1. Welcome to In-unit Seminar on Nutritional Management of Diabetes Mellitus Meera kaur, Ph.D., R.D. May 13, 2009

2. 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

3. 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: –Alcohol: <14 and <9 std. drinks for men and women/week respectively

4. 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

5. One in two type-2 diabetes patients in Canada are not at target (<7%).

6. 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.

7. Risk Reduction for Diabetes By Achieving a Specific Lifestyle Target – Diabetes Prevention Study GoalRRR(%) Weight Loss >5% 66 Total Fat <30% Energy 53 Saturated Fat <10% Energy 54 Fiber >15 gram/100kcal 71 Exercise >4 hours/week 62 N Eng J Medicine 2001: 344: 1343-50.

8. Glycemic Index –Has been around for over 20 years. –May help to: Control blood glucose levels Control blood glucose levels Control cholesterol levels Control cholesterol levels Control appetite Control appetite Lower risk of getting heart disease Lower risk of getting heart disease Lower risk of getting type 2 diabetes 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.

9. –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) What Affects GI?

10. Blood Glucose Levels

11. 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.

12. Better Yet… Better to give direct recommendations. –Increase whole grains, nuts, legumes, fruits, and non-starchy vegetables. –Decrease white stuff, desserts, and pop.

13. Fiber InsolubleSoluble –Improves glucose control

14. 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.

15. What your plate should look like…

16. 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.

17. InadequateMore than 14Action Required Suboptimal11-14Action May be Required Ideal5-10Target Goal InadequateMore than 10Action Required Suboptimal7-10Action may be Required Ideal4-7Target Goal Too LowLess than 4Risk of Reaction High Fasting or Before Meals One or Two Hours after a Meal

18. 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.

19. 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.

20. 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

21. 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

22. 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

23. 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?

24. Other Nutrients of Importance? Which other nutrients in foods will decrease the glucose surge when eaten with CHO foods? –Protein –Fat –Fiber

25. 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?

26. 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?

27. 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.

28. 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.

29. 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

30. 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

31. 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.

32. 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).