 1. Diet is high in total fat, saturated fat, and calories. 2. Lack of routine physical activity. 3. Currently overweight. 4. Diet is poorly balanced. Education Goals 1. Provide client with information to lower fat content of diet. 2. Assist client in developing a routine of physical activity. 3. Provide client with a meal planning tool to enhance the nutrition quality of the diet.
3.
Counting meal planning approach (see Table). Review appropriate material and establish goal for fat intake.
4. Continue food records. Session 6 1. Review food records. 2. Answer questions 3.
about
Fat
Counting. Review guidelines dining out/alco-
hol use. 4. Establish
new
goals.
Session 7 1. Review food records and goals.
2.
Discuss support group activities and encourage enrollment.
In this case study, the dietitian has utilized three different meal planning approaches. The client has previously been taught the use of exchanges, which the client felt was not realistic for her family environment. Therefore, the dietitian looked at simpler ways of helping the client change her eating habits. Emphasis was placed on changing the fat content of the diet and eating a balanced diet through the use of the U.S. Dietary Guidelines and the Basic Four Food Groups. In order to help the client better understand the fat content of her diet, the use of fat counting was implemented, an approach that also would help with weight and lipid man-
agement. Diabetes nutrition education can be best accomplished by involving the client in the education process and by utilizing various meal planning approaches. A client may utilize one or more meal planning approaches over time in order to meet the nutrition goals in managing diabetes. The educator should not assume that one meal planning approach is all that will be necessary. The educator must be aware of the changing educational needs of each client, and thus the need for various meal planning approaches. No one meal planning approach will meet the needs of all clients. Each client must have an individualized meal plan that begins with selecting an approach that meets the client’s learning needs. References 1. Green J, Holler H. Meal planning approaches in the nutrition management of the person with diabetes. Chicago: The American Dietetic Associa-
tion,1987:9-19. 2. Holler H, Green Pastors J. Nutrition guidelines and meal planning. Diabetes Spectrum 1991;4:58. 3. Green Pastors J. Alternatives to the exchange system for teaching meal planning to persons with diabetes. Diabetes Educator 1992;18:57.
The purpose of this department is to provide a fornrrrt for sharing innovative educational strategies or tools for use in patient or profes.sional diabetes education. Author.B’ are invited to submit manuscripts that describe a strategy or tool and its implications for practice. Manuscripts should be limited to three to five double-spaced pages and sent to Tool Chest editor Kathryn Godley, MS, RN, CDE, 23 Harrison Avenue, Deiniar, NY 12054.
Downloaded from tde.sagepub.com at Mount Royal University on April 30, 2015
