Aims of Dietary Management. Dietary Management of Diabetes. Aims of Dietary Management. Optimal Nutritional Status. Near Normal Blood Glucose Levels

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1 Aims of Dietary Management Dietary Management of Diabetes Deborah Foote Senior Dietitian Diabetes Centre Royal Prince Alfred Hospital Optimal nutritional status Near normal blood glucose levels Optimal blood lipid levels Normal blood pressure Aims of Dietary Management Reasonable body weight Reduce acute symptoms and complications Reduce risk of long term complications Optimal psychological well-being Optimal Nutritional Status Wide variety of foods No foods forbidden Intake of all nutrients necessary to maintain optimal health Consider stage of life ie childhood, adolescence, pregnancy etc Near Normal Blood Glucose Levels Diabetes Control and Complications Trial (DCCT) near normoglycaemia slows onset and progression of microvascular and neuropathic complications in type 1 Aim for HbA1c <7% Intensive management required Near Normal Blood Glucose Control United Kingdom Prospective Diabetes Study (UKPDS) First evidence that better blood glucose control improves outcome in Type 2 1% reduction in HbA1c reduces risk of complications by 35% 1

2 Optimal Blood Lipid Levels Normal Blood Pressure Diabetes is a strong independent risk factor for heart disease Treat raised lipid levels aggressively Goals Total cholesterol < 4.0mmol/L LDL cholesterol < 2.5mmol/L HDL cholesterol > 1.0mmol/L Triglycerides < 2.0mmol/L UKPDS showed strict management of blood pressure reduced risk of microvascular complications Goal BP < 130/80 < 125/75 (high risk) May need 3-4 anti-hypertensive agents Appropriate Energy Intake Prevention of Complications Adequate energy for maintaining or achieving reasonable body weight - may not be ideal weight Maintain normal growth and development in children and adolescents Adequate energy intake for increased needs in pregnancy and lactation, and catabolic illness Reduce acute symptoms Polyuria Polydipsia Lethargy and fatigue Weight loss Avoid and treat acute complications of hypoglycaemia, hyperglycaemia, ketoacidosis Prevention of Complications Psychological Well-being Reduce risk of long term complications Macrovascular coronary heart disease cerebrovascular disease peripheral vascular dis Microvascular retinopathy nephropathy neuropathy Optimise overall health and psychological well-being Individualise nutrition care Specific treatment goals Desired outcomes Teach self management skills 2

3 ADA & EASD Recommendations Protein Individualised diet comprising 10-20% energy as protein <7% energy as saturated fat <10% energy as poly-unsaturated fat 60-70% energy divided between carbohydrate and mono-unsaturated fat As for the general population 10-20% of energy 0.75g/kg/day when overt nephropathy Debate over usefulness of reducing to 0.6g/kg/day when GFR begins to fall Fat Fat vs Carbohydrate <7% energy as saturated fat <10% energy as poly-unsaturated fat Encourage mono-unsaturated fats as primary type Omega 3 poly-unsaturated fats not to be limited 60-70% total energy to be divided between mono-unsaturated fat and carbohydrate Higher carbohydrate improves glucose tolerance but raises triglycerides <30% total fat for weight reduction Higher mono-unsaturated fat if triglycerides and VLDL chol raised Carbohydrate All types of sugars and starches can be included in meal plan for diabetes Lower glycaemic index foods preferred but high GI not banned Quantities have greatest effect on blood glucose response Should be distributed (evenly) over day Sodium High priority to treat hypertension Individuals have variable sensitivity to sodium intake re blood pressure Recommend intake as for general population ie < 2300mg Reduce to < 2000mg if hypertensive, on ACE inhibitor or have nephropathy 3

4 Fibre Aim for 25-35g soluble and insoluble fibre per day Most Australians would need to increase fibre intake choose more wholegrain foods Artificial Sweeteners Non-nutritive sweeteners do not raise blood glucose levels and may be used Saccharin, cyclamate, aspartame, sucralose, acesulphame Artificial Sweeteners Alcohol Nutritive sweeteners contribute energy to diet and raise blood glucose levels Sucrose, fructose (include as part of cabohydrate intake) Sorbitol, mannitol, xylitol (sugar alcohols) are allowed but not encouraged Limit to 1-2 standard drinks per day and 2 days per week alcohol free Liver cannot metabolise alcohol and perform gluconeogenesis at same time Caution re hypos when drinking always eat carbohydrate at same time as drinking alcohol avoid alcohol straight after exercise Diabetes Nutrition Assessment To develop an individualised nutrition care plan you need a comprehensive assessment Type of diabetes Type 1 Type 2 GDM Secondary to other condition or medication Diabetes Nutrition Assessment Medication for diabetes Tablets - type and doses Insulin - type, timing and doses Prescribed vs taking Other medical conditions and treatment Hypertension Coronary heart disease Vascular disease 4

5 Anthropometry Diabetes Nutrition Assessment Height, weight, waist, hip measurements Weight history Recent changes Deliberate or unplanned weight loss Maximum and minimum adult weights Desired weight vs ideal weight Complications of diabetes Diabetes Nutrition Assessment Biochemical parameters Blood glucose levels When testing, how often HbA1c or fructosamine Cholesterol total, LDL, HDL Triglycerides Microalbuminuria, proteinuria LFTs, TFTs Diabetes Nutrition Assessment Physical activity Type of work (sedentary or physical) Sports played or regular exercise Timing and duration of exercise Intensity of exercise Any adjustments made to routine when exercising Food history Diabetes Nutrition Assessment Types and amounts of carbohydrate Types and amounts of fat Timing of meals and snacks Regularity day to day, variations on weekends Recent changes since diagnosis Diabetes Nutrition Assessment Nutrition knowledge and attitudes Previous dietary education/knowledge Previous diets tried Attitudes to food and diets Readiness for change Develop Individualised Nutrition Plan Prioritise goals considering Existing medical conditions Medications Glycaemic control Lipids Blood pressure Meal plan to fit usual activities and routine Work, school, sport 5

6 Select Meal Planning Approach Healthy food choices Food pyramid or plate model Semi-quantitative Simple, easy to teach Select Meal Planing Approach Full exchange system Total energy controlled Protein, fat, carbohydrate all measured Complicated, demanding Select Meal Planning Approach Carbohydrate counting use carbohydrate exchanges, serving food = 15g carb Count grams carbohydrate All carbohydrate foods considered interchangeable but not equal Protein and fat not measured as do not raise blood glucose significantly Select Meal Planning Approach Fat gram counting Main emphasis on weight reduction Carbohydrate not controlled Glycaemic index Incorporate into any approach Not a stand alone educational tool Glycaemic Index Glycaemic index Ranking of CHO foods according to how much they raise blood glucose relative to standard dose of glucose simple sugars not high GI complex CHO not all low GI Foods with a low GI raise the blood glucose more slowly and not so high encourage more low GI foods be chosen wherever possible a low GI meal improves glucose tolerance at the next meal 6

7 Low GI foods Intermediate GI Foods legumes eg lentils, dried or canned beans, chick peas oats barley milk fruit from temperate climate eg stone fruit, citrus, apples, pears Pasta and noodles tropical fruits eg watermelon, pineapple, mango, banana Basmati and Doongara rice sweet potato, corn, taro, cassava multigrain, unleavened, sourdough breads High GI Foods Glucose powder, tablets or sports drinks rice, Rice Bubbles, rice cakes white or smooth wholemeal bread potato Using the GI in Diabetes Encourage culturally appropriate low GI foods lentils, white beans for Italians and Greeks baked beans, split pea soup, multigrain breads and cereals for anglo-australians cassava, taro, yam for Pacific islanders Basmati rice for Indians non-tropical fruit for all groups most biscuits and crackers Using GI in Diabetic Diets Allow a full range of CHO foods promote low GI by preference Combine foods with low and high GI in same meal Use high GI foods to treat hypos Type 2 Diabetes 80-90% diabetes Majority are over weight or obese Frequently have existing hypertension and/or dyslipidaemia Many are very inactive 7

8 Type 2 Diabetes Lifestyle should be modified to treat diabetes increase exercise adapt diet Nutrition Therapy for Type 2 Negotiate individual goals for blood glucose Blood lipids Blood pressure Modest weight loss (5-10kg) improves all if overweight Large weight loss is not primary goal Nutrition Therapy for Type 2 Even spread of carbohydrate over day Small meals and regular snacks Reduce saturated fat intake Increase physical activity Improves insulin sensitivity Reduces blood pressure Improves lipid profile Carbohydrate for type 2 Individually determine, 45-60% energy Many patients have very high CHO intake Not necessary to teach exchanges but suggest approx 3-4 exchanges per meal If having snacks must reduce size of meals Fat for type 2 Reduce saturated fat Trim visible fat from meat Use low fat dairy products Avoid fried takeaway and restaurant foods Use monounsaturated fats Olive oil, canola margarine, avocado, nuts Limit quantities for weight control Omega 3 polyunsaturates Fish twice weekly Managing Hypertension Reduce sodium intake to 2300mg/day Gradually cut down salt at table, salt in cooking Avoid high salt condiments, seasonings, restaurant foods Increase fruit and vegetable intake Ensure adequate calcium intake Limit alcohol 8

9 Atkins Diet Scientific Evidence A Low-Carbohydrate as Compared to Low-Fat Diet in Severe Obesity Frederick Samaha, et al N Engl J Med, 348: p month study, 132 subjects 39% subjects Type 2 DM 43% metabolic syndrome Mean weight = 130kg, BMI = 43 Atkins Diet - Scientific Evidence Drop out rate higher in low fat group at 3 months but not 6 months Atkins group greater weight loss (6 vs 2kg) Decreased TG Improvement in glycaemic control Caution Small magnitude of overall weight loss Low dietary adherence Short term Increased risk of hypoglycaemia Zone Diet - Scientific Evidence Effect of a High-Protein, High-Monounsaturated Fat Weight Loss Diet on Glycaemic Control and Lipid Levels in Type 2 Diabetes B.Parker et al, Diabetes Care,25, 2002, p High protein vs Low protein (28%-42%-28%) vs (16%-55%-26%) 8 weeks energy deficit (1600cal) + 4 weeks energy balance Both groups reduced weight, fasting glucose and insulin Women on HP lost more total and abdominal fat Protein Fat CHO 1500 Calorie Diet Conventional Diet 75 g 50 g 187 g Atkins Diet >140g >95 g <20 g Zone Diet 112 g 50 g 150 g Cabbage Soup 0-70 g 0-30 g g Consider Weight Reduction pharmacological agents eg orlistat, sibutramine psychological intervention/behaviour modification Bariatric surgery Losing Weight vs Maintaining Weight Loss Any type of diet with an energy deficit can achieve weight loss Successful weight losers mostly Follow a low fat (<25% energy as fat), high carbohydrate diet Pay attention to total calories Weigh themselves frequently Rarely skip breakfast Do 60 minutes per day moderate intensity exercise! 9

10 Type 1 Diabetes 10-15% all diabetes Condition of insulin deficiency 90% auto-immune Occurs in all age groups Diagnosis peaks 3-4 and years children 50% diagnosed as adults May be healthy weight or under or overweight Type 1 Diabetes Treatment should be adapted to fit the individual s lifestyle determine appropriate food pattern adjust insulin regimen to suit food and activity Aim for maximum flexibility in lifestyle Some are very active eg physical work or regular sport / training The Problems We Face Conventional bd insulin 1. Time action profiles of conventional insulins do not closely approximate normal physiological insulin secretion Onset Peak Duration Short acting 30 mins 2-4 hrs 6-8 hrs Intermediate acting 1-2 hr 4-12 hrs hrs Conventional basal bolus insulin Basal bolus regimen using rapid acting insulin analogues Onset Peak Duration mins 1-3 hrs 3-5 hrs 10

11 Addressing the gap - using bd intermediate acting insulin Addressing the gap - using tds intermediate acting insulin 8 am 1 pm 8.30 pm The Problems We Face 2. Human nature / People s busy lives The Problems We Face 3. Inter- and intra-person variability Factors Influencing Variability The Ideal Basal Insulin Sites Weather Hot shower/bath Lipohypertrophy Depth of injection Amount and type of insulin used Mimics normal pancreatic basal insulin secretion Smooth, peakless profile Long lasting effect Once daily administration Reproducible and predictable effects Reduced risk of hypoglycaemia, particularly nocturnal Mixable with other insulin and analogues 11

12 The Ideal Bolus Insulin The best solution yet - combining the insulin analogues Rapid onset Can be taken before/during or immediately after meal Onset Peak Duration mins 1-3 hrs 3-5 hrs mins 1-3 hrs 24 hrs Peak at 30 minutes Duration of less than 4 hours Reproducible and predictable effects 8 am 1 pm 8.30 pm Mixable with other insulin and analogues Basal Bolus Regimen: A Step Closer To Good Control Pros Improved psychological adjustment Early good control reaps long term benefits Decreased hypoglycaemia at same level of control Flexibility Weight management Cons More injections Potential weight gain Makes diabetes more 24/7 The Opposition: Insulin Pumps Pros More physiological insulin profile Decreased hypoglycaemia Flexibility Weight management Less needles Cons More blood glucose monitoring Wearing the pump Cost Makes diabetes 24/7 Only suitable for small section of T1 Nutrition Therapy for Type 1 Overall healthy diet appropriate for stage of life First priority optimal glycaemic control Secondary considerations Lipids Weight management hypertension Taking A History Check when last had dietary education Blood glucose monitoring How often, when, is it recorded Insulin types and doses Adjustments to insulin or food Exercise Alcohol (especially binges) 12

13 Nutrition Therapy for Type 1 Carbohydrate Counting Determine appropriate energy intake Usual food intake Activity pattern Achieve appropriate weight (often regain) Balance food, insulin and activity Regular food intake to match fixed insulin profile Variable carbohydrate intake and adjust insulin doses (intensive management) Basic use either carbohydrate exchanges or count grams keep to regular intake day to day health professional makes all insulin adjustments Insulin doses fixed day to day Blood Glucose Monitoring Patient to test before and 2 hours after meals Occasional test overnight Before meal BG levels reflect effect of long acting insulin 2 hrs after meal BG assesses effect of rapid acting insulin Making insulin adjustments If BG levels before meals are not target then adjust long acting insulin If BG levels after meals are higher than before then increase rapid acting insulin If BG levels after meals are lower than before then reduce rapid acting insulin Carbohydrate Counting Moving on keep to regular carbohydrate intake day to day Patient is taught to recognise patterns in blood glucose response and make own adjustments to insulin doses maintain same doses until a change is needed then keep to new dose Moving On Give feedback on blood glucose levels Ensure actually counting carbohydrate accurately Teach trouble shooting skills What causes hypos What causes hyperglycaemia Effects of exercise Knowledge of personal insulin action profile Use Blood Glucose Awareness Training (BGAT) 13

14 Carbohydrate Counting Determine rapid acting insulin : carb ratio units per exchange or grams carbohydrate Allow variation in carbohydrate intake day to day Adjust insulin doses on meal by meal basis keeping to same ratio Can add small correction dose Advanced Carb Counting For patients who are highly motivated with good trouble shooting skills Requires ongoing frequent monitoring, preferably paired testing Gives maximum flexibility of lifestyle Possible to achieve best degree of control of blood glucose Carb Counting Most patients make reactive insulin dose adjustments Advanced carb counting is pro-active Aim to avoid frequent additional doses rapid acting insulin to reduce high BG Teach patients that avoiding hypoglycaemia often reduces hyperglycaemia Practicalities Time consuming to do intensive management initial assessment at least 1.5 hours patient to keep detailed records follow-up appts 1 hour phone calls to discuss results 1/2 hour Patient needs to make a commitment Nutrition Therapy for Type 1 Review at each change of lifestyle Changing school to uni or work Moving out of home Starting new sport or exercise program Getting married or divorced Re-educate if control poor, having hypos Follow - up Advise when something more than dietary manipulation is necessary Minimise weight gain or promote weight loss/maintenance Act as a resource person for patients, families, health professionals 14

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