Slides current until 2008 Nutritional needs of people with type 1 diabetes and type 2 diabetes.

Slides current until 2008

Nutritional needs of people with type 1 diabetes and type 2 diabetes

Nutrition in diabetesCurriculum Module III-5

Slide 2 of 59ACTIVITY


Identify factors that need to be

considered before developing an

individual dietary plan.


Slide 3 of 59


Diabetes nutrition therapy

Aims to help people with diabetes attain a quality of life and life expectancy similar to that of the general population. This is achieved through reducing diabetes complications.


Slide 4 of 59


Behaviours which contribute positively to improved glycaemic control:• Adherence to meal plan• Consistent snacking behaviour• Adjusted food and insulin when hyperglycaemia detected• Appropriate treatment of hypoglycaemia

Type 1 diabetes – Diabetes Control and Complications Trial

DCCT Research Group, 1993Delahanty and Halford, 1993


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Type 2 diabetes - United Kingdom Prospective Diabetes Study

Trial outcome:

Tight control of blood glucose and blood pressure in people with type 2 diabetes reduces the risk of long-term micro- and macrovascular complications.

UKPDS 1998


Slide 6 of 59


Type 2 Diabetes – Diabetes Prevention Program

Trial outcome:

Lifestyle changes such as weight loss and moderate daily exercise reduced the risk of developing type 2 diabetes by 58% (over 3 years) in people with impaired glucose tolerance.

DPP 1999


Slide 7 of 59


Dietary approaches to stop hypertension (DASH)

First trial:

• DASH diet significantly lowered blood pressure

Second trial:

• DASH diet lowered blood pressure at high, intermediate and low levels of sodium

Sacks 1997, 2001


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Dietary advice to control blood pressure

DASH diet:

• High in fruit and vegetables

• Low-fat dairy products

• Nuts

• Fish/chicken in preference to red meat

• Small amounts of red meat

Sacks 1997, 2001


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Aims of diet therapy

Attain and maintain metabolic outcomes through:

• Good blood glucose levels

• Optimum lipid profile

• Controlled blood pressure levels

• Optimum body weight


Slide 10 of 59


Aims of diet therapy

• To prevent and treat obesity, dyslipidaemia, cardiovascular disease, hypertension and nephropathy through modification of diet and lifestyle

• To consider the person’s nutritional needs while taking into account personal and cultural preferences and lifestyle issues

• Respect the individual’s rights, decisions and willingness to change

• Optimize quality of life


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Person-centred approach to diet therapy

• Education/advice needs to be individualized and holistic

• Individual assessment of the person with diabetes is vital

• Diabetes is a progressive condition requiring regular review


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Achieving optimum glycaemic control in type 1 diabetes

• Insulin action profiles selected to suit the person’s meal pattern with particular attention to CHO intake and distribution

• High intake of soluble fibre preferred

• Education for healthy food choices should be given

• Low glycaemic index should be encouraged


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Insulin action profiles

Rapid-acting analogue insulin

Onset: <0.5 hr Peak: 1 hr Duration: 3-4 hr

Soluble insulin

Onset: 1/2 hr Peak: 1-3 hr Duration: 6-8 hr

Lente insulin

Onset: 2 1/2 hr Peak: 7-15 hr Duration: 24 hr

NPH insulin

Onset: 1 1/ 2 hr Peak: 4-12 hr Duration: 24 hr

Biphasic insulin

Onset: 1/2 hr Peak: 2-8 hr Duration: 24 hr

Biphasic analogue insulin

Onset: <0.5 hr Peak: 1-4 hr Duration: 24 hr

Long-acting analogue insulin

Onset: 2-3 hr Peak: none Duration: 24 hr


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Selecting insulin to suit the individual and meal pattern

Meal pattern Number of injections and insulin type

Two large meals Twice a day: mixture of short- and intermediate-acting before meals

Three meals: breakfast, light lunch and dinner

Twice a day: mixture of rapid-/short- and intermediate-acting before breakfast and before dinner


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Selecting insulin to suit the individual and meal pattern

Meal pattern Number of injections and insulin type

3/4 meals: breakfast, light lunch, mid-afternoon and evening meal

2-3 per day: mixture of rapid-/short- and intermediate-acting before breakfast; rapid/short for the afternoon snack and mixture of rapid-/short- and intermediate-acting before the evening meal; or long-acting analogue 1-2/day and 3-4 rapid acting

3 meals; 3 snacks 4-6: rapid-/short-acting before meals and snacks, NPH or long-acting analogue 1-2 per day


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Achieving optimal glycaemic control in type 2 diabetes

Type 2 diabetes is progressive

• Glycaemic control will deteriorate with time

• Most people will require polypharmacy including:– glucose lowering medicines– insulin– anti-hypertensive, anti-

thrombolytic and lipid-lowering drugs UKPDS 1995, Gaede 1999, Gaede 2003


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Achieving optimal glycaemic control in type 2 diabetes

• Regular carbohydrate intake essential

• Low glycaemic index

• Assessment of total energy requirements

• Healthy eating principles


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Dyslipidaemia in type 1 diabetes and type 2 diabetes

• An abnormal lipid profile

• Three out of four deaths are caused by cardiovascular disease

DCCT 1995, J Am Med Assoc 1997, Laing et al 2000, Larsen et al 2002, DCCT 2003


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Dietary influences on dyslipidaemia

• High fat intake reduces insulin sensitivity

• Saturated and trans fats increase LDL cholesterol

• Monounsaturated lower LDL cholesterol and triglycerides

• High carbohydrate intake may exaggerate the post-meal triglyceride response


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National cholesterol education programme recommendations

Energy distribution and recommendations

Total fat 25-35% of total energy

Saturated fat <7% total kcal

Polyunsaturated fat Up to 10% total kcal

Monounsaturated fat Up to 15% total kcal

Carbohydrates 50-60% total kcal

Protein Approx 15% of total energy

Total calories To achieve and maintain healthy weight

Fibre (pref soluble) 10–25 g/dayPlant stanols/sterols (2 g/day)

Cholesterol <200 mg/day National Cholesterol Education Program 2004


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Practical advice

• Decrease total fat, particularly saturated and trans fatty acids

• Increase monounsaturated fats

• Include two portions of fish in the weekly diet (omega-3 fatty acids)

• Ensure adequate sources of antioxidants - flavonoids, soluble fibre and potassium (five portions of fruit and vegetables daily)




Identify foods in the local dietthat contribute to intake of saturated, total and trans fats.

Discuss ways of modifying diet to decrease total dietary fat and improve the fatty acid profile.


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Weight management

A weight management programme includes:

• Dietary change

• Increased physical activity

• Behaviour modification

• Support and monitoring


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Benefits of weight loss

Diabetes related deaths by 30% to 40%

Risk of developing diabetes by 50%

Systolic and diastolic BP by 10 mmHg

Fasting glucose by 30% to 50% (improved insulin sensitivity)

HbA1c by 15%

Total cholesterol by 10%LDL by 15%Triglycerides by 30% HDL by 8%

Jung 1997, Goldstein 1992

10% weight loss

Decreased insulin

requirements


Slide 25 of 59


Associated weight gain with some glucose-lowering medicines

UKPDS showed:

• On metformin, weight gain of 1 kg over a 6-year period

• On sulphonylurea, weight gain of 4 kg over a 6-year period

• On insulin, weight gain of 6 kg over a 6-year period


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Assessing the patient for weight management

Assess the person’s agenda and lifestyle, particularly:

• Motivation

• Cultural issues

• Importance of weight loss

• Opportunities for increased physical activity


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Dietary modification

Practical advice• Avoid fatty foods• Do not add fat• Use low-fat cooking methods• Decrease sugary foods• Do not add sugar

Portion size• Use easy measures for

descriptions of food quantity• Negotiate acceptable portion

sizes for all foods


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Dietary recommendations

Practical evidence-based dietary recommendations

• European Association for the Study of Diabetes (1999)

• Diabetes UK (2003)

• American Diabetes Association (2004)• Canadian Diabetes Association (2004)


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Dietary recommendations

• Weight reduction for overweight/obese people

• Regular starchy meals• Low sugar diet Total fat intake by 30% Intake of fruit and vegetables Protein intake by 15% to 20% Salt to 6 g per day (1 teaspoon)• Alcohol in moderation• Diabetic products are not advised


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Education tools

Glycaemic index:

Ranks carbohydrate-rich foods according to the increase in blood glucose levels they cause in comparison with a standard food (white bread/glucose).


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Advanced education tools

• Glycaemic index and load

• Food exchanges

• Carbohydrate counting


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Glycaemic response of glucose and lentils

Blo

od

glu

cose

level

Glucose Lentils

© Reprinted with permission from Canadian Diabetes Association 2004


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• Type of sugar– glucose, fructose, galactose

• Nature of starch– amylose, amylopectin

• Starch-nutrient interactions– resistant starch

• Cooking/food processing

Factors affecting the glycaemic index


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• Processing/form of the food

– gelatinization

– particle size

– cellular structure

• Presence of other food components

– fat and protein

– dietary fibre

Factors affecting the glycaemic index

Brand Miller J 1998


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Glycaemic index of foods

Low glycaemic index foods

Intermediate glycaemic index

High glycaemic index

Lentils/dahl Rye bread Glucose

Most fruit and vegetables

Some rice (long grain)

Mashed and baked potatoes

Yogurt Bananas Processed breakfast cereal

Milk Pasta White bread

Oats Grapes White rice


Slide 36 of 59


Practical advice

• Eat more vegetables, fruit, whole grains, and low-fat milk

• One low GI food at each meal • Mix high and low GI food =

intermediate GI meal• Substitute high GI

cereals/breads/rice with low GI cereals/bread/rice

• Eat low GI snacks instead of high GI snacks (remember to choose lower fat snacks)


Slide 37 of 59


• Promotes healthy eating

• Increases fibre intake

• Helps control appetite

• Helps control blood glucose levels

• Helps lower blood lipid levels

• Assists weight loss

• Offers a more comprehensive approach for type 2 diabetes

• Reduces risk of type 2 diabetes and heart disease

Low glycaemic index diet – advantages


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• Mixed meal is a combination of the glycaemic effect of all the foods

• Does not include guidance on fat intake

• May reduce choice and flexibility

• Difficult to maintain a low glycaemic index diet for long periods

• Requires an effort to remember which foods have high or low glycaemic index

Low glycaemic index diet – disadvantages


Slide 39 of 59


Food exchanges

• Carbohydrate exchange

• Cereal and pulse exchange

• Fat/oil exchange

• Protein exchange

• Milk exchange

• Fruit exchange

• Vegetable exchange


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Food exchanges

• Similar food types placed in exchange groups

• Within groups, a single food based on weight/measure/size has the same carbohydrate or kcal value as another and can be interchanged

• In the case of cereal exchanges: 1 slice of bread can be exchanged for 1/3 cup rice

• Foods from different groups cannot be interchanged – 1 slice of bread cannot be exchanged for 1½ tsp of butter


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Carbohydrate counting – Level 1

• Assesses only CHO not protein or fat

• Goal

– carbohydrate consistency with food intake and blood levels

• Advantage

– flexible food choices

• Useful for

– all types of diabetes


Slide 42 of 59



•Goal– adjust medication/food/activities

based on blood glucose patterns from daily records

•Advantage– lifestyle flexibility

•Useful for– people taking part in diets, using

glucose-lowering medicines and insulin who can implement Level 1


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• Goal – to be able to adjust insulin dose

using a carbohydrate/insulin ratio• Advantage

– flexibility of food and insulin regimen with tight glucose control

• Useful for– people on intensive insulin therapy – people who have mastered insulin

adjustment and supplementation


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Carbohydrate exchanges

• Amount and type influences blood glucose levels

• Sucrose can be substituted for equal amounts of another carbohydrate without adverse effect

• Carbohydrate rich foods are – grains/potatoes/legumes– fruit– milk

ADA 2004


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• 1 carbohydrate exchange = 10-15 g carbohydrate

• 1 starch/cereal exchange (10-15 g)• 1 small potato/legume exchange (10-

15 g)• 1 fruit exchange (10-15 g)• 1 milk exchange (10-15 g)

Example: ½ cup pasta = 1 cup milk = 1 small banana = 1/3 cup rice


Slide 46 of 59



• Use exchange lists to count carbohydrate

– 1 carbohydrate exchange = 15 g = 1/3 cup rice

– 1 cup rice = 45 g carbohydrate

• Calculate carbohydrate amount for each meal

– count carbohydrate as above for each food item in the meal


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Carbohydrate counting

Information sources

• Prepared carbohydrate exchange lists for meal planning

• Food labels

• Nutrient reference books

• Computerized, pre-programmed food scales

• Internet websites


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Carbohydrate counting

Food diary

• Type of food

• Portion size

• Record amount of carbohydrate in each food

• Time of food intake

eg 1 cup rice (45 g carbohydrate) for lunch at 13.00 hr


Slide 49 of 59


Counting recipes

Moroccan chicken stew (serves 4) Carb (g)

2 cups chicken broth 0

¼ cup tomato paste 6

1 tsp cummin 0

1 tsp salt 0

1/8 tsp cinnamon 0

½ cup dark raisins 58

1 medium onion, finely sliced 16

1 tblsp mince garlic 4

1 can (440 g) of chick peas 108

8 chicken thighs 0

Total carbohydrate 192

Per person 48




Examine a carbohydrate exchange list

• Discuss how useful they would be in meal planning

• Are carbohydrate exchanges suitable for all people?

• What are the advantages and disadvantages of carbohydrate counting?


Slide 51 of 59


Carbohydrate counting – advantages

• Focus on nutrient with greatest impact on blood glucose

• Permits flexible food choices • Food and insulin can be adjusted

easily and accurately• Offers potential for improved blood

glucose, especially for those on insulin

• People become skilled and feel more in control

• Improves quality of life


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• Need for arithmetic agility and understanding

• Requires accurate and detailed food records

• Difficult to estimate portion sizes initially– requires weighing and

measuring• Does not consider amount of fat,

protein or type of carbohydrate

Carbohydrate counting –disadvantages


Slide 53 of 59


• Does not specify fibre content• Requires frequent blood glucose

estimations• Difficult and expensive to record blood

glucose • Depends on people being motivated• May be too complicated for some

people and detract from pleasure of eating

Carbohydrate counting – disadvantages




• Identify local carbohydrate foods (staples)

• Identify local foods that may be discouraged due to diabetes

• Discuss myths and appropriate educational strategies


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Summary

Diabetes dietary management requires:

• Individual assessment

• Regular dietetic review

• Weight management

• HbA1c control

• Lipid management

• Control of hypertension

• Tailoring medication and/or insulin around food patterns


Slide 56 of 59


Summary

The behavioural/counselling approach to diet management includes identifying barriers to change and includes:• Dietary management/food preferences and patterns• Lifestyle• Culture• Social issues• Physical activity


Slide 57 of 59


References

1. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336(16): 1117-24.

2. Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M; American Diabetes Association. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2003; 26 Suppl 1: S51-61.

3. Bailey CJ, Feher MD. Therapies for diabetes including oral agents and insulins. Sherbourne Gibbs Ltd, 2004. ISBN 1.905036.00.0

4. Brand Miller J, Foster-Powell K, Colagiuri S, Leeds A. The GI factor. Hodder 1998.

5. Franz M, Montz A, Bergenstal R, et al. Outcomes and Cost-effectiveness of Medical Nutrition Therapy for non-insulin dependent diabetes mellitus. Diabetes Spectrum 1996; 2: 122-27.

6. DCCT Research Group. Effect of intensive diabetes management on macrovascular events and risk factors in the Diabetes Control and Complications Trial. Am J Card 1995; 75(14): 894-903.

7. DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329(14): 977-86.

8. Gillespie SJ, Kulkarni KD, Daly AE. Using carbohydrate counting in diabetes clinical practice. J Am Diet Assoc 1998; 98(8): 897-905.


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References

9. Diabetes Prevention Research Group. Reduction in the evidence of type 2 diabetes with life-style intervention or metformin. N Engl J Med 2002; 346: 393-403.

10. Gaede P, Vedel P, Parving HH, Pedersen O. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet 1999; 353(9153): 617-22.

11. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348(5): 383-93.

12. Glycemic Index Explained (cited 2004 Nov 14) (23 pages) Available from URL: http://www.diabetes.ca/Files/Glycemic%20Index%20Presentation.pdf

13. Goldstein DJ. Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord 1992; 16(6): 397-415.

14. Jung RT. Obesity as a disease. British Medical Bulletin 1997; 53(2): 307-21.

15. Laing SP, Swerdlow AJ, Slater SD, Burden AC, Morris A, Waugh NR, Gatling W, Bingley PJ, Patterson CC. Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes. Diabetologia 2003; 46(6): 760-5.

16. Larsen J, Brekke M, Sandvik L, et al. Silent coronary atheromatosis in type 1 diabetic patients and its relation to long-term glycemic control. Diabetes 2002; 51(8): 2637-41.

17. Multiple Risk Factor Intervention Trial. Risk factor changes and mortality results. Multiple Risk Factor Intervention Trial Research Group. JAMA 1997; 277(7): 582-94.


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References

18. Nathan DM, Lachin J, Cleary P, et al. Diabetes Control and Complications Trial. Epidemiology of Diabetes Interventions and Complications Research Group. Intensive diabetes therapy and carotid intima-media thickness in type 1 diabetes mellitus. N Engl J Med 2003; 348(23): 2294-303.

19. Powers MA. Medical Nutrition Therapy for Diabetes, Handbook of Diabetes Medical Nutrition Therapy, Aspen Publication. 1996.

20. Sacks FM, Svetkey LP, Vollmer WM, et al. DASH-Sodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001; 344(1): 3-10.

21. UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). [erratum appears in Lancet 1999 Aug 14; 354(9178): 602]. Lancet 1998; 352: 837-53.

22. UKPDS Group. Overview of 6 years' therapy of type II diabetes: a progressive disease. U.K. Prospective Diabetes Study Group.(UKPDS 16). [erratum appears in Diabetes 1996; 12; 45(11):1655]. Diabetes 1995; 44(11): 1249-58.

23. UKPDS Group. Efficacy of atenolol and captropril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998; 317: 713-20.

Slides current until 2008 Nutritional needs of people with type 1 diabetes and type 2 diabetes.

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Transcript of Slides current until 2008 Nutritional needs of people with type 1 diabetes and type 2 diabetes.