Disclosure Financial relationships: 1 Employee of New Mexico State - - PDF document

6/1/2018 1

All About Discovery!TM New Mexico State University aces.nmsu.edu

The College of Agricultural, Consumer and Environmental Sciences is an engine for economic and community development in New Mexico, improving the lives of New Mexicans through academic, research, and Extension programs.

All About Discovery!TM New Mexico State University aces.nmsu.edu

College of Agricultural, Consumer and Environmental Sciences

All About Discovery!TM New Mexico State University aces.nmsu.edu

Disclosure

I have no relevant financial relationship with any commercial interests that create a conflict of interest to affect CME content about products or services.

1a Employee of New Mexico State University 1 Coordinator of the Kitchen Creations program, which receives funding from the NMDOH Diabetes Prevention & Control Program

Financial relationships:

6/1/2018 2

Objectives

At the conclusion of this presentation, participants will be able to:

2

Discuss strategies used in managing diabetes in pregnancy

1

Develop a list of resources to use with women who have diabetes in pregnancy

Lifestyle management1

MNT Physical activity Weight management

70‐85% of women with gestational diabetes (GDM) can control it with lifestyle modification alone

6/1/2018 3

Medical Nutrition Therapy1,2

Nutrition assessment (DRI) Adequate calories Glycemic goals GWG

• ≥175g carbohydrate
• ≥71g protein
• 28g fiber

Fasting: <95 mg/dL 1 hr postprandial: <140 mg/dL 2 hr postprandial: <120 mg/dL

1st MNT visit: 60‐90 min 2nd MNT visit within one week: 30‐45 min 3rd MNT visit within 2‐3 weeks: 15‐45 min Additional visits every 2‐3 weeks or as needed for duration of pregnancy

GWG Recommendations3,4

Twins

50‐62 lb5 16.8‐24.5 kg (37‐54 lb) 14.1‐22.7 kg (31‐50 lb) 11.3‐19.1 kg (25‐42 lb)

2.7‐6.4 6‐14

6/1/2018 4

GWG Recommendations6 GWG Recommendations

6/1/2018 5

Physical activity7

PAGA: ≥150 minutes/week moderate‐intensity aerobic activity

• Walking
• Swimming
• Stationary cycling
• Low‐impact aerobics
• Yoga, modified
• Pilates, modified

If done regularly before pregnancy and provider approves:

• Running or jogging
• Strength training

Safe

• Contact sports
• Activities with a high risk of falling
• Scuba diving
• Sky diving
• Hot yoga
• Hot pilates

Unsafe

Insulin Management1

•  insulin sensitivity
•  daily insulin

requirements

•  hypoglycemia
•  frequent blood

glucose self‐ monitoring

•  insulin

resistance

•  insulin dose

weekly/biweekly

• <50% basal insulin
• >50% prandial

insulin

•  insulin

resistance

• Leveling off/small

decrease of insulin requirements late in trimester

• Referral to

specialized center

1 2 3

6/1/2018 6

1

2 3

Mark Twain

“Habit is habit, and not to be flung out of the window, but coaxed downstairs a step at a time.”

How does your patient feel?8

6/1/2018 7

What can/can’t they change? Increasing adherence

Self‐ monitoring Stress management Goal setting Stimulus control Social support Open‐ended questions Cognitive restructuring Contingency management Affirmations Reflective statements Summary points Importance & confidence rulers

6/1/2018 8

Successful counseling

Cognitive Behavioral Therapy (CBT) Counselor Motivational Interviewing (MI)

Example Text

Successful counseling

6/1/2018 9

Praise

• Positive reinforcement
• Promote change talk
• Must be genuine
• What does she value?

What motivates her?

Praise

Avoid

• utcomes

Avoid

• utcomes

Reinforce efforts Reinforce efforts

Weight Glycemic #s Diet Activity Monitoring Showing up

6/1/2018 10

Praise

Tina has GDM and is in the second trimester of her

• pregnancy. She has not been prescribed medication

but was asked to test her blood glucose levels in the morning (fasting) and two hours after each meal and to bring her log to each appointment. She did not bring her log to her first appointment and confessed that she often forgets to test anyway.

Your turn!

Speaker: Tell someone next to you about a recent accomplishment that made you happy or proud. Listener: Listen for behaviors and motivators that led to the accomplishment, and offer praise.

Fasting 2 hours after breakfast 2 hours after lunch 2 hours after dinner Notes

Monday

109 122 115

Tuesday

106 152

Missed walk after dinner

Wednesday

126 121 131 120

Thursday

113 128 179 247

Sick

Friday

159 150

Sick

Saturday

127

Sunday

119 121 140

Praise

6/1/2018 11

OARS

Resist the righting reflex!

A R S Open-ended questions O Affirmations Summary points Reflective listening

OARS

When asked what concerns she wanted to add to the agenda, Tina said she wants to talk about how to control her blood sugars. You begin addressing her concern with: “What do you think will help you achieve the blood sugars you want?” Tina: “I don’t know. Walking seems to work pretty well, but sometimes my sugars are still high. I know you taught me about how to eat healthy, but it feels like too much to take on. Taking time to walk is already a challenge. I don’t know how to fit in the meal changes.”

6/1/2018 12

OARS

Counselor reflects: “I think what you are saying is that you can’t see a way to find time to address the changes needed to improve your eating. Is that correct?” Tina: “Yes, I guess it is, but I know it’s important for my

• baby. I just feel overwhelmed by all that I have to do.”

OARS

Counselor: “What are the things that you would like to see change with your eating?” Tina: “Well, I know I need to watch my carbs, but the foods I’m used to eating are usually high in carbs. I need to plan meals that have low‐carb foods, too. I would also like to eat

• ut less.

6/1/2018 13

OARS

Counselor: “Here is what I’ve heard so far. You have made positive changes in your physical activity and think eating healthier is the next step you should take. On one hand, you’re concerned about the time that will take, but on the

• ther hand, it’s important to you because you want the

best for your baby. You want to plan low‐carb foods into your meals and eat out less. Is there anything you want to add or correct?

Shops with her child after work Shops with her child after work Stops for samples Stops for samples Browses aisles Browses aisles Plans dinners while shopping Plans dinners while shopping Buys high carb snack foods Buys high carb snack foods Checks out Checks out Buys fast food Buys fast food Skips her walk Skips her walk No meals for Sat‐Mon No meals for Sat‐Mon

6/1/2018 14

Stimulus control

• Identify triggers associated with non‐adherence
• Help her address the issue before it happens
• People don’t live in isolation
• Create safe spaces

Goal setting & MI rulers

• SMART goals
• Importance ruler
• Confidence ruler

1 2 3 4 5 6 7 8

“Why a 7, and not a 5?” Promotes change talk

9 10

Not at all important/ confident Super important/ confident

“Why a 7, and not a 10?” Identifies barriers

6/1/2018 15 ADA Diabetes Food Hub: https://www.diabetesfoodhub.org/ University of Nebraska‐Lincoln food and nutrition resources: https://food.unl.edu/free‐food‐nutrition‐fitness‐and‐food‐ safety‐educational‐powerpoints‐and‐handouts

6/1/2018 16

Pre pa ring F re e ze r Me a ls At Ho me

 1. Sa ve s mo ne y  2. I

nc o rpo ra te s fa mily fa vo rite s

 3. Allo ws c o ntro l o ve r ing re die nts  4. Allo ws c o ntro l the a mo unt a nd po rtio n

size s

• 5. Pro vide s kno wle dg e o f nutritio na l info

 6. Sa ve s time

06/ 01/ 2018

Do n’ t Be I ntimida te d

 Sta rt sma ll  Ge t c o mfo rta b le with the ide a  Co o k thing s yo u kno w yo ur fa mily like s  T

ry a fe w dishe s

 Build o n yo ur skills  No t e ve rything ha s to b e a c a sse ro le

06/ 01/ 2018

6/1/2018 17

Wha t Ca n Yo u F re e ze ?

 Answe r: a lmo st a nything

 Be wa re o f c re a m sa uc e s, ma yo  Ra w me a t vs. c o o ke d me a t  Qua lity ing re die nts  Ba ke d Go o ds

https:/ / www.fsis.usda .g o v/ wps/ po rta l/ fsis/ to pic s/ fo o d-sa fe ty-e d uc a tio n

06/ 01/ 2018

Ha ve I c o nvinc e d yo u ye t?

 Pre pa re to diffe re nt sta g e s o f c o mple tio n

 Bro wn la rg e b a tc h o f g ro und b e e f a nd fre e ze in o ne po und

se rving s fo r q uic k me a ls

 Cho p se ve ra l o nio ns a nd fre e ze in o ne c up se rving s  Ma king me a tlo a f? Ma ke a n e xtra a nd fre e ze it.  Do ub le a fa vo rite re c ipe a nd fre e ze o ne

06/ 01/ 2018

6/1/2018 18 Re c ipe De mo nstra tio n Slo w Co o ke r Chipo tle Burrito s



2 lb s. b o ne le ss, skinle ss c hic ke n b re a sts



1 16 o z. jar o f sa lsa



1 te a spo o n c hili po wde r



1 te a spo o n drie d o re g a no



1 o nio n, c ho ppe d



1 c a nne d c hipo tle pe ppe r in a do b o sa uc e *, c ho ppe d



1 c a n b la c k b e a ns, dra ine d a nd rinse d



1 c a n who le ke rne l c o rn



F lo ur o r c o rn to rtilla s



Optio na l to pping s: pic o de g a llo , shre dde d le ttuc e , so ur c re a m, shre dde d c he e se , bla c k o live s, a vo c a do , e tc . DIRE CT I ONS:



Pla c e c hic ke n in a 3 o r 4-q ua rt c ro c k po t. Co mb ine the sa lsa , c hili po wde r,

• re g a no , c hipo tle pe ppe r, c o rn a nd b e a ns. Stir fo r a fe w se c o nds until we ll mixe d

a nd po ur o ve r me a t. Co ve r a nd c o o k o n lo w fo r 6-8 ho urs. Shre d me a t with 2 fo rks. Se rve o n to rtilla s with to pping s o f yo ur c ho ic e . F RE E ZI NG DIRE CT I ONS:



Pla c e c hic ke n in g a llo n fre e ze r b a g . Co mb ine the sa lsa , c hili po wde r, o re g a no , a nd c hipo tle pe ppe r. Ble nd fo r a fe w se c o nds until we ll mixe d a nd po ur o ve r me a t. Add b e a ns a nd c o rn. Se a l a nd pla c e fla t in fre e ze r. Whe n re a dy to use , pla c e b a g in re frig e ra to r to tha w. Afte r ing re die nts have tha we d, pla c e in c ro c kpo t a nd fo llo w dire c tio ns a b o ve . *Sinc e this re c ipe o nly use s 1 c hipo tle pe ppe r, I like to fre e ze the re ma ining pe ppe rs fro m the c a n in ic e c ub e tra ys (1 pe ppe r pe r c ub e ). Onc e fro ze n, I sto re the m in a zip- to p b a g in the fre e ze r a nd use a s ne e de d in re c ipe s. 06/ 01/ 2018

E a sy Pre pa ra tio n

 Whe n re a dy to pre pa re , tha w nig ht b e fo re in re frig e ra to r.  T

hro w in the slo w c o o ke r the ne xt mo rning o n lo w.

 Shre d whe n yo u g e t ho me a nd se rve with to rtilla s, so ur

c re a m, a nd c he e se .

 Ca n fre e ze the re st fo r la te r use a lso .

06/ 01/ 2018

6/1/2018 19

T hre e Che e se L a sa g na Ro ll-ups

 20 la sa g na no o dle s, who le  32 o unc e s ric o tta c he e se  2 la rg e e g g s  1 c up shre dde d Pa rme sa n c he e se  ½ te a spo o n sa lt  1 te a spo o n pe ppe r  ½ c up fre sh spina c h, c ho ppe d  1 ta b le spo o n fre sh b a sil, minc e d  1-2 c ups mo zza re lla c he e se , g ra te d*  Pa sta sa uc e *

* I ndic a te s ing re die nt wo n’ t b e use d until c o o king time

 Ma ke s 20 ro llups 06/ 01/ 2018

What would you like to try?

6/1/2018 20

Self‐monitoring

• Consistently been shown to increase

positive behavior changes

• Increases awareness
• Can provide important information
• Can help with patients that are stuck

Pregnancy blood glucose targets1

Fasting <95 mg/dL Fasting <95 mg/dL 1 hr PP <140 mg/dL 1 hr PP <140 mg/dL 2 hr PP <120 mg/dL 2 hr PP <120 mg/dL

Women with mild GDM who meet glucose goals after a week of MNT may perform self‐monitoring

• f blood glucose every other day instead of daily

6/1/2018 21

Resources

Website/App Food intake Physical activity Weight Social support MyFitnessPal     Lose It!     FatSecret     Cron‐o‐meter    SparkPeople     https://www.healthline.com/nutrition/5‐best‐calorie‐counters https://www.healthline.com/health/diabetes/top‐iphone‐android‐apps

Social support

People

Role models Commitment Accountability Scrutiny Overcome barriers

6/1/2018 22

Is that it?8 Lowering DM risk1

Postpartum weight loss, then weight maintenance <240 minutes moderate‐ intensity aerobic exercise/week Healthy eating patterns Metformin

6/1/2018 23

505‐850‐0176  575‐703‐2343  888‐900‐2629

References

• 1. American Diabetes Association. 13. Management of diabetes in pregnancy:

standards of medical care in diabetes. Diabetes Care. 2018;41(Suppl. 1):S137–S143. Available at: http://care.diabetesjournals.org/content/41/Supplement_1/S137.

• 2. Academy of Nutrition and Dietetics, Evidence Analysis Library. GDM: executive

summary of recommendations. 2016.

• 3. IOM (Institute of Medicine) and NRC (National Research Council). 2009. Weight

gain during pregnancy: reexamining the guidelines. 2009:1–13. Available at: https://www.ncbi.nlm.nih.gov/books/NBK32813/.

• 4. Weight gain during pregnancy. Committee Opinion No. 548. American College of

Obstetricians and Gynecologists. Obstet Gynecol. 2013;121:210–2. Available at: https://www.acog.org/Clinical‐Guidance‐and‐Publications/Committee‐ Opinions/Committee‐on‐Obstetric‐Practice/Weight‐Gain‐During‐Pregnancy.

6/1/2018 24

References

• 5. Luke B, Hediger ML, Nugent C, Newman RB, Mauldin JG, Witter FR, et al. Body mass

index‐specific weight gains associated with optimal birth weights in twin pregnancies. J Reprod Med. 2003;48:217–24.

• 6. Healthy weight gain during pregnancy. What is the right amount of weight to gain

during pregnancy? Available at: http://resources.nationalacademies.org/Pregnancy/WhatToGain.html#.

• 7. Physical activity and exercise during pregnancy and the postpartum period.

Committee Opinion No. 650. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e135–42. Available at: https://www.acog.org/Clinical‐ Guidance‐and‐Publications/Committee‐Opinions/Committee‐on‐Obstetric‐ Practice/Physical‐Activity‐and‐Exercise‐During‐Pregnancy‐and‐the‐Postpartum‐Period.

• 8. https://www.youtube.com/watch?v=2o9bKzmWCWg

Cassandra Vanderpool, MS, RDN, LD

College of Agricultural, Consumer, and Environmental Sciences Department of Extension Family and Consumer Sciences New Mexico State University cvpool@nmsu.edu; 575‐202‐5065 kitchencreations.nmsu.edu Follow us on social media:

?

?

Questions

The College of Agricultural, Consumer and Environmental Sciences is an engine for economic and community development in New Mexico, improving the lives

• f New Mexicans through academic, research, and extension programs.

New Mexico State University is an equal

• pportunity/affirmative action employer and educator.

NMSU and the U.S. Department of Agriculture cooperating.

Motivational Interviewing and CBT: Combining Strategies for Maximum Effectiveness by Naar & Safren