Transcript Carbohydrate Control in Diabetes

Welcome to In-unit Seminar
on
Nutritional Management of
Diabetes Mellitus
Meera kaur, Ph.D., R.D.
May 13, 2009
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
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: <14 and <9 std. drinks for men and
women/week respectively
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
Glycemic Control in Canada
Controlled
AIC
51%
Uncontrolled
AIC
49%
One in two type-2 diabetes patients in Canada are not at
target (<7%).
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.
Risk Reduction for Diabetes By Achieving a Specific
Lifestyle Target – Diabetes Prevention Study
Goal
RRR(%)
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.
Glycemic Index
– Has been around for over 20 years.
– May help to:
Control blood glucose levels
Control cholesterol levels
Control appetite
Lower risk of getting heart disease
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.
What Affects GI?
– Size of particle
– Cooking
Spaghetti boiled 5 min
Spaghetti boiled 10-15 min
GI = 34
GI = 40
– Processing
Cornflakes
Porridge
GI = 86
GI = 49
– Fat (Lowers GI)
Potato Chips
Baked Potato
GI = 75
GI = 93
– Acidity – lower pH slows gastric emptying= lowers GI
– Mixture of meals (Protein, Fat, CHO)
Blood Glucose
Blood Glucose Levels
Glucose
Lentils
Time (2 hours)
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.
Better Yet…
Better to give direct
recommendations.
– Increase whole grains, nuts, legumes,
fruits, and non-starchy vegetables.
– Decrease white stuff, desserts, and pop.
Fiber
Insoluble
Soluble
– Improves glucose control
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.
What your plate should look
like…
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.
Fasting or Before Meals
Inadequate
More than 10
Action Required
Suboptimal
7-10
Action may be Required
Ideal
4-7
Target Goal
Too Low
Less than 4
Risk of Reaction High
One or Two Hours after a Meal
Inadequate
More than 14
Action Required
Suboptimal
11-14
Action May be
Required
Ideal
5-10
Target Goal
UKPDS: Decreased Risk of Diabetes Related
Complications Associated with a 1% Decrease in A1C
0
-10
Stroke
-20
-30
All-cause
mortality
myocardial
infarction
-12%
-14%
Any diabetes
-related
endpoint,
-21%
Cataract
extraction
Diabetes
-related
death,
-19%
-21%
Macrovascular
disease
-40
Peripheral
vascular disease
-50
-37%
-43%
Percentage increase in relative risk corresponding to a 1% risk in
HbA1C
Adapted from Stratton, IM, et al. UKPDS 35. BMJ 2000; 321:405.
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.
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
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
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
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?
Other Nutrients of Importance?
Which other nutrients in foods will
decrease the glucose surge when eaten
with CHO foods?
– Protein
– Fat
– Fiber
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?
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?
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.
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.
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
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
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.
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) .