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Taking Diabetes Back to School

Maura Jones, LD, CDE

Objectives:

Promote use of practical tips for School Nurse’s to support optimal

diabetes management by:

• How and why carb counting supports optimal insulin dosing

• Diabetes and Healthy diet

• Preventing and treating low blood sugar

• Adjustments for exercise

• Sick Day Management and managing ketones

Protein

• impact BG- only after high protein load

meal • usually adds fat

• intake slows carb absorption BG

Fat

• direct impact on BG

• BG’s stay elevated longer

• Linked to insulin resistance

• Goal: Monounsaturated oils

fullness to carb intake

Saturated Fat

• Linked to higher blood cholesterol (animal

sources)

• Dairy fat, fatty meats, lard, shortening,

hydrogenated fat

• coconut & palm oil - veg based OK in

moderation

COUNTING

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~ 50 % Calories from Carbs

Calories 1600 1800 2100 2400

Carb 200g 225g 260g 300g

Meal Carb Range = 30-90 g per meal

~ 45-75 g / meal & 15 g Snacks x 2-3

Protein

• impact BG- only after high protein load

meal • usually adds fat

• intake slows carb absorption BG

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Fat

• direct impact on BG

• BG’s stay elevated longer

• Linked to insulin resistance

• Goal: Monounsaturated oils

fullness to carb intake

Saturated Fat

• Linked to higher blood cholesterol (animal

sources)

• Dairy fat, fatty meats, lard, shortening,

hydrogenated fat

• coconut & palm oil - veg based OK in

moderation

Carb Gram System:

• Allows flexibility

• Tally carbohydrate grams

• Include incidentals

• Free Foods - veggies

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Sugar Alcohol & Fiber

Subtract ½ g

Fiber & Sugar Alcohol &

From Total Carbs

(If > 5 g)

Carb Friendly Schools

Nutrition information availability

Communication with food service staff

Portion consistency

State of NH Special Diet form – generally not needed for diabetes

504 plans –helpful for ongoing support

Carb Counting vs. Carb Guessing

How long since diabetes education with RD or CDE?

How will student access menu nutrition carb info?

Insulin (& math) before or after meals?

Should they be cover snacks?

What is student’s carb ratio? (lower = accuracy)

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15 g Carb Snacks:

• ½ c Fruit + 1 string cheese

• ½ English muffin pizza

• 6 saltines + peanut butter

• 3 cups popcorn

• 2 graham crackers +1/2 c milk

and BG does not come down and BG does not come down

Balanced meals have veggies and fruits

ANTI-OXIDATION

Free Radicals

Low Grade Inflammation

Injure Artery Walls LDL Sticky Plaque

Cell Membranes Leak Cell Death

DNA Breaks Errors Cancer & Autoimmune Dx

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Oxidation

• Rusting inside

• BG damage

How do carnivores get antioxidants?

Support and supervise adherence:

• BG monitoring school plan

• Medication administration

• Promote exercise

• Reinforce healthy food

TYPE 2 LIFESTYLE MANAGEMENT

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School Nutrition Challenges

• Meal and snack time

• Peer “culture”

• Food selection

Taste bud training

- Learning to love healthy Foods

- Taste food 10 X before kids “dislike” it

- OK to spit it out

SAFE AT SCHOOL:

EXERCISE, HYPOGLYCEMIA &

SICK DAYS

Exercise

• Benefits

improved BG control

• Challenges

• hypoglycemia

• medical alert

EXERCISE & PREVENTING LOWS

• Subtract 10-15 g carb (or 1 -2 units)

• Temp basal

• May need a snack before exercise

• Check BG after 1 hour of exercise

Blood Sugar Decrease Insulin or Add Carb Snack

less than 120 subtract 1-2 units 15-30 g carb

120 to 180 subtract ~1 unit 10- 15 g carb

180 or higher not needed not needed

Preventing Lows w/ Exercise

Moderate Intensity ~ 1 hour i.e swim, jog

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Hypoglycemia

Rule of 15 for Lows

Blood Sugar under 70 (< 80 @ school)

• TREAT Fast Acting Carbs

Rule of “15” 15 grams

(8 g for age 6 and under)

Re BG after 15 minutes (rest)

QUICK ACTING CARBS

Age 6 and Over : 15 g

Pick one:

• 4 Glucose Tabs

• 4 oz. Juice

• 8 oz. Skim milk

Age 6 & Under : 8 g

Pick one:

2 Glucose Tabs

2 oz. Juice

4 oz. Skim milk

Glucose sources - Fastest

Avoid OVER-treating Lows

Most common result of Low

High

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Glucagon – For Severe Lows

SICK DAY MANAGEMENT AT SCHOOL

Why Check for ketones?

• Avoiding life threatening DKA

• Avoiding hospitalization for medical

management of acidosis

• If the blood sugar is high and you don’t know

why – check for Ketones

When to Check Ketones

• If blood glucose is 250 or higher:

Pumpers x 1 Injections x 2

• During any illness: fever, cold, GI vomiting

(even if BG normal)

• Fruity or acetone (nail polish remover) breath smell

MODERATE TO LARGE URINE KETONES

Call Parents or Provider

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Blood Ketone Results For Injections Moderate to Large Ketones:

Re-test every urine until negative x 2

• Give insulin based on BG / CF - q 2 hrs

• Basal insulin ?

• Add carb coverage if eating

• May need higher dose

Ketones and Pumps

• Blood sugar > 250 check ketones

• Change set

• Insulin Correction by syringe

• Push Fluids

• Stay in school

unless inter-current illness

Positive Ketones: What to Do

Check Ketones

< small Mod -LG

Check site red, swollen, sore?

Check last bolus

Give correction-pump Recheck in 1-2 hrs

Correct with syringe Change set Push fluids

Recheck in 1-2 hrs.

BG OK No change

BG still high Correct with syringe Change set

BG OK Ketone less Watch

BG high Ketones Mod - Lg

CALL

Exercise with ketones

May exacerbate hyperglycemia

hepatic glucose

cells uptake of glucose during insulin deficiency

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RESOURCES

CARB COUNTING RESOURCES

School Café staff

Calorie King- book, app or web

Nutrition Data base on line

Diabetes Apps

• Glucose Buddy enter blood glucose numbers, carbs,

insulin doses & activity tracker

• Insulin Calculator Input blood sugar and carb grams to

determine insulin dose to nearest ½ unit

• Glucagon By Lilly -instruction video, storage tips etc.

• Figwee pictures of food portions w/ nutrition and

carb counts of foods

• Lenny the Lion Carb counting teaching games

• NutritionFacts.org nutrition science videos

THANK YOU! CONTACT INFO:

Maura Jones, RDN, LD, CDE Maura.R.Jones@Hitchcock.org