Transcript Diabetes Care

MNT in Diabetes and Related
Disorders
key components of
diabetes management
•healthful eating pattern
•Regular physical activity
•pharmacotherapy
.
Goals of nutrition therapy

To promote and support healthful eating
patterns, emphasizing a variety of nutrient
dense foods in appropriate portion sizes
Goals of nutrition therapy
MNT Strategies in Type 2 Diabetes
Implement lifestyle changes that reduce intakes
of energy, saturated and trans fatty acids,
cholesterol, and sodium and increase physical
activity in order to improve glycemia,
dyslipidemia, blood pressure (E)
 Plasma glucose monitoring can be used to
determine whether adjustments to foods and
meals will be sufficient to achieve blood glucose
goals or if medication(s) needs to be combined
with MNT

Nutrition recommendations and interventions for diabetes. Diabetes
Care 30; S48-65, 2007
Carbohydrates in Diabetes
Dietary pattern that includes CHO from
fruits, vegetables, whole grains, legumes,
and low fat milk is encouraged for good
health (B)
 Monitoring CHO, whether by CHO
counting, exchange, or estimation remains
a key strategy in achieving glycemic
control (A)
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Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Carbohydrate and Diabetes

Sucrose-containing foods can be
substituted for other carbohydrates in the
meal plan or, if added to the meal plan,
covered with insulin or other glucoselowering medications. Care should be
taken to avoid excess energy intake. (A)
Nutrition recommendations and interventions for diabetes. Diabetes
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Carbohydrate and Diabetes

The use of glycemic index and load may
provide a modest additional benefit over
that observed when total CHO is
considered alone (B)
Nutrition recommendations and interventions for diabetes. Diabetes
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Glycemic Index

The blood glucose response of a given food
compared to an equal amount of a CHO
standard (typically glucose or white bread)
Glycemic Index
Influenced by various factors
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Starch structure
Fiber content
Cooking methods
Degree of processing
Whether it is eaten in the context of a meal
Presence or absence of fat
A given food can elicit highly variable responses
Glycemic Index and Glycemic
Load of Foods
Food
Glycemic Index Glycemic Load
Carrots
47
3
Potato baked
Sweet corn
Apple
Chocolate cake
85
60
38
38
26
11
6
20
Corn flakes
Oatmeal
Pumpkin
92
42
75
24
9
3
Sucrose
68
7
Krause’s Food & Nutrition Therapy, 12th ed., Appendix 43
Fiber and Diabetes

As for the general population, people with diabetes are
encouraged to consume a variety of fiber-containing
foods. However, evidence is lacking to recommend a
higher fiber intake for people with diabetes than for the
population as a whole. (B)

It requires very large amount of fiber (~50 grams) to have
a beneficial effect on glycemia, insulinemia, lipemia
Sweeteners and Diabetes

Sugar alcohols and nonnutritive
sweeteners are safe when consumed
within the daily intake levels established
by the Food and Drug Administration
(FDA) (A)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Nutritive Sweeteners: Fructose
Delivers 4 kcals/gram
 Has lower glycemic index than sucrose or
starch
 Large amounts may negatively affect lipids
 No advantage to substituting it for
sucrose
 Found naturally in foods such as fruits and
vegetables
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Nutritive Sweeteners: Sugar
Alcohols
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Sorbitol, mannitol, xylitol, isomalt, lactitol,
hydrogenated starch hydrolysates
Lower glycemic response, lower calorie content
than sucrose
Not water-soluble so often combined with fats
in foods; often deliver as many calories as
sucrose-sweetened foods
Unlikely to have a beneficial effect on blood
sugars
In large quantities, may cause GI distress and
diarrhea
Non-Caloric Sweeteners
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Saccharin (Sweet’N Low®)
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Aspartame (NutraSweet®)
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Acesulfame potassium,
acesulfame-K (Sweet One®)
Sucralose (SPLENDA®)
Nonnutritive Sweeteners
Include aspartame, acesulfame K, sucralose, and
saccharin
 FDA has established an acceptable daily intake
(ADI) for food additives
 Average intake of aspartame is 2 to 4 mg/kg/day,
whereas the ADI is 50 mg/kg/day
 ADI of acesulfame K is 15 mg/kg, which is the
equivalent of a 60 kg person eating 36
teaspoons of sugar daily
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Noncaloric Sweeteners:
All FDA-approved nonnutritive sweeteners can
be used by persons with
diabetes
 The carbohydrate and
calorie content of sugar
blends must be taken into
account
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Protein and Diabetes
Insufficient evidence to suggest that usual
protein intake (15-20% of energy) should
be modified (E)
 In individuals with Type 2 diabetes, ingested
protein can increase insulin response
without increasing plasma glucose
concentrations. Therefore, protein should
not be used to treat acute or prevent
nighttime hypoglycemia (A)
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Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Protein and Diabetes
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High-protein diets are not recommended as a method
for weight loss at this time. The long-term effects of
protein intake >20% of calories on diabetes
management and its complications are unknown.
Although such diets may produce short-term weight
loss and improved glycemia, it has not been established
that these benefits are maintained long term, and longterm effects on kidney function for persons with
diabetes are unknown. (E)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Dietary Fat
Saturated Fat: <7% of total calories (A)
 Cholesterol: <200 mg/day in people with
diabetes
 Minimize intake of trans-fatty acids (E)
 Two or more servings of fish per week
providing n-3 polyunsaturated fatty acids
are recommended (B)
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Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
MFA vs CHO
↑ CHO diet (>55% ) may ↑ triglycerides
and postprandial glucose compared with
↑ MFA diet
 However, ↑ CHO ↓ fat diet can produce
modest weight loss
 Metabolic profile and need for weight loss
will determine balance between CHO and
MFA
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Optimal Mix of Macronutrients
The best mix of protein, CHO and fat
varies depending on individual
circumstances
 The DRIs recommend that healthy adults
should consume 45-65% of energy from
CHO, 20-35% from fat, and 10-35% from
protein
 Total caloric intake must be appropriate
for weight management
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Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Lipid Goals in Diabetes
LDL cholesterol
 HDL cholesterol
Men
Women
 Triglycerides
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<100 mg/dl
>40 mg/dl
>50 mg/dl
<150 mg/dl
American Diabetes Assoc. Standards of Medical care for Adults with
Diabetes. Diabetes Care 30 (supplement 1) 2007. Accessed 2/13/07
Blood Pressure Goals in
Diabetes
 Patients
with diabetes should be
treated to a systolic blood pressure
<130 mmHg (C)
 Patients with diabetes should be
treated to a diastolic blood pressure
of <80 mmHg (B)
American Diabetes Assoc. Standards of Medical Care in Diabetes-2007.
Diabetes Care 30 (supplement 1) 2007. Accessed 2/14/07
Fiber and Phytoesterols
Soluble fiber: 3 grams of soluble fiber (3
servings of oatmeal) or 3 apples can
lower total cholesterol by 5 mg (2%)
 Plant stanols: 2-3 grams can lower total
and LDL-C by 9 to 20%
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Energy Balance, Overwt and
Obesity
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In overweight and obese insulin-resistant individuals,
modest weight loss has been shown to improve insulin
resistance. Thus, weight loss is recommended for all such
individuals who have or are at risk for diabetes. (A)
For weight loss, either low-carbohydrate or low-fat
calorie-restricted diets may be effective in the short term
(up to 1 year). (A)
For patients on low-carbohydrate diets, monitor lipid
profiles, renal function, and protein intake (in those with
nephropathy), and adjust hypoglycemic therapy as needed.
(E)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Energy Balance, Overwt and
Obesity
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Physical activity and behavior modification are important
components of weight loss programs and are most helpful
in maintenance of weight loss. (B)
Weight loss medications may be considered in the
treatment of overweight and obese individuals with type 2
diabetes and can help achieve a 5–10% weight loss when
combined with lifestyle modification. (B)
American Diabetes Association Nutrition Recommendations and
interventions for Diabetes, Diabetes Care 31:S61-S78, 2008
Energy Balance, Overweight, and
Obesity
Bariatric surgery may be considered for
individuals with type 2 diabetes and
BMI>35 kg/m2 and can result in marked
improvements in glycemia
 Long term benefits and risks of bariatric
surgery in individuals with pre-diabetes or
diabetes continue to be studied (B)
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Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Energy Balance and Obesity
Improved glycemic control with intensive insulin
therapy sometimes results in weight gain
 Insulin therapy should be integrated into usual
eating and exercise habits
 Overtreatment of hypoglycemia should be
avoided
 Adjustments of insulin should be made for
exercise
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Obesity and Prognosis
Obesity in diabetic persons is not
associated with mortality or
microvascular, macrovascular
complications
 Short term weight loss in subjects with
Type 2 diabetes is associated with
improvement in insulin resistance,
glycemia, serum lipids, and blood pressure
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Alcohol
In the fasting state, alcohol may cause
hypoglycemia in persons using exogenous
insulin or insulin secretagogues
 Alcohol is a source of energy, but not
converted to glucose; interferes with
gluconeogensis
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Alcohol
Drinks should be limited to 1 drink a day (women)
or 2 (men) (E)
 To reduce risk of nocturnal hypoglycemia in
individuals using insulin or insulin secretagogues,
alcohol should be consumed with food (E)
 In individuals with diabetes, moderate alcohol
consumption (when ingested alone) has no acute
effect on glucose and insulin concentrations, but
carbohydrate coingested with alcohol (as in a
mixed drink) may raise blood glucose (B)
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Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Alcohol
Occasional use of alcoholic beverages
should be considered an addition to the
regular meal plan, and no food should be
omitted
 Excessive amounts of alcohol (three or
more drinks per day) on a consistent
basis, contributes to hyperglycemia
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Alcohol
For individuals with diabetes, light to
moderate alcohol intake (one to two drinks
per day; 15-30 g alcohol) is associated with a
decreased risk of CVD
 Does not appear to be due to an increase in
HDL-C
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Micronutrients
There is no clear evidence of benefit from vitamin or
mineral supplementation in people with diabetes
(compared with the general population) who do not
have underlying deficiencies (A)
 Routine supplementation with antioxidants such as
vitamins E and C and carotene is not advised because of
lack of evidence of efficacy and concern related to long
term safety (A)
 Benefit from chromium supplementation in individuals
with diabetes or obesity has not been clearly
demonstrated and therefore can not be recommended
(E)
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Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
“Diabetes” Supplements
“Diabetes” Supplements
Gymnema sylvestre (herb)
 Vitamin E: Antioxidant - maintains a healthy heart.
 Chromium Picolinate: Necessary for proper
carbohydrate metabolism.
 Selenium: Antioxidant - Helps protect the body from
free radicals.
 Lutein: promotes eye health
 Folic Acid: Helps maintain heart health.
 Vitamin C: Antioxidant - Boosts the immune system.
 Alpha Lipoic Acid: Antioxidant - Stimulates other
antioxidants
 Vanadium
 Resveratrol
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Micronutrients
Vitamin/mineral needs of people with diabetes
who are healthy appear to be adequately met by
the RDAs.
 Those who may need supplementation include
those on extreme weight-reducing diets, strict
vegetarians, the elderly, pregnant or lactating
women, clients with malabsorption disorders,
congestive heart failure (CHF) or myocardial
infarction (MI)
 Chromium and magnesium are beneficial only if
the client is deficient.
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Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Sodium
Association between hypertension (HTN) and
both types of diabetes mellitus (DM)
 Same intake as general population is
recommended for otherwise healthy people with
DM—less than 3000 mg/day
 For people with mild HTN and diabetes—should
have less than 2400 mg/day
 For people with more serious HTN or
edematous clients with nephropathy recommend
2000 mg/day or less
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Goals of MNT for Diabetes in
Children
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Maintain normal growth and development
◦ Evaluate using growth charts every 3-6 months
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Base nutrition prescription on the nutrition
assessment
◦ Re-evaluate every 3-6 months
Meal planning approach can be based on CHO
counting for increased flexibility or other
systems
 Review blood glucose records and revise
medication regimen as necessary
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Estimating Minimum Energy
Requirements for Youth
Age
1 yr
2-11 yr
Energy Requirements
1000 kcals for first year
Add 100 kcals/yr to 1000 kcals up to 2000
kcals at age 10
Girls 12-15 2000 kcals + 50-100 kcals/yr after age 10
>15 years Calculate as for an adult
Boys 12-15 2000 kcals plus 200 kcal/yr after age 10
>15 yr
Sedentary 16 kcals/lb (30-35 kcals/kg)
Moderate activity 18 kcals/lb (40 kcals/kg)
Very physically active: 23 kcals/lb (50
kcals/kg)
MNT for Type 2 Diabetes in
Youth
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Cessation of excessive weight gain
Promotion of normal growth and development
Encourage healthy eating habits and increased
activity for the whole family
Address other health risk factors
Add Metformin if lifestyle changes are
insufficient to achieve goals
Estimating Energy Requirements
for Adults
Obese and very inactive
persons and chronic
dieters
10-12 kcals/lb or 20
kcals/kg
Persons >55 yr, active
women, sedentary men
13 kcals/lb, 25 kcals/kg
Active men, very active
women
15 kcals/lb, 30 kcals/kg
Thin or very active men
20 kcals/lb or 40 kcals/kg
Source: Franz MJ, Reader D, Monk A. Implementing group and individual medical nutrition therapy for
diabetes. Alexandria, VA, 2002, American Diabetes Association
Basic MNT Self-Management Skills
for Persons with DM
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Basic food and meal planning guidelines
Physical activity guidelines
Self-monitoring of blood glucose levels
For insulin or insulin secretagogue users, signs,
symptoms, treatment, and prevention of
hypoglycemia
For insulin or insulin secretagogue users
guidelines for managing short-term illness
Plans for follow-up and ongoing education
MNT Essential Self-Management
Skills
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Sources of CHO, pro,
fat
Understanding
nutrition labels
Modification of fat
intake
Alcohol guidelines
Use of BG
monitoring data for
problem solving
Recipes, menu ideas,
cookbooks
 Vitamin, mineral,
botanical
supplements
 Behavior modification
techniques
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MNT Essential Self-Management
Skills
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Adjustments of CHO or
insulin for exercise
Grocery shopping
guidelines
Guidelines for eating out
Snack choices
Mealtime adjustments
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Use of sugar-containing
foods and non-nutritive
sweeteners
Problem solving tips for
special occasions
Travel schedule changes
Work shifts if applicable
Nutrition Self Management for
Diabetes
Goals of MNT for Prevention and
Treatment of Diabetes
Achieve and maintain
 Blood glucose levels in the normal range, or
as close to normal as is safely possible
 A lipid and lipoprotein profile that reduces the
risk for vascular disease
 Blood pressure levels in the normal range or
as close to normal as is safely possible
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008.
Goals of MNT for Prevention and
Treatment of Diabetes
To prevent or at least slow the rate of
development of the chronic complications of
diabetes by modifying nutrient intake and
lifestyle
 To address individual nutrition needs, taking into
account personal and cultural preferences and
willingness to change
 To maintain the pleasure of eating by only
limiting food choices when indicated by
scientific evidence
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Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008.
Goals of MNT that Apply to
Specific Situations
For youth with type 1 diabetes, youth with type
2 diabetes, pregnant and lactating women, and
older adults with diabetes, to meet the
nutritional needs of these unique times in the
life cycle
 For individuals treated with insulin or insulin
secretagogues, to provide self-management
training for safe conduct of exercise, including
the prevention and treatment of hypoglycemia
and diabetes treatment during acute illness
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Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Effectiveness of MNT
Recommendations
Individuals who have pre-diabetes or diabetes
should receive individualized MNT; such therapy
is best provided by a registered dietitian familiar
with the components of diabetes MNT (B)
 Nutrition counseling should be sensitive to the
personal needs, willingness to change, and ability
to make changes of the individual with prediabetes or diabetes (E)
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Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Diabetes Assessment: Referral
Data
Age
 Diagnosis of diabetes
and other pertinent
medical history
 Medications,
including diabetes
and other pertinent
meds
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Laboratory data
(A1C, cholesterol/
lipid profile, albumin
to creatinine ratio)
 Blood pressure
 Clearance for
exercise

Diabetes Assessment Data
Diabetes history: previous diabetes education,
use of blood glucose monitoring, diabetes
problems/ concerns
 Food/nutrient history: current eating habits with
beginning modifications
 Social history: occupation, hours worked/away
from home, living situation, financial issues
 Medications/supplements: medications taken,
vitamin/mineral/supplement use, herbal
supplements
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Diabetes Assessment Data: Diet
History
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Usual caloric intake
Quality of the usual diet
Times, sizes, and contents of meals and snacks
Food idiosyncrasies
Restaurant eating
Who usually prepares meals
Eating problems/intolerances
Alcoholic beverage intake
Supplements used
Diabetes Assessment Data: Daily
Schedule
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Time of waking
Usual meal and eating times
Work schedule or school hours
Type, amount, and timing of exercise
Usual sleep habits
Basic Strategies for Type 1
Diabetes
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For individuals with type 1 diabetes, insulin therapy should be
integrated into an individual’s dietary and physical activity pattern. (E)
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Individuals using rapid-acting insulin by injection or an insulin pump
should adjust the meal and snack insulin doses based on the
carbohydrate content of the meals and snacks. (A)
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For individuals using fixed daily insulin doses, carbohydrate intake on a
day-to-day basis should be kept consistent with respect to time and
amount. (C)
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For planned exercise, insulin doses can be adjusted. For unplanned
exercise, extra carbohydrate may be needed. (E)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Basic Strategies for Type 2
Diabetes
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Encourage weight loss.
Moderate calorie restriction (250–500 kcal/day
less) is associated with improved control
independent of weight loss.
Spread nutrient intake, especially carbohydrate
(CHO) throughout the day.
Encourage physical activity.
Decrease fat intake.
Monitor BG, and add medications if needed.
Food Guide Pyramid
Use basic guide
 Use diabetesspecific guide
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National Diabetes Education Program.
http://www.ndep.nih.gov/diabetes/MealPlanner/images/mypyramid.jpg
Recommendations for Weight
Management
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Make permanent changes in eating behavior.
Eat regularly.
Slow, gradual weight loss is best.
Choose lower-fat foods.
Incorporate regular physical activity.
The Diabetes Meal Plan
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The meal plan should be based on
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the patient’s current eating habits
diabetes medications, if any
current weight status
collaborative goals (e.g., does the patient
desire to lose weight?)
Macronutrients Based On
Patient’s current eating
habits (CHO, fat, protein)
 Lipid levels and glycemic
control
 Patient goals
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Meal Plan
Estimate current energy, carbohydrate, protein,
and fat intake
 Evaluate current meal pattern and schedule
 Adjust meal plan to promote treatment goals
(energy, fat, carbohydrate distribution)
 Evaluate based on standard meal planning
standards (e.g. Food Guide Pyramid)
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Meal Plan: Patient on MNT Only
Often start with 3-4 CHO servings per meal
(includes fruits, starches, milk, sweets) for
women and 4-5 for men plus 1-2 for snack if
desired
 Evaluate feasibility of meal plan with patient
 Trial meal plan and evaluate blood glucose
records
 Adjust plan as necessary
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Examples of CHO Servings Mix
and Match
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Apple, 1 small
Fruit cocktail, ½ c
Nonfat milk, 1 c
Orange juice, ½ c
Bread, 1 slice
Oatmeal, ½ c
Pasta, 1/3 c
Potatoes, ½ c
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Brownie, 1 small
Yogurt, frozen, ½ c
Cake, frosted, 2 inch
square, (2 CHO)
Corn, ½ c
Baked beans 1/3 c
Hummus 1/3 c
Meal Plan: Oral Medications
May do well with smaller, more frequent
meals and snacks, especially if taking an
insulin secretagogue
 Snack servings should be taken from the
meal plan
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Meal Plan: Insulin
Can start with the meal plan and devise an
insulin regimen to fit
 Many patients require a bedtime snack to
prevent night-time hypoglycemia
 Patients who use morning intermediate-acting
insulin (NPH) may require afternoon snack
 Patients on rapid-acting insulin do not need a
snack
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Meal Planning: Carbohydrate
Counting
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Focuses on CHO as major driver of postprandial blood glucose
Can be used for intensive management or for
basic meal planning
May be most appropriate for Type 1 patients at
desirable weight
Must still address energy needs and
composition of overall diet
Allows increased flexibility
1 carbohydrate serving = 15 grams
Managing Acute Complications
Hypoglycemia
Low blood glucose
 Common side effect of insulin therapy
 Sometimes affects patients taking insulin
secretagogues
 Can be life-threatening
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Hypoglycemia Symptoms
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Shakiness
Sweating
Palpitations
Hunger
Slurred speech
Mental confusion, disorientation
Extreme fatigue, lethargy
Seizures and unconsciousness
Hypoglycemia Treatment
Glucose of 70 mg/dL or lower should be
treated immediately
 A level of 60 to 80 mg/dL may require
carbohydrate ingestion, deferral of exercise,
change in insulin dosage
 Treatment involves ingestion of glucose or
carbohydrate-containing food (glucose
preferred)
 Protein does not help with treatment or prevent
recurrence of hypoglycemia
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Hypoglycemia Treatment
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Ingestion of 15-20 grams of glucose (3 glucose
tablets, ½ cup fruit juice or regular soft drink, 6
saltine crackers, 1 tbsp honey or sugar)
Wait 15 minutes and retest; if BG<70 mg/dL,
take another 15 g CHO
Repeat until BG is WNL
If next meal is >1 hour away, take additional 15 g
glucose
Glucagon injection may be prescribed for pts at
risk for severe hypoglycemia
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Hypoglycemia Treatment

Individuals with hypoglycemia unawareness or
one or more episodes of severe hypoglycemia
should be advised to raise their glycemic targets
to strictly avoid further hypoglycemia for at
least several weeks in order to partially reverse
hypoglycemia unawareness and reduce risk of
future episodes. (B)
Standards of Medical Care for Diabetes Diabetes Care 31:S3-S4,
2008
Causes of Hypoglycemia
Medication errors
 Excessive insulin or oral medications
 Improper timing of insulin in relation to
food intake
 Intensive insulin therapy
 Inadequate food intake
 Omitted or inadequate meals or snacks

Causes of Hypoglycemia
Delayed meals or snacks
 Increased exercise or activity
 Unplanned activities
 Prolonged duration or increased intensity
of exercise
 Alcohol intake without food
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Diabetic Ketoacidosis (DKA)
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Caused by hyperglycemia
Life-threatening but reversible
Severe disturbances in carbohydrate, protein,
and fat metabolism
Caused by inadequate insulin for glucose
utilization
Body uses fat for energy, forming ketones
Acidosis results from ↑ production and ↓
utilization of fatty acid metabolites
Diabetic Ketoacidosis
Elevated blood glucose levels (≥250
mg/dL but usually <600 mg/dL)
 Presence of ketones in blood and urine
 Polyuria, polydipsia, hyperventilation,
dehydration, fruity odor, fatigue
 Can lead to coma and death
 Often occurs during acute illness (flu,
colds, vomiting and diarrhea)

DKA Prevented by
SMBG
 Testing for ketones
 Medical intervention
 Appropriate sick day guidelines

DKA Treatment
Supplemental insulin
 Fluid and electrolyte replacement
 Medical monitoring
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Sick Day Guidelines

Take usual doses of insulin
◦ Need for insulin continues or may increase during
illness due to stress hormones
◦ During acute illnesses, testing of plasma glucose and
ketones, drinking adequate amounts of fluids, and
ingesting carbohydrate are all important. (B)
◦ Monitor BG and urine or blood ketones at least 4x
daily
◦ Levels exceeding 240 mg/dL and ketones are signals
that additional insulin is needed
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Sick Day Guidelines

If regular foods are not tolerated, liquid or soft
CHO-containing foods (regular soft drinks,
soup, juices, ice cream)
◦ At least 50 grams (3-4 CHO choices) should be
consumed every 3-4 hours

Ample amounts of liquid should be consumed
every hour
◦ If nausea/vomiting, small sips every 15-30 minutes. If
vomiting continues, health care team should be
notified
Sick Day Guidelines

The health care team should be called if illness
continues for more than 1 day
Causes of Fasting Hyperglycemia
Waning insulin action
 “Dawn” phenomenon
 Somogyi Effect (“rebound” hyperglycemia)

Waning Insulin Action
Inadequate insulin dose overnight
 Requires adjustment of insulin doses

Dawn Phenomenon
Insulin needs are lower in predawn period (1-3
a.m.) than at dawn (4-8 a.m.)
 Excessive hepatic glucose output overnight
(type 2)
 Blood glucose will drop from 1-3 a.m. and then
increase
 Treat with metformin (type 2) or taking an
intermediate insulin at bedtime or using a
peakless insulin (glargine)

Somogyi Effect
Hypoglycemia followed by “rebound”
hyperglycemia as counter-regulatory hormones
are secreted
 Hepatic glucose production is stimulated
 Usually caused by excessive exogenous insulin
 Decrease bedtime insulin doses, take
intermediate insulin at bedtime, or switch to a
long-acting insulin

Hyperosmolar Hyperglycemic
State






Extremely high blood glucose level (600-2000
mg/dL)
Absence of or small amounts of ketones
Profound dehydration
Pts have sufficient insulin to prevent lipolysis
and ketosis
Occurs in older patients with type 2 diabetes
Treatment: hydration and small doses of insulin
to correct the hyperglycemia
Long Term Complications
Macrovascular Disease
Disease of large blood vessels, including
cardiovascular diseases
 Begins with insulin resistance, which
predates diabetes by several years
 Produces metabolic changes called
metabolic syndrome

Macrovascular Disease
Includes coronary heart disease,
peripheral vascular disease, and
cerebrovascular disease
 More common, occurs at an earlier age,
more extensive and severe in people with
diabetes
 Women in particular are at risk

Treatment and Mgt of CVD risk
Target A1C as close to normal as possible
without significant hypoglycemia (B)
 Diets high in fruits, vegetables, and whole
grains may reduce risk (C)
 For pts with heart failure, dietary sodium
intake of <2000 mg/day may reduce
symptoms

Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Treatment and Mgt of CVD Risk
In normotensive and hypertensive
individuals, reduced sodium intake (e.g.
2300 mg/day) with diet high in fruits,
vegetables, and low-fat dairy products
lowers blood pressure (A)
 In most individuals, modest weight loss
beneficially affects blood pressure.(C)

Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Dyslipidemia
11-44% of adults with diabetes
 Type 2: hypercholesterolemia prevalence
is 28-34%; 5-14% have high TG; low HDLC is common
 Patients with Type 2 diabetes have smaller,
denser LDL particles, increasing
atherogenicity

Dyslipidemia
Primary therapy (lifestyle interventions) directed
at lowering LDL-C to ≤ 100 mg/dL
 Pharmacologic therapy at LDL-C>130 mg/dL
 If HDL-C is <40 mg/dL, fibric acid treatment
 Aspirin therapy in adult pts with diabetes and
macrovascular disease or for primary
prevention in patients >40 years with diabetes
and CVD risk factors

Dyslipidemia MNT
Saturated fat should be
limited to 7%
 Substitute CHO or MFA

Nephropathy

In the US diabetic nephropathy occurs in
20-40% of persons with diabetes and is
the single leading cause of end stage renal
disease.
American Diabetes Association Standards of medical care in diabetes.
Diabetes Care 30:S4-S36, 2007
Nephropathy
First symptom is microalbuminuria (>30
mg daily or 20 mcg/minute)
 Progresses to clinical albuminuria (≥300
mg/day), hypertension, ↓ in glomerular
filtration rate
 Albuminuria is a marker for increased
CVD risk also

Nephropathy Screening
Perform an annual test for
microalbuminuria in type 1 diabetic
patients with diabetes duration >5 years
and in all type 2 diabetes pts (E)
 Serum creatinine should be measured
annually to determine GFR in all adults
with diabetes to stage the level of chronic
kidney disease (E)

Nephropathy Treatment
Glucose and blood pressure control
should be optimized
 MNT: optimize BG control and BP; limit
protein to .8-1.0 g/kg in individuals in
early stage of CKD and to .8 g/kg in later
stages is recommended (B)

Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Retinopathy
Most frequent cause of new cases of
blindness among adults 20-74 years
 After 20 years of DM, nearly all pts with
Type 1 and >60% of Type 2 have some
retinopathy
 Laser photocoagulation surgery can
reduce risk of further vision loss but not
correct previous losses

Neuropathy
Nerve damage; affects 60-70% of patients with
Type 1 and Type 2 diabetes
 Peripheral: affects nerves that control sensation in
the feet and hands
 Autonomic: affects various organ systems including
GI tract, cardiovascular system
 Sexual dysfunction: erectile dysfunction in 35-75%
of men with diabetes

Gastroparesis
Delayed or irregular contractions of the
stomach
 Symptoms include feelings of fullness,
bloating, nausea, vomiting, diarrhea,
constipation
 Can affect blood glucose control

Gastroparesis Treatment
Small, frequent meals
 Low in fiber and fat
 Liquid meals if necessary
 Adjustments in insulin administration
 May need to take insulin after the meal
 Frequent blood glucose monitoring

Nutrition Intervention Resources






Dietary Guidelines for 
Americans
Guide to good eating 
Food Guide Pyramid 
The first step in

diabetes meal planning
Healthy food choices 
Healthy eating


Single-topic diabetes
resources
Individualized menus
Month of meals
Exchange lists for meal
planning
CHO counting
Calorie counting
Fat counting
Metabolic Syndrome and
Diabetes Prevention
Metabolic Syndrome
Intra-abdominal obesity (waist
circumference>40 inches in men and >35
inches in women)
 Dyslipidemia
 Hypertension
 Glucose intolerance
 Compensatory hyperinsulinemia
 ↑ macrovascular complications

Metabolic Syndrome MNT
Modest weight loss
 Improved glycemic control
 Restricted saturated fats
 Increased physical activity
 If weight is not an issue, add MFA
 For ↑ triglycerides

◦ high dose statins or fibric acid
◦ Fat restriction, fish oil supplementation
Finnish Diabetes Prevention Study
522 middle-aged, overweight persons with
IGT
 Randomized to brief diet and exercise
counseling or intensive individualized
instruction: goal 5% wt reduction, sfa<10%
energy, fat <30% energy, fiber >15
grams/1000 kcals; physical activity (>150
minutes weekly)

Tuomilehto J et al: Prevention of type 2 diabetes mellitus by changes in lifestyle
among subjects with impaired glucose tolerance. N Engl J Med 344;1390:2001.
Finnish Diabetes Prevention Study
Finnish Diabetes Prevention Study
Results
Tuomilehto J et al: Prevention of type 2 diabetes mellitus by changes in lifestyle
among subjects with impaired glucose tolerance. N Engl J Med 344;1390:2001.
Diabetes Prevention Program (DPP)
Randomized 3234 persons (45% minority)
with IGT to placebo, metformin, or
lifestyle intervention
 Subjects in metformin and placebo groups
received standard lifestyle
recommendations including written
information and an annual 20-30 minute
individual session

Orchard TJ et al. Ann Int Med 142;611-619, 2005
Diabetes Prevention Program
Subjects in lifestyle arm expected to achieve
weight loss of at least 7% and to perform 150
minutes of physical activity/week
 Subjects seen weekly for first 24 weeks, then
monthly
 After 2.8 years, 58% reduction in diabetes
progression in lifestyle group vs 31% in
metformin group

Prevention/Delay of Type 2 Diabetes

Among individuals at high risk for developing type 2
diabetes, structured programs that emphasize
lifestyle changes that include moderate weight loss
(7% body weight) and regular physical activity (150
min/week), with dietary strategies including reduced
calories and reduced intake of dietary fat, can
reduce the risk for developing diabetes and are
therefore recommended. (A)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Prevention/Delay of Type 2 Diabetes

Individuals at high risk for type 2 diabetes should be
encouraged to achieve the U.S. Department of
Agriculture (USDA) recommendation for dietary fiber
(14 g fiber/1,000 kcal) and foods containing whole
grains (one-half of grain intake). (B)

There is not sufficient, consistent information to
conclude that low–glycemic load diets reduce the risk
for diabetes. Nevertheless, low–glycemic index foods
that are rich in fiber and other important nutrients are
to be encouraged. (E)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Prevention/Delay of Type 2 Diabetes

In addition to lifestyle counseling, metformin
may be considered in those who are at very
high risk (combined IFG and IGT plus other risk
factors) and who are obese and under 60 years
of age. (E)

Monitoring for the development of diabetes in
those with pre-diabetes should be performed
every year. (E)
Standards of Medical Care for Diabetes. Diabetes Care 31:S12-S54,
2008
MNT in Non-Diabetic
Hypoglycemia
Types of Hypoglycemia





Postprandial hypoglycemia
Alimentary hyperinsulinemia
Idiopathic reactive hypoglycemia
Fasting hypoglycemia
Factitious hypoglycemia
Postprandial (Reactive)
Hypoglycemia
Blood glucose levels fall below normal 2-5
hours after eating
 Caused by exaggerated insulin response
due to insulin resistance, elevated
glucagon-like-peptide-1 (GLP-1) renal
glycosuria, defects in glucagon response,
high insulin sensitivity

Alimentary Hyperinsulinism (dumping
syndrome)
Most common type of documented
postprandial hypoglycemia
 Seen after gastric surgery; due to rapid
delivery of food to the small intestine →
rapid absorption of glucose →
exaggerated insulin response

Idiopathic Reactive Hypoglycemia
Normal insulin secretion but increased
insulin sensitivity
 Reduced response of glucagon to acute
hypoglycemia
 Rare, but often inappropriately
overdiagnosed

Fasting Hypoglycemia
Usually the result of a serious underlying
medical condition
 Causes include hormone deficiency states,
certain drugs, insulinoma and other
nonpancreatic tumors
 Diagnostic criteria: BG<50 mg/dL,
especially during symptomatic episodes

Treatment of Hypoglycemic
Symptoms
Eat small meals and snacks (5-6 small
meals)
 Spread the intake of CHO through the
day (2-4 CHO servings at a meal, 1-2 at a
snack)
 Avoid foods that contain large amounts of
CHO (regular soda, syrups, candy, regular
yogurt, pies, cakes)

Treatment of Hypoglycemic
Symptoms
Avoid beverages and foods containing
caffeine
 Limit or avoid alcoholic beverages;
interferes with the liver’s ability to release
stored glucose; take ETOH with food
 Decrease fat intake (fat may increase
insulin resistance)

PATIENT EDUCATION
This is the cornerstone of effective
diabetes care.
Sufficient time and resources should
be made available in order to do this
effectively.
T McD Kluyts
127
RECORD DEGREE OF CONTROL
T McD Kluyts

Patients with poor or brittle control,
should be seen at least once a month.

Well controlled diabetics can be seen at
longer intervals eg 2-4 monthly.
128
WEIGHT
T McD Kluyts

As obesity virtually always accompanies
type 2 diabetes, it should be targeted in
its own right.

A weight loss of 5-10% should be the
initial aim. It has been shown to improve
insulin resistance and all its associated
parameters
129
Weight
Body Mass Index (BMI) = Mass in
kg/Length in meter2
Optimal Acceptable
BMI
T McD Kluyts
<25
20 - 26
Action needed
>27
130
WEIGHT
Evidence demonstrates that:
• structured, intensive
lifestyle programs involving
participant education,
• reduced dietary fat and
energy intake,
• regular physical activity
• and frequent participant
contact
are necessary to produce
long-term weight loss of
>5% of starting weight.
T McD Kluyts
131
Exercise Record

The exercise parameters are as follow:
• To reach a pulse rate of max – 20% for age
and sex and maintain for 20 minutes at
least
• 3 times per week at least
• Walking or running or cycling or swimming
or any combination thereof
T McD Kluyts
132
Weight and diet record
T McD Kluyts

This should include weekly weight measurements

Dietary notes where indicated to explain weight
changes

Doctor/dietician’s comments
133
Glucose control record
 The ideal would be twice daily blood-glucose recording:
morning and evening.
 This might be impossible for unsubsidised patients to attain, and
daily urine testing will have to suffice as a minimum requirement.
 Blood glucose should be done fasting in the mornings,
and 2 hours postprandial at night.
 Urine glucose should be measured fasting in the
morning 1 hour after emptying the overnight bladder,
and/or 15 minutes after emptying the 2 hour
postprandial bladder in the evening.
T McD Kluyts
134
Nutrition Recommendations

Carbohydrate
◦ 60-70% calories from carbohydrates and
monounsaturated fats

Protein
◦ 10-20% total calories
Nutrition Recommendations

Fat
◦ <10% calories from saturated fat
◦ 10% calories from PUFA
◦ <300 mg cholesterol

Fiber
◦ 20-35 grams/day

Alcohol
◦ Type I – limit to 2 drinks/day, with meals
◦ Type II – substitute for fat calories
2003Diabetic Exchange Lists
Food Group
CHO
(grams)
Protein
(grams)
Fat
(grams)
Calories
Starch
15
3
0-1
80
Fruit
15
60
Milk
12
12
12
8
8
8
0-3
5
8
90
120
150
Other
Carbohydrate
15
varies
varies
Varies
Nonstarchy
Vegetables
5
2
0
25
Skim
Low-Fat
Whole
2003 Diabetic Exchange Lists
Food
Group
CHO
Protein
(grams)
Fat
(grams)
Calories
7
0-1
35
7
7
7
3
5
8
55
75
100
5
45
Meat
Very
Lean
Lean
Medium
Fat
High Fat
Fat
2003 Diabetic Exchange Lists

Carbohydrate Exchanges – 3 g. protein, 0-1 g.
fat and 80 calories
◦
◦
◦
◦
◦
◦
Bread: bagel, bread, English muffin, tortilla
Cereal: cold and hot cereal, pasta, rice
Starchy vegetables: corn, peas, potato, squash
Crackers and snacks
Dried beans
Starch prepared foods with fat: biscuits, muffins
2003 Diabetic Exchange Lists

Fruit Exchanges
◦ 15 grams carbohydrate and 60 calories
◦ Fruit and fruit juice

Vegetables
◦ 5 g. carbohydrate, 2. G protein and 25 calories
2003 Diabetic Exchange Lists

Other Carbohydrates
◦
◦
◦
◦
◦
Exchanges and Serving size vary
Angel food cake – 2 carbohydrates
Cake, frosted – 2 carbohydrates, 1 fat
Donut, plain cake - 1 ½ carbohydrates, 2 fats
Potato chips – 1 carbohydrate, 2 fats
2003 Diabetic Exchange Lists
Milk – 12 g. carbohydrate, 8 g. protein and
0-8 g. fat
 Meat and Meat Substitutes
 Very Lean Meat (7 g protein, 0-1 g. fat and
35 calories)

◦ Chicken, turkey – white meat
◦ Shellfish (clams, crab, lobster, shrimp)
2003 Diabetic Exchange Lists

Lean Meat (7 g protein, 3 g. fat and 55
calories)
◦ Select or choice beef, trimmed of fat
◦ Lean pork
◦ Poultry, turkey –dark meat
2003 Diabetic Exchange Lists

Medium Fat Meat (7 g protein, 5 g. fat and 75 calories)
◦ Most beef products – corned beef, ribs, prime grades
◦ Ground turkey
◦ Chicken – dark meat with skin

High Fat Meat (7 g protein, 8 g. fat and 75 calories)
◦ All cheeses
◦ Processed meats, hot dogs
Daily Meal Plan
Time
Exchanges
8 AM
___Fruit exchanges
___Starch exchanges
___ Meat exchanges
___ Milk exchanges
___ Fat exchanges
10 AM
12:30 PM
___ Fruit exchanges
___Starch exchanges
___ Meat exchanges
___ Milk exchanges
___ Fat exchanges
6:30 PM
___ Fruit exchanges
___Starch exchanges
___ Meat exchanges
___ Milk exchanges
___ Fat exchanges
8 PM
Menus
Carbohydrate Counting
A serving of carbohydrate is considered
15 grams
 A serving of fruit or starch or 3 servings
of vegetable is = to 1 carbohydrate
 One milk serving is considered equal to
one carbohydrate

Carbohydrate Counting
Example: Meal plan = 9 carbohydrate
servings
 4 fruit and 5 starches or
 3 fruit + 4 starches + 3 vegetables and 1
milk or
 2 fruit + 4 starches + 3 vegetables and 2
milk

Daily Meal Plan
Time
Grams of Carbohydrate
8 AM
___Carbohydrate choices
___ Meat exchanges
___ Fat exchanges
10 AM
___ Carbohydrate Choices
12:30 PM
___Carbohydrate choices
___ Meat exchanges
___ Fat exchanges
6:30 PM
___Carbohydrate choices
___ Meat exchanges
___ Fat exchanges
8 PM
____ Carbohydrate Choices
Menus
Exchange Lists
Calories
g CHO
g Pro
g Fat
Starch
80
15
3
0 -1
Fruit
60
15
0
0
Skim Milk
90
12
8
0-3
Low-fat Milk
120
12
8
5
Whole Milk
150
12
8
8
Vegetable
25
5
2
0
Very Lean Meat
35
0
7
0-1
Lean Meat
55
0
7
3
Medium Fat Meat
75
0
7
5
High Fat Meat
100
0
7
8
Fat
45
0
0
5
Starch Group

15 g CHO
◦
◦
◦
◦
◦
◦
◦
1 slice bread (Belgium 30g)
small tortilla
small potato
1/2 cup pasta (60g)
1/2 cup corn (60g)
1/3 cup rice (70g)
3 cups popcorn (180g)
Fruit Group

15 grams CHO
◦
◦
◦
◦
◦
◦
◦
small apple
small orange
17 grapes
1/2 grapefruit
1 cup cantaloupe
3 prunes
4 ounces orange juice (120g)
Milk Group

15 g CHO each
◦ 1 cup milk (200ml)
◦ 3/4 cup plain yogurt (150g)
◦ 1 cup aspartame yogurt (200g)
Vegetable Group

5 grams CHO each
◦ 1 cup raw vegis (225g)
◦ 1/2 cup cooked vegis (100g)
◦ 1/2 cup vegetable juice (150ml)
Digestion Timing
Peak Post Prandial BG is typically 1-2
hours after a standard mixed meal.
 Liquids (juice/soda) digest quicker.
 High fat meals digest slower.

Meal Planning

Set Carbohydrate Intake
◦ specific amount of CHO set to match
prescribed insulin regimen (less flexible)

Adjust Insulin to Desired Carbo Intake
◦ insulin to carbohydrate ratio
 1 unit per 10-15 g carbohydrate
 1 unit for every 50 mg/dl elevated above target
(above doses may vary)
Insulin Action Times
Type of Insulin
Start
Peak
Duration
Humalog “Lispro”
5-15 min
30-90 min
2-4 hrs
Novolog “Aspart”
5-15 min
30-90 min
2-4 hrs
Regular
30-60 min
2-3 hrs
3-6 hrs
NPH
2-4 hrs
4-10 hrs
10-16 hrs
Lente
3-4 hrs
4-12 hrs
12-18 hrs
Ultralente
6-10 hrs
no peak
18-20 hrs
Glargine
1 hr
no peak
24 hrs
Insulin Delivery
Syringes
 Insulin Pens
 Insulin Pump

◦ delivers short acting insulin (sub-Q catheter)
◦ adjustable basal rate (usually 0.5-1.0 u/hr)
◦ programmable bolus for food or BG
correction
Insulin Pens


Pre-filled with 300 units. Disposable.
Dial dose in 1 unit increments up to 60 unit dose.
Insulin Pump

Programmable insulin pump
◦ holds 300 units
◦ insulin is delivered through sub-Q infusion set/tubing

Remote control
◦ discrete dosing
Exercise



Improves insulin
sensitivity
Lowers Blood Glucose
Uses Glycogen Stores
◦ muscle
◦ liver

Increases release of FFA
from adipose
For Patients with BMI ≥25 kg/m2…
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
Choose low glycemic index
carbohydrates
www.guidelines.diabetes.ca
Figure 1 – Nutritional management of hyperglycemia in type 2 diabetes
Clinical assessment
2013
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
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
Properties of Macronutrients
2013
Dietary interventions
A1C
Advantages
Disadvantages
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
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 Dietary Patterns
Dietary Pattern
A1C
2013
Advantages
Disadvantages
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
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]
Recommendations 3 and 4
3. Individuals with diabetes should be encouraged to
follow Eating Well with Canada’s 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
2013
should be followed to achieve and maintain a lower,
healthier body weight [Grade A, Level 1A]
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
2013
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
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]
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]
Recommendation
10
2013
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]
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]
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 evening’s 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].
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for
professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients
Assessment of Health status must incorporate the entire
bio – psycho-social aspects within the context of the
environment.
v
Health belief
v
Personal habits sleep and wake patterns
v
Recreational patterns
v
Nutritional patterns
v
Stress and coping patterns
v
Socio-economic status
v
Environmental issues
v
Occupational health patterns
v
Self concept
v
Cultural, spiritual etc
v
Family role and relationships
v
Sexuality
v
Social support
v
Emotional health
(Mallik et al 1998)
The process of dietary
assessment provides an
opportunity to explain the types of
dietary changes needed and to
explore how these may be met.