1. Canadian Diabetes Association Clinical Practice Guidelines Nutrition Therapy Chapter 11 Paula D. Dworatzek, Kathryn Arcudi, Réjeanne Gougeon, Nadira Husein, John L. Sievenpiper, Sandi Williams

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Nutrition Checklist REFER for nutrition counseling by a registered dietitian FOLLOW Eating Well with Canadas Food Guide INDIVIDUALIZE dietary advice based on preferences and treatment goals CHOOSE low glycemic index carbohydrate food sources 2013

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Nutrition Checklist (continued) KNOW alternative dietary patterns for type 2 diabetes ENCOURAGE matching of insulin to carbohydrate in type 1 diabetes ENCOURAGE nutritionally balanced, calorie-reduced diet in overweight or obese patients 2013

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Encourage patients to follow Eating Well with Canadas Food Guide in order to meet their nutritional needs http://www.hc- sc.gc.ca/fn-an/food- guide- aliment/index- eng.php

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Macronutrient Distribution (% Total Energy) CarbohydratesProteinFat % of total energy 45-60%15-20% (or 1-1.5g / kg BW) 20-35% Calories per gram 449 Grams for 2000 calorie/day diet 225-30075-10044-78 BW = body weight

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Choosing Foods Using % Daily Value http://www.hc-sc.gc.ca/fn-an/label- etiquet/nutrition/cons/fact-fiche-eng.php Daily Values > 15% = a lot Daily Value < 5% = a little

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association For Patients with BMI 25 kg/m 2 … Nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight Weight loss of 5-10% of initial body weight Improved insulin sensitivity, glycemic control, blood pressure control, lipid levels

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Choose low glycemic index carbohydrates www.guidelines.diabetes.ca

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Clinical assessment Lifestyle intervention by Registered Dietitian Initiate intensive lifestyle intervention or energy restriction + increased physical activity to achieve/maintain a healthy body weight Provide counselling on a diet best suited to the individual based on preferences, abilities, and treatment goals using the advantages/disadvantages listed below If not at target Figure 1 – Nutritional management of hyperglycemia in type 2 diabetes Continue lifestyle intervention and add pharmacotherapy Timely adjustments to lifestyle intervention and/or pharmacotherapy should be made to attain target A1C within 2 to 3 months for lifestyle intervention alone or 3-6 months for any combination with pharmacotherapy 2013

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association A1C = glycated hemoglobin CRP = C reactive protein TC = total cholesterol CHO = carbohydrate MUFA = monounsaturated fatty acid LDL = low-density lipoprotein BP = blood pressure TG = triglycerides FPG = fasting plasma glucose GI = gastrointestinal = <1% decrease in A1C HDL = high-density lipoprotein Properties of Macronutrients Dietary interventionsA1CAdvantagesDisadvantages Hi-CHO (low-glycemic index [GI]) HDL-C, CRP, hypoglycemia - Hi-CHO (high fibre) TC, LDL-C HDL-C, GI side effects Hi-MUFA TG - Lo-CHO TG Micronutrients, renal load Hi-protein BP, TG, preserve lean mass Micronutrients, renal load Long chain omega 3 fatty acids TG Methyl-Hg exposure, environmental impact 2013

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Properties of Dietary Patterns Dietary PatternA1CAdvantagesDisadvantages Vegetarian Diet LDL-C, HDL-C Vitamin B12 Mediterranean Diets BP, CRP, TC, HDL-C, TC:HDL-C, TG none DASH Weight, BP, CRP, LDL-C, HDL-C none Atkins diet Weight, TC, HDL-C, TC:HDL-C, TG LDL-C, micronutrients, adherence Protein Power Plan Weight Micronutrients, adherence, renal load Ornish - Weight, LDL-C:HDL-C FPG, adherence Weight Watchers - Weight, LDL-C:HDL-C FPG, adherence Zone Diet - Weight, LDL-C:HDL-C FPG, adherence Dietary Pulses TC, LDL-C GI side effects Nuts LDL-C, apo-B, apo-B:apo-A1 none Meal Replacements weight Temporary intervention 2013

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 1 and 2 1.People with diabetes should receive nutrition counseling by a registered dietitian to lower A1C levels [Grade B, Level 2, for type 2 diabetes; Grade D, Consensus, for type 1 diabetes], and reduce hospitalization rates [Grade C, Level 2] 2.Nutrition education is effective when delivered in either a small group or one-on-one setting [Grade B, Level 2]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role-playing, and group discussions [Grade B, Level 2]

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 3 and 4 3.Individuals with diabetes should be encouraged to follow Eating Well with Canadas Food Guide in order to meet their nutritional needs [Grade D, Consensus] 4.In overweight or obese people with diabetes a nutritionally balanced, calorie reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A] 2013

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 5 and 6 5.In adults with diabetes, the macronutrient distribution as a percentage of total energy can range from 45- 60% carbohydrate, 15-20% protein, and 20-35% fat to allow for individualization of nutrition therapy based on preference and treatment goals [Grade D, consensus] 6.Adults with diabetes should consume no more than 7% of total daily energy from saturated fats [Grade D, Consensus] and should limit intake of trans fatty acids to a minimum [Grade D, Consensus] 2013

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 7 and 8 7.Added sucrose or added fructose can be substituted for other carbohydrates as part of mixed meals up to a maximum of 10% of total daily energy intake, provided adequate control of BG and lipids is maintained [Grade C, Level 3] 8.People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4]

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 9 9.Dietary advice may emphasize choosing carbohydrate food sources with a low glycemic index to help optimize glycemic control [type 1 diabetes: Grade B, Level 2; type 2 diabetes: Grade B, Level 2]

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 10 10. Alternative dietary patterns may be used in people with T2DM to improve glycemic control, (including): Mediterranean-style dietary pattern [Grade B, Level 2] Vegan or vegetarian dietary pattern [Grade B, Level 2] Incorporation of dietary pulses (e.g., beans, peas, check peas, lentils) [Grade B, Level 2] Dietary Approaches to stop Hypertension (DASH) dietary pattern [Grade B, Level 2] 2013

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 11 and 12 11. An intensive lifestyle intervention program combining dietary modification and increased physical activity may be used to achieve weight loss and improvements in glycemic control, and cardiovascular risk factors [Grade A, Level 1A] 12. People with type 1 diabetes should be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2] ; or should maintain consistency in carbohydrate quantity and quality [Grade D, Level 4]

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 13 13. People using insulin or insulin secretagogues should be informed of the risk of delayed hypoglycemia resulting from alcohol consumed with or after the previous evenings meal [Grade C, Level 3] and should be advised on preventive actions such as carbohydrate intake and/or insulin dose adjustments, and increased BG monitoring [Grade D, Consensus].

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients