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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 seminar on nutritional management of diabetes mellitus

Welcome to In-unit Seminaron Nutritional Management of Diabetes Mellitus

Meerakaur, Ph.D., R.D.

May 13, 2009

nutritional management of dm
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 dm1
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 dm2
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
glycemic control in canada
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
Risk Reduction for Diabetes By Achieving a Specific Lifestyle Target – Diabetes Prevention Study

N Eng J Medicine 2001: 344: 1343-50.

glycemic index
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
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
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 Yet…
  • Better to give direct recommendations.
    • Increase whole grains, nuts, legumes, fruits, and non-starchy vegetables.
    • Decrease white stuff, desserts, and pop.
  • Insoluble
  • Soluble
    • Improves glucose control
all about meals
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
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
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
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
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
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
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

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
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
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?
  • 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?

  • Food with 5+ grams of fiber per serving:
    • Subtract this from total CHO content in serving.


1/3 cup All-Bran Buds

23 grams CHO, 12 grams fiber

23-12= 11 grams of digestible CHO.

prevention of type 2 diabetes
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
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
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
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
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) .