By Mary Ellen Posthauer, RDN, CD, LD, FAND

Part 2 in a series discussing nutritional status and diabetic foot ulcer risk.
To read Part 1,Click Here

Last month, I discussed the steps that could be taken for a client who is a qualifying beneficiary under Medicare Part B, to receive the services of a dietician for Medical Nutrition Therapy (MNT) and/or to a Diabetes Self Management Training (DSMT) program for assistance in achieving glycemic control. This month we will follow a client though the assessment and treatment process.

We will assume Mr. X is a 70-year-old man with Type 2 diabetes and a chronic diabetic foot ulcer. His other diagnosis includes hypertension, which is controlled with medication, hypercholesterolemia and pernicious anemia. His HbA1C runs between 8-9.5%, which is above the desired 7%, and his cholesterol/lipid levels are also elevated. His treatment plan includes a daily oral hypoglycemic, hypertensive medication, a statin, daily multivitamin, and a monthly B12 injection. Mr. X is 68" tall, weighs 250lb with a BMI of 38. His chronic diabetic foot ulcer limits his daily activity so he is sedentary and spends the majority of his day watching television or reading.

On his first visit with the dietitian, they discuss his routine meal and snack pattern. In an effort to determine what he actually eats and drinks he is asked to complete a food diary for a week. It is important to not only determine what is eaten but when. For example, if he consumes his meals while watching TV, the dietitian may suggest he eat in another room so he can concentrate on just completing the meal, which will probably reduce the quantity of food he eats. It is important to establish routine meal times and consume a consistent amount of carbohydrate at each meal.

Together the dietitian and Mr. X will discuss the medications he is taking including any over the counter or herbal supplements. In addition to the medications prescribed by his physician, Mr. X is taking a laxative, analgesic and an antacid.
Mr. X was concerned because his chronic diabetic foot ulcer is limiting his activity and his social life. His continued weight gain over the past three years has compounded his mobility problems and increased his health problems, in particular his glycemic control. He has made the decision to embark on a medical nutrition plan by adjusting his eating habits with a goal to lose weight and increase his daily exercise.

Together they develop a plan that will fit his lifestyle and include food that he can prepare easily, since he lives alone. Mr. X has always enjoyed a hearty breakfast of bacon or sausage, eggs, etc. The dietitian suggests that he limit his eggs to one a day (giving up the eggs completely isn't an option for him currently) and add turkey sausage to his plan. He is willing to switch from whole milk to skim milk. Since protein is important for wound healing, he purchases baking hens, small roasts and lean beef patties to not only stretch his protein options but also give him food to freeze for a later date. Fresh fruit is substituted for snacks and chips between meals. He learns when they are consumed on a consistent basis that they do help to stabilize his blood glucose levels and reduce his constipation problems. The dietitian recommends that he increase the fiber in his diet by incorporating more whole grain bread, cereal, beans, and legumes and reduce the amount of canned and processed food that he is purchasing. The learning process includes reading and understanding food labels. Habits do not change quickly but the objective is to set small achievable goals, such as losing 1- 2 lbs. a week and/or trying one new type of food with a long-range goal of having an HbA1C of 7%.

Exercise is part of his plan which incorporates a visit to a physical therapist who suggests an exercise program at the senior center. The program includes resistance training exercises to improve his muscle strength. Mr. X attends the classes three days a week and notes that not only is his endurance improving but also his attitude and mood are better. While it appears that Mr. X is the ideal patient, achieving success requires dedication and the results can be slow but effective.

What about the candidate who is resistive to change or who lacks the resources to effectively alter his/her lifestyle? Stay tuned and I'll tackle those issues next month.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the Academy of Nutrition and Dietetics’s Unintentional Weight Loss work group.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.