Welcome to in unit seminar on nutritional management of diabetes mellitus
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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 minGI = 40

  • Processing

    • CornflakesGI = 86

    • PorridgeGI = 49

  • Fat (Lowers GI)

    • Potato ChipsGI = 75

    • Baked PotatoGI = 93

  • Acidity – lower pH slows gastric emptying= lowers GI

  • Mixture of meals (Protein, Fat, CHO)


Blood Glucose Levels


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.


What your plate should look like…


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) .


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