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Welcome to In-unit Seminar on Nutritional Management of Diabetes Mellitus. Meera kaur , Ph.D., R.D. May 13, 2009. Nutritional Management of DM. Goals are to achieve target blood sugar level achieve and maintain desirable body weight prevent the complications
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Welcome to In-unit Seminaron Nutritional Management of Diabetes Mellitus Meerakaur, Ph.D., R.D. May 13, 2009
Nutritional Management of DM.. • Goals are to • achieve target blood sugar level • achieve and maintain desirable body weight • prevent the complications • manage the complications if already developed • improve the overall quality of life
Nutritional Management of DM.. • At the bottom line: • To follow Canada’s Food Guide for Healthy Eating • Carbohydrates: 45-60% of energy (choose complex CHO with low glycemic index) • Protein: 15-20% of energy (encourage more fish than meat, specially fatty fish) • Fat: <35% of energy (SFA: <%7, PUFA: <%10; include PUFA-especially n-3 PUFA) • Vitamins+Minerals: Routine supplementation is not necessary • Alcohol: <14 and <9 std. drinks for men and women/week respectively
Nutritional Management of DM • At the bottom line: • Referral to RD • Education to those patients on intensive insulin therapy about matching insulin to CHO content of meals (CHO counting) • Weight management • Regular physical activities • Team approach
One in two type-2 diabetes patients in Canada are not at target (<7%).
Glycemic Control in Canada • Even though only ½ have glycemic control, only 12% of patients are currently on insulin. • Harris, E. et al, Diabetes Res Clin Pract 2005;70:90.
Risk Reduction for Diabetes By Achieving a Specific Lifestyle Target – Diabetes Prevention Study N Eng J Medicine 2001: 344: 1343-50.
Glycemic Index • Has been around for over 20 years. • May help to: • Control blood glucose levels • Control cholesterol levels • Control appetite • Lower risk of getting heart disease • Lower risk of getting type 2 diabetes • Ranks foods by how much they raise blood glucose levels compared to glucose or white bread. • In general, the lower the rating, the better the quality of carbohydrate. • Usually low in calories and fat, while also being high in fiber, nutrients and antioxidants.
What Affects GI? • Size of particle • Cooking • Spaghetti boiled 5 min GI = 34 • Spaghetti boiled 10-15 min GI = 40 • Processing • Cornflakes GI = 86 • Porridge GI = 49 • Fat (Lowers GI) • Potato Chips GI = 75 • Baked Potato GI = 93 • Acidity – lower pH slows gastric emptying= lowers GI • Mixture of meals (Protein, Fat, CHO)
Glycemic Load vs. Glycemic Index • The glycemic load is calculated by multiplying the glycemic index by the amount of CHO in grams provided by a food and dividing the total by 100. • Takes into account quality (glycemic index) and quantity of CHO in a meal. • Glycemic Load may be a better indicator. • Confuses the issue even more.
Better Yet… • Better to give direct recommendations. • Increase whole grains, nuts, legumes, fruits, and non-starchy vegetables. • Decrease white stuff, desserts, and pop.
Fiber • Insoluble • Soluble • Improves glucose control
All about Meals • Quantity is important. • What foods have CHO in them? • Quality is important • Foods that slow digestion (protein, fibre) vs. foods that speed through (soft drinks, candy). • Protein at each meal. • 20-30 g fiber each day. • Spacing of meals. • Wave Effect. Want consistency. • Meals should be 3-4 hours apart. • Do not skip meals.
Other Important Lifestyle changes… • Exercise • 150 minutes per week of moderate-intensity aerobic physical activity. • Should be at least 3 days/week, no more than 2 consecutive days without physical activity. • Same recommendation for those with impaired fasting blood glucose or diabetes. • Stress test may be needed. • Consistent exercise for 8 weeks can lower HgA1C by 1% (New Recommendations Regarding Exercise and type 2 Diabetes ) • Weight loss • Even 5-10% of BW makes a difference. • Shows improvement in glycemic control, lipid profiles, insulin sensitivity and BP.
Fasting or Before Meals One or Two Hours after a Meal
UKPDS: Decreased Risk of Diabetes Related Complications Associated with a 1% Decrease in A1C Adapted from Stratton, IM, et al. UKPDS 35. BMJ 2000; 321:405.
BOTTOM LINE: We need to be controlling blood sugars better! • Require: • Appropriate glucose monitoring • Learning meaning behind test results • Using test results to understand the link between food and blood glucose. • Important for all people with diabetes. • Modern insulin thinking • If their sugars are not in control, use all that is in your toolbox. • Adaptive thinking.
When starting insulin… • Rapid acting • Humalog/NovoRapid • Target PPG = 7-8 mmol/L • Select largest meal first • Start with low dose : 4-6 u and titrate • Adjust for the meal content • Less hypoglycemia
Carbohydrate Counting • 1 CHO Choice = 15 gram CHO • Males • 3-5 CHO choices, 1 protein choice per meal • 1-3 CHO choice, ½ protein choice per snack • Females • 2-4 CHO choices, 1 protein choice per meal • 1-2 CHO choice, ½ protein choice per snack
Hypoglycemia Guidelines • Rule of 15 • If <4 mmol/L • Treat with 15 grams CHO (glucose or sucrose) • Wait 15 minutes • Re-check blood sugars • Re-treat if <4 mmol/l
Question Which food will raise blood sugar quicker? • Whole wheat bread or pita bread? • Shredded Wheat or Cheerios? • Pasta or short-grain rice? • Sweet potato or Russet potato? • Popcorn or Rice Cakes?
Other Nutrients of Importance? • Which other nutrients in foods will decrease the glucose surge when eaten with CHO foods? • Protein • Fat • Fiber
Your patient, Sandra • 55 YO, diagnosed with type 2 diabetes one-year ago. • Blood sugars are not in control. • Typical day of blood sugars: • am 9, 2 hour post breakfast 10 • Before lunch 8, 2 hour post lunch 9 • Before supper 9, 2 hour post supper 15 • Before bed 13-14 • Ideas for management?
Management • Start insulin with largest meal of the day (supper) • Typical supper: 2 c kraft dinner, ½ c cottage cheese, 3 toast with peanut butter, 1 c ice-cream for dessert. If we were giving pt insulin based on CHO consumption, what would you recommend Sandra take for insulin at this meal?
Fiber • Food with 5+ grams of fiber per serving: • Subtract this from total CHO content in serving. Example 1/3 cup All-Bran Buds 23 grams CHO, 12 grams fiber 23-12= 11 grams of digestible CHO.
Prevention of Type 2 Diabetes • All countries agree that we need a structured program for weight loss and physical activity. • For IGT, recommend that metformin and/or acarbose be used to prevent diabetes onset. • 2008 Canadian Practice Guidelines for Diabetes Prevention and management are released now for more information.
Management of GDM • Nutritionally adequate diet following Canada’s Food Guide for healthy eating • Adequate in energy to promote normal weight gain and prevent ketonuria • Low in simple sugars and juices • Food distributed between 3 small meals and 3 healthy snacks at regular time • Adequate fluid intake (6-8 cups/day) • Sweetener may be used within the acceptable daily intake limits. • Avoid alcohol
Management of Postpartum • Encourage breastfeeding • Encourage maintaining/ achieving healthy wt. for ht. for prevention or delay of diabetes later in life and/or subsequent pregnancies • Encourage to follow diet suggested for management of diabetes early in subsequent pregnancies
Key Messages • Nutrition therapy can reduce the glycated hemoglobin by 1.0-2.0%. • Consistency in carbohydrate intake + regularity in meal time and meal spacing may help control blood glucose and body weight. • Replacing high-glycemic index carbohydrates with low-glycemic index carbohydrates in mixed meal has a clinically significant effect on glycemic control in people with Type 1 or type 2 diabetes.
Resources Used Today • Tuomilehto, J et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine, 344, 1343-1350. • Knowler, W. et al (2002). Reduction in the incident of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346, 393-403. • Management of Diabetes in Pregnancy: Challenges and Trends. Meltzer, S. Canadian Journal of Diabetes, 2005; 29(3); 246-256. • Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes (2008); 32 (Supplement 1) .