Diabetes

Question 1

How does ethnicity affect the risk of developing T2DM?

Answer 1

South asian - T2DM 6x more likely
African and african-caribbean origin. - 3x more likely

Both these populations develop it 10 years earlier than white counterparts

Question 2

What are the aims of nutritional management in type 1 and type 2 diabetes?

Answer 2

Good glycaemic control (hba1c ≤ 48 mmol/mol and limit hypos)

Minimise risk of long-term microvascular and macrovascular complications

Cvd risk reduction: weight, blood pressure and lipid management

Enjoyment of food and good quality of life

Facilitation of health behaviour changes and self management

Question 3

Describe nutritional management of type 1 diabetes?

Answer 3

Aspects fall under:
Insulin

Diet  

Exercise 

Overall, assessing carbohydrate intake and matching to insulin dose.

Question 4

List examples of rapid-acting, short-acting and intermediate-acting insulin.

Answer 4

Rapid acting analogue insulin – humalog, novorapid, apidra

Short acting human insulin – humulin s, actrapid

Intermediate nph insulin – humulin i
Nph - neutral protamine hagedorn also known as humulin i

Question 5

Describe bolus insulin regimens?

Answer 5

A long-acting background insulin eg glargine or detemir
WITH a rapid-acting insulin eg novorapid/ humalog/ apidra with

–most need 0.5-0.8 units of insulin per kg.
–can adjust insulin to match food timing and quantities

Question 6

Describe consistent insulin regimens?

Answer 6

Twice daily mixed insulin doses. Best suited to those with a:
–consistent meal pattern
–consistent carbohydrate intake

Question 7

Describe continuous insulin infusion?

Answer 7

Continuous subcutaneous insulin infusion (csii)/insulin pump therapy: continuous infusion of rapid-acting insulin with bolus for meals & snacks.

Question 8

What are the benefits of insulin pump therapy?

Answer 8

This offers the most flexible & physiological regimen available.
• smaller insulin increments.
• carb ratios can be fine tuned.
• bolus for intake for as little as 5g carbohydrate.
• extra boluses don’t involve an extra injection therefore. Patients
more likely to bolus for every meal and snack.

Question 9

What does nice guidance ta151 (2008)

advise about when to use csii?

Answer 9

Csii can be considered for adults and children over 12 years if:
–attempts to meet target hba1c results in disabling hypoglycaemia (repeated and unpredictable occurrence of hypoglycaemia resulting in anxiety and a negative effect on quality of life).
–hba1c has remained above 8.5% despite a high level of care.

Question 10

Describe uses of blood glucose monitoring?

Answer 10

• Identifies patterns.
• Tests response to foods & medication.
• Enables adjustment of medication and calculation of insulin doses.

Question 11

Where do we find carbohydrates?

Answer 11

Cereal derived starch products: breakfast cereals, grains, bread,
rice, pasta, couscous, flour based products [pastry, biscuits, cakes]

Vegetable starch: potato, legumes [lentils, beans, peas], yam,
sweet potato

Fructose: fruit, fruit juice

Lactose: milk, yoghurt, ice cream, custard

Sucrose (table sugar): chocolate & confectionary, ordinary soft-
drinks, desserts, cakes, etc

Question 12

Which foods don’t contain carbs?

Answer 12

• meat, fish, chicken, eggs, nuts
• cheese
• most vegetables (except starchy vegetables)
• diet drinks, sugar free drinks, most artificial sweeteners

Question 13

What’s the evidence for carbohydrate counting?

Answer 13

Dafne – dose adjustment for normal eating

169 adults with type 1 diabetes across 3 english centres
Training program emphasizing flexibility with respect to insulin self- adjustments for variable carbohydrate intake

Results at 6 months:
–significantly improved hba1c.
–impact of diabetes on dietary freedom and quality of life
significantly improved.
–no change to severe hypoglycaemia, weight or lipids
27

Question 14

Name 10 ways to eat well with diabetes

Answer 14

1. Eat regular meals
2. Keep an eye on portion sizes
3. Carbs count
4. Cut the fat
5. Get your five a day
6. Cut back on salt
7. Eat more fish
8. Eat more beans
9. Limit added sugar
10. Keep hydrated

Question 15

Why is it important for diabetics to include starchy carbohydrates as part of their diet?

Answer 15

starchy carbs such as bread, rice, pasta, potatoes, yam, plantain, cereals etc help keep blood glucose levels stable

Question 16

What’s the glycaemic index ?

Answer 16

The glycaemic index (gi) is a ranking of carbohydrates on a scale according to the extent to which they raise blood glucose levels after eating.

Question 17

Describe the effect of high gi carbohydrates ?

Answer 17

¥ Rapidly digested and absorbed

¥ Sharp increase in blood glucose levels

Question 18

What affects glycaemic index?

Answer 18

¥ Type of sugar – glucose, fructose etc

¥ Nature of starch – amylose, amylopectin

¥ Cooking

¥ Processing/ physical form

¥ Presence of other food components
–fat and protein (slows stomach emptying)
–fibre

¥ Acidity (slows stomach emptying)

Question 19

Name examples of foods and their glycaemic index

Answer 19

High gi 70+ white bread, wholemeal bread, rice krispies, cornflake, most potatoes (mashed, baked, boiled), jasmine rice, broadbeans, watermelon, short grain rice, sugary drinks

Medium gi 56-69 new potatoes, digestive biscuits, cous cous, long grain rice, basmati rice, cream crackers, oat cakes, croissants, wholemeal pitta bread

Low gi 55 and under pasta, lentils, beans, seeded/granary bread, tortillas, chapattis, quinoa, rye crispbread with seeds, oats, temperate climate fruits •

Question 20

What are the benefits of physical activity?

Answer 20

–35% lower risk of coronary heart disease and stroke
–50% lower risk of colon cancer
–20% lower risk of breast cancer
–30% lower risk of early death
–83% lower risk of osteoarthritis
–68% lower risk of hip fracture
–30% lower risk of falls (among older adults)
–30% lower risk of depression
–30% lower risk of dementia
–50% lower risk of developing type 2 diabetes

Question 21

What are the benefits of physical activity in those who already have diabetes ?

Answer 21

improved glycaemic control increased insulin sensitivity increased fat free mass
decrease in visceral adipose tissue

Question 22

Name recommended exercise targets?

Answer 22

Adults should aim to be active daily and should do:
–at least 150 minutes of moderate intensity activity/week OR 75 minutes of vigorous intensity activity/week OR a combination of moderate and vigorous intensity activity

AND

undertake physical activity to improve muscle strength on at least 2x/week
minimize the amount of time spent being sedentary for extended periods.

Question 23

What is moderate intensity activity?

Answer 23

Activity that raises your heart rate, makes you breathe faster and feel warmer.
–you should still be able to talk, but not able to sing the words to a song.

• walking fast
• water aerobics
• riding a bike on level ground or with few hills
• doubles tennis
• pushing a lawn mower
• hiking
• skateboarding
• rollerblading
• volleyball
• basketball

Question 24

What is vigorous intensity activity?

Answer 24

Activity that makes you breathe hard and fast and accelerates your heart rate.
–if you’re working at this level, you won’t be able to say more than a few words without pausing for breath.

• jogging or running
• swimming fast
• riding a bike fast or on hills singles tennis
• football, rugby or hockey
• skipping rope
• aerobics
• gymnastics
• martial arts

Question 25

Descrive the role of weight management in type 2 diabetes

Answer 25

Weight reduction and energy restriction are the best predictors of
Improved outcomes in t2dm.
5-10% weight reduction can have a significant effect.

Look ahead study in US (2010) - lifestyle interventions, including a low- fat diet:
–reduced bodyweight
–hba1c
–reduced cardiovascular risk factors maintained over four years

Question 26

Describe impact of low carbohydrate diets?

Answer 26

Popular for optimising glycaemic control and aiding weight loss in type 2 diabetes.
Can improve hba1c
No evidence to promote long term use.

Disadvantages are: nutritional adequacy, constipation, headaches

Question 27

Describe impacts of vlcd (very low calorie diet)?

Answer 27

Newcastle study
–11 people with diabetes
–800 calories per day for 8 weeks
• optifast meal replacements and non-starchy veg
–7 out of 11 went into diabetes remission and retained normal blood glucose control after 3 months.

Question 28

Describe the impact of metabolic surgery ?

Answer 28

Rcts consistently demonstrate that metabolic surgery achieves superior glycaemic control

Surgery summit (dss-ii) state that obesity surgery, which was 
 originally designed to induce weight loss, should be included among the current treatment options for people with T2DM.

Nice Guidance (CG189) suggests bariatric assessment should be considered for people with a BMI >30 (or lower in Asian population) who have recent-onset T2DM.

Question 29

What’s different between diabetics and non diabetics wrt weight management?

Answer 29

People with diabetes respond more slowly to weight management strategies than those without diabetes (guare 1995, paisey et al. 1998, khan et al. 2000)

Obesity management in diabetes requires long-term investment of time, resources and enthusiasm

Question 30

Give examples of structured education for type 2 diabetes.

Answer 30

Diabetes Education and Self Management for Ongoing and Newly Diagnosed - DESMOND

Question 31

How do we prevent t2dm?

Answer 31

Reduce weight, total fat & saturated fat intake, increase fibre intake & exercise.
–> Diabetes Prevention Study (DPS)
Participants in intervention group received individualised dietary counselling from a nutritionist in addition to circuit type resistance training sessions. Most intensive during the first year.
Measures of glycaemia and lipaemia improved more in the intervention group

Question 32

What are the recommendations for the prevention of type 2 diabetes in high risk groups? Which foods increase and decrease risk?

Answer 32

Protective:
–low intakes of saturated fat and higher intakes of unsaturated fat
–low glycaemic index/glycaemic load
–high dietary fibre and wholegrains

Reduced risk: 
–low fat dairy foods
–green leafy vegetables
 –coffee 
–moderate intakes of alcohol

Increased risk:
–red meats
–processed meat products –fried potatoes

Question 33

Describe how diabetes is affected in pregnancy and the management of gestational diabetes ?

Answer 33

Tight bg control reduces maternal and foetal risks

Careful assessment of current eating pattern- aim for even spread of food, cho portion control, low g.i choices and weight management (if needed)

Encourage physical activity

If extra treatment required, use metformin and/or insulin

Advise (diet, exercise, weight management) post pregnancy to reduce risk of type 2 dm in future

Question 34

Describe dietary management for inpatients?

Answer 34

Uncontrolled blood glucose levels are common in hospital and could be due to :

• infection/inflammation/sepsis
• the need to adjust medication
• timing of medication/meals

Encourage regular meals and snacks
As last meal of day is at 6pm, bed-time snacks should be offered
Identify patients at risk of malnutrition using nutrition screening tool
Refer to dietitian if identified as at risk
Supplements may be prescribed - important to meet nutritional requirements and adjust medication as necessary
Importance of meeting nutritional requirements (immune system,
wound healing, feeling of well-being).
Healthy eating principles may not be appropriate while in hospital. Foods that are higher in calories (including fats and sugars) may
be required. Important to re-iterate healthy eating should be resumed on
discharge.
Education can be provided on discharge.

Question 35

Summarise management in t1 and t2 diabetics?

Answer 35

Type 1 diabetes – main focus is on carbohydrate counting with insulin dose adjustment

Type 2 diabetes – focus on weight management + healthy eating/ cvd risk reduction + carbohydrate awareness (regular meals, watch cho portions)

Structured education recommended for both

Question 36

What are patient education working group recommendations? Name 3 examples.

Answer 36

Recommends all patients with type 1 and type 2 diabetes are offered structured education

¥ Dafne – dose adjustment for normal eating (type 1)

¥ Icicle – imperial college insulin carbohydrate lifestyle education

¥ Bertie – bournemouth type 1 intensive education programme

Question 37

Who would you refer to a dietitian?

Answer 37

All patients newly diagnosed with diabetes

Patients with diabetes starting on insulin

All patients with diabetes in pregnancy

Patients with diabetes who have never seen a dietitian

Patients with a high nutritional screening tool score in hospital