Overview of diabetes nutrition guidelines Application of those guidelines Introduction to and practice with some meal planning tools

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1 Slide 1 Nutrition for the Non-Dietitian The University of Georgia Cooperative Extension Service Connie Crawley, MS, RD, LD Slide 2 Today s objectives Overview of diabetes nutrition guidelines Application of those guidelines Introduction to and practice with some meal planning tools Slide 3 Nutrition Goals Blood glucose as close to normal as possible Lipids profile that lowers risk for CVD Blood pressure low enough to prevent vascular disease Prevent complications Improve health Address individual nutrition needs Fit personal and cultural differences

2 Slide 4 Incorporates Nutrition Recommendations from - American Heart Association USDA National Cholesterol Education Program Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure Slide 5 What are the Recommendations for Carbohydrate? Slide 6 Strong Evidence for Carb Use Total carbohydrate more important than type Adjust pre-meal insulin to carbohydrate content of meal Include whole grains, fruits and vegetables and low fat milk

3 Slide 7 Does the Type of Carbohydrate Matter? Various carbohydrates have slightly different effects on blood glucose processing, cooking, fiber, mixed meals with with fat or protein affect glucose response Slide 8 New Dietary Guidelines At least half of grains should be whole more is even better! 7-9 servings of vegetables and fruits per day 2 cups per day fruit 2.5 cups of vegetables per day The darker, the brighter the better! 3 cups of reduced fat or non-fat dairy foods Slide 9 Variety in vegetables each week! 3 cups dark green 2 cups orange 3 cups legumes 3 cups starchy 6.5 cups other

4 Slide 10 Sample Pattern for the Day Breakfast 1 fruit Lunch 2 vegetables and 1 fruit 1 starchy and 1 non-starchy Supper 2 vegetables and 1 fruit 1 starchy and 1 non-starchy Snacks 1-2 fruits and 1-2 vegetables Slide 11 Some Evidence Eat consistent amounts of carbohydrate if on fixed insulin dose Low glycemic foods may reduce post parandial blood glucose Fiber needs are the same as those without diabetes Percent carbohydrate depends on assessment Slide 12 What is Glycemic Index? Effect on blood glucose of 50 grams of carbohydrate from a specific food in comparison to the same amount of carbohydrate from glucose or white bread

5 Slide 13 Not all 50 grams are alike 5 Cups 1 Sandwich Slide 14 What is Glycemic Load? Amount of available carbohydrate in specific X glycemic index food in grams Divided by 100 Slide 15 Glycemic Index or Load? No evidence that long term glycemic control benefits (A1c), but may affect blood glucose right after a meal Glycemic load may be more helpful May have more effect on triglycerides and HDL levels prevention of diabetes

6 Slide 16 Things to consider about Glycemic Index or Load Complex method of meal planning More helpful - client develops own index based on after meal monitoring May have limited value in mixed meal Slide 17 Healthy Low Glycemic Foods are High Fiber Foods Goal grams of fiber per day Do that and you will Lower glycemic index or load Increase satiety Help with weight loss Improve overall quality of nutrients consumed Reduce constipation Improve lipids Slide 18 Expert consensus Amount of calories from carbohydrate and monounsaturated fats should total 60-70% Distribution depends on weight control needs and metabolic profile Blood glucose levels after meals Lipids

7 Slide 19 When carbs need to be cut or replaced with monos BG 2 hrs. after meals- 180 mg/dl (ADA) 140 g/dl (Endocrinologists) Tg over 150 HDL Under 40 for men Under 50 for women Slide 20 Strong Evidence for the Use of Sweeteners Sugar has no greater impact on BG than equal amount of starch Substitute sucrose for other carbohydrate or add glucose lowering medicine to cover addition Slide 21 Amounts matter 1 frosted brownie = 2 slices bread 1 cup ice-cream = 1 cup cereal (30 grams carbohydrate)

8 Slide 22 Use of Sugar in the Meal Plan Can be used in moderation share desserts in restaurants ask for child-sized portions of ice-cream keep large portions of sweets out of the house Substitute for other carbohydrate in the same meal Check actual effect on blood glucose Slide 23 Some Evidence Fructose has less effect on BG than sucrose or starch Large amounts of added fructose may hurt lipids Sugar alcohols are safe but can cause diarrhea Slide 24 Expert Consensus Eat sucrose in context of healthy diet consider the added fat and calories No reason to avoid natural fructose sources Unlikely current level of sugar alcohols intake will really affect calorie or carbohydrate intake

9 Slide 25 What are the Protein Recommendations? Slide 26 Evidence Recommendations for Protein Strong evidence Protein will not raise BG in well-controlled Type 2 Some evidence No reason to lower protein if normal renal function If hyperglycemic, may need more protein but not more than average person consumes Protein doesn t slow carbohydrate absorption Slide 27 Some evidence Higher carbohydrate diets may improve insulin uptake by cells Both low and high carb diets have similar effect on weight loss over the long term Weight registry information maintenance with higher carb, low fat diets

10 Slide 28 Protein Recommendations Expert Consensus Limited evidence Long term safety of It may be wise to low carbohydrate/high avoid protein intakes protein diet unknown over 20% Low carbohydrate/high protein diet does have short term positive effect on BG but long term effects on weight control and lipids uncertain Slide 29 Keep protein portions small 3 ounces or less per serving Lean More fish and skinless poultry More beans, if count starch content as well 3 ounces Slide 30 What are the Fat Recommendations?

11 Slide 31 Strong Evidence <300 of dietary cholesterol per day (<200 if high risk) Fat replacers are safe Saturated fat only 7-10% of calories depending on dyslipidemia To lose weight, cut saturated fat calories To maintain weight, replace saturated fat with carbohydrate or monounsaturated fat Slide 32 Some Evidence PUFA - 10% of calories If maintaining weight, use monounsaturated fat instead of carbohydrate to lower Tg and BG Plant sterols and stanols can lower cholesterol (Benecol/Take Control) Long term, low fat meals help weight control and lipids Slide 33 Expert Consensus Individualize fat intake based on ethnic/cultural background Fat replacers may help lower calories 2 servings of fish per week may help increase omega-3 fatty acids

12 Slide 34 Trans fats Unsaturated oils with hydrogen added to them to make more solid and stable at room temp Hydrogenated and partially hydrogenated oils On label in 2006 Slide 35 How to do this? More Fish, skinless poultry and lean meat Non-fat and reduced fat dairy Liquid oils, soft margarines Legumes and nuts Plant-based meals Less Fatty meat, poultry with skin Fried food Whole fat dairy foods Butter, stick margarine, fat back, bacon Shortening Baked goods Slide 36 If LDL cholesterol is more than 25 mg/dl above desire level- Probably will need to take lipid lowering medicine Saturated fat and trans fats will not lower enough alone

13 Slide 37 What are the Recommendations for Weight Control? Slide 38 Strong Evidence Weight loss of 5-10% can control short term BG (esp. when pancreas still working) A structured weight loss and lifestyle change program is needed for long term weight loss Behavior modification helps Slide 39 Weight Registry Results Successful losers of at least 30 pounds for at least 1 year Average caloric intake 1400 calories Average amount of activity minutes per day Average fat intake 24% of calories Stick to lifestyle 7 days a week

14 Slide 40 Some Evidence Weight loss drugs have modest benefit Use only if BMI over 27 Slide 41 Drugs for Long Term Use Appetite Surpressants Silbutramine Symlin (Type 1) Byetta (Type 2) Fat Malabsorption Orlistat Slide 42 Limited Evidence Gastric by-pass may benefit those with BMI over 35

15 Slide 43 What About Sodium? Slide 44 The Facts 1/3 or less of the sodium we eat is added at the table most in processed foods Most people get over 4,000 mg per day IOM recommendation 1500 mg/day Dietary Guidelines - < 2300 mg/day Slide 45 Sodium effect over time Nations with high intakes have gradual rise in blood pressure as people get older Restriction has more positive effects on the older person

16 Slide 46 It usually takes 21 days to adjust to low sodium intake To do it Eat more vegetables and fruits fresh, frozen or canned without salt Eat out less Make most food from scratch Skip Cured meats Frozen entrees Foods with sauces Most canned and boxed foods Processed snack foods Slide 47 Look at the %DV Choose most foods that have a percent daily value of 5% or less or 140 mg. or less If food higher, balance out with lower sodium foods % Daily Value Sodium 140 mg 5 % Slide 48 Follow DASH Diet 8-10 Fruits and Vegetables Whole grains 2-3 Dairy foods 3-6 oz. seafood, skinless poultry or lean meat Beans, nuts, seeds Oils

17 Slide 49 Anti-hypertensive drugs work better with sodium restriction Drop in BP causes kidneys to retain sodium so BP will not go down too much Restricted sodium causes less fluid and salt to be retained by kidneys so BP goes down better Slide 50 Effect of sodium restriction Almost as effective as taking one antihypertensive drug Some doctors find that half their patient can control BP without drugs Slide 51 What are the Recommendations for Supplements?

18 Slide 52 Some Evidence for Supplement Recommendations No clear evidence showing benefits except folate for pregnancy and calcium for osteoporosis prevention If deficiency found, supplements may help There is questionable safety and efficacy for antioxidant supplements Slide 53 Expert Consensus on Supplements Certain populations may benefit from multivitamin mineral supplement Elderly Pregnant and lactating Strict vegans Those on calorie restricted diets No long term benefits from herbal supplements Slide 54 What are the Recommendations for Alcohol?

19 Slide 55 Strong Evidence For most people, 1-2 drinks per day OK Any type of alcohol has a similar effect Consume with food to prevent low BG if on insulin or insulin secretalogues Light to moderate amounts no BP effect None during pregnancy, pancreatitis, high TG, or if alcohol abuse or severe neuropathy Slide 56 Alcohol Recommendations Some Evidence Moderate amounts may reduce risk for diabetes and cardiovascular disease Expert Consensus Add alcohol to meal plan don t omit food Slide 57 What equals one drink? 12 ounces of light beer 4 ounces of wine 1 ½ ounces of distilled liquor

20 Slide 58 Basic Meal Planning Options Slide 59 Pre-made Menus Month of Meals American Diabetes Association Pre-made menus The University of Georgia Extension Service 14 days of menus calories Down-home and uptown Way to begin to learn exchanges and carb counting Slide 60 Sample menus

21 Slide 61 How to decide the calories? Take desired weight and multiple by 10 if want to lose 15 if want to maintain and not that active 20 if want to maintain and are very active or want to gain Slide 62 To practice, calculate your own calories Your Desired Weight x 10 Equals or x 15 or x 20 Slide 63 Plate Method Advantages Easy to teach to group Balance, variety and proportion No measuring Great for low literacy audience, elderly, those just needing survival skills and those with low math skills Disadvantages Less accurate Doesn t handle mixed dishes well Little consideration of added fat and sugar

22 Slide 64 Basic principles Uses 9 inch plate Approximately calories Same pattern at same time each day Must know starchy vegetables Must not pile too high Slide 65 Plate Method option 1 Lunch and/or Dinner Fruit Starch Vegetable Milk Protein Food Slide 66 Plate Method option 2 Lunch and/or Supper Fruit Vegetable Starch Milk Protein Food

23 Slide 67 Breakfast Plate Method Starch Fruit Milk Protein Food Optional Slide 68 How much is enough? 1 woman s palm = ½ cup starchy vegetable ½ cup non-starchy vegetable ½ cup fruit 3 oz. meat, poultry or fish Slide 69 How much is enough? 1 fist = 1 piece fresh fruit 1 baked potato

24 Slide 70 Recommended Tool Slide 71 American Diabetes Association New Publication Eating for the Health of It 1 copy available for free at DIABETES Multiples will be available to professionals for a fee Slide 72 Now You Try the Plate Method Plan one breakfast and one lunch or supper Share with your neighbor. Check each other and make corrections.

25 Slide 73 What is Carbohydrate Counting? Counting the amount of carbohydrate eaten at meals and snacks Keeping carbohydrate intake consistent from day to day Matching insulin injections to carbohydrate intake (for some) Slide 74 Carbohydrate Counting Advantages: Easier - you only count carbohydrate Allows more flexibility in food choices Virtually any food can be worked into meal plan Disadvantages Does require some reading/ math skills Not designed for weight loss Needs to know amount per meal and in each food or drink Slide 75 Why Count Carbohydrate?

26 Slide 76 Which Contain Carbohydrate? Taco Brussels sprouts Sugar-free jello Skim milk Fat-free frozen yogurt Baked chicken Rice Orange juice Diet soda Oreos Slide 77 Amount of Carbohydrate is More Important Than the Type 1 frosted brownie = 2 slices bread 1 cup ice-cream = 1 cup cereal (30 grams carbohydrate) Slide 78 2 Ways to Count Carbohydrate Choices Food Exchanges or Servings Carbohydrate Grams Specific number of grams of carbohydrate per meal or snack

27 Slide 79 Carbohydrate Choices Each food in fruit, starch, milk group contains about 15 grams carbohydrate One carbohydrate choice = 15 grams carbohydrate Slide 80 How Much Carbohydrate Needed? Depends on : calorie needs height weight physical activity level of fat in blood (triglycerides) usual food habits and schedule In general Women need 3-4 carb choice per meal or about grams of carbs per meal Men need 4-5 carb choices per meal or grams of carb Snacks are 1-2 carb choices (30-45 grams) Slide 81 Each Carbohydrate Choice = 15 grams Carbohydrate Example: Breakfast: 3 carb choices = 45 grams Lunch: 2 carb choices = 30 grams Snack: 1 carb choice = 15 grams Dinner: 3 carb choices = 45 grams Evening Snack: 1 carb choice = 15 grams

28 Slide 82 Carbohydrate Needs (Example) 1500 Calories: 188 grams/day 3 carb choices at breakfast 4 carb choices at lunch 4 carb choices at dinner 1 carb choice at bedtime Slide 83 Nutrition Facts Label Best resource for carbohydrate counting Pay attention to: Serving Size Total Carbohydrate Slide 84 Nutrition Facts Serving Size 1 cup (228 g) Servings per Container 8 Calories 170 Calories from fat 18 Total Fat 2 g Saturated Fat 0 g Cholesterol 0 g Sodium 330 mg Total Carbohydrate 32 g Dietary Fiber 8 g Sugars 5 g Protein 6 g Vit A 35% Vit C 4% Calcium 10% Iron 20%

29 Slide 85 Example Using Label Your meal plan: 2 carb choices (30 grams carb) Food label (ice-cream): Serving size = 1/2 cup Total carbohydrate = 15 grams How much ice-cream should you have? Slide 86 Another label example If your meal plan at breakfast is: 45 grams carbohydrate Food label: Cereal Milk Serving size: 1/2 cup 1 cup Total Carb: 15 grams 12 grams How much cereal and milk should you have? Slide 87 Carbohydrate Counting Books Use for foods without a Nutrition Facts Label Fresh fruits Fresh vegetables Breads from a bakery or farmer s market Restaurant foods

30 Slide 88 Measuring and Weighing Foods Can t accurately count carbohydrate without weighing and measuring Weigh at least once a week Practice essential. Slide 89 What to Weigh and Measure Weigh: Bread, rolls, bagels, some fruits, baked potatoes Measure: mashed potatoes, popcorn, pasta, rice, vegetables, fruit juice Slide 90 Restaurant Dining Dining Out in Restaurants Use books on restaurant eating or company web sites Estimate carbohydrate content Check blood glucose 2 hours after meal Take-out - Measure food at home to determine carbohydrate content

31 Slide 91 Fast Food Restaurants Subway Carb Exchanges Classic Italian 43 g 2 1/2 starch 2 meat,1 veg, 1 fat Tuna g 2 1/2 starch 1 meat, 1 veg 5 fat Slide 92 Fiber and Carbohydrate Counting If a food or a meal contains over 5 grams of fiber, that amount can be subtracted from the total amount of carbs. Example 1 cup of cereal has 30 grams total carb and 10 grams of dietary fiber - really only 20 grams of carbs to affect blood glucose. Slide 93 Now You Try Carb Counting Using the McDonald s Nutrition Information, choose a breakfast and lunch that contains 60 g. of carbohydrate Plus or minus 5 grams Share with neighbor on left and correct each other if needed

32 Slide 94 Recommended Tools Ready, Set, Start Counting Carbohydrate Counting: Focus on Consistency Slide 95 Low Literacy Tools Slide 96 Low Literacy Series from UGA/ Medical College of Georgia

33 Slide 97 Clearly Medical Nutrition Therapy Needed The University of Georgia and Ft. Valley State University, the U.S. Department of Agriculture and counties of the state cooperating. The University of Georgia Cooperative Extension and the Colleges of Agricultural and Environmental Sciences & Family and Consumer Sciences offer educational programs, assistance and materials to all people without regard to race, color, national origin, age, sex or disability. An Equal Opportunity Employer/Affirmative Action Organization Committed to a Diverse Work Force Bulletin # FDN-SE Date August 2005 Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, The University of Georgia Colleges of Agricultural and Environmental Sciences and Family and Consumer Sciences and the U.S. Department of Agriculture cooperating. Dr. Scott Angle, Dean and Director

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