Diabetes - Diet Approach Flashcards
What are the Goals of Diet Therapy in diabetes?
¢ maintenance of a healthy body weight
¢ the best possible metabolic control
- Glycemic control: near-normal or targets
- Lipid profile: primary target LDL-C ≤2.0 mmol/L
- Blood pressure <130/80
¢ To delay or prevent complications associated with diabetes
¢ To provide specific guidelines for different stages in the lifecycle
¢ To promote self-care by providing the necessary knowledge, skills, resources and support
¢ To encourage overall health by practical instructions in optimal nutrition
What is the Nutrition Checklist provided by CDA?
- REFER for nutrition counseling by a registered dietitian
- FOLLOW Eating Well with Canada’s Food Guide
- INDIVIDUALIZE dietary advice based on
preferences and treatment goals - CHOOSE low glycemic index carbohydrate food sources
- KNOW alternative dietary patterns for type 2 diabetes
2013 - ENCOURAGE matching of insulin to carbohydrate in type 1 diabetes
- ENCOURAGE nutritionally balanced, calorie- reduced diet in overweight or obese patients
What are the recommendations for patients with BMI ≥25 kg/m2?
Nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier (and realistic) body weight
What are the benefits of weight loss?
Weight loss of 5-10% of initial body weight –> Improves:
- insulin sensitivity
- glycemic control
- blood pressure control,
- lipid levels
What is the order of Nutritional management of hyperglycemia in type 2 diabetes provided by CDA?
Clinical assessment
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
What is the target CHO for diabetic patients?
Carbohydrates : 45-60%
- Minimum intake of 130 g/d
- <45% may not provide enough vitamins & minerals
- Higher range should include low GI index and high fiber intake
- <10% of added sugar (sucrose)
What is glycemic index?
Scale 0-100 compared to glucose standard
- Area under the curve (AUC) in blood glucose response of a given food compared to standard (glucose or white bread) for the same content in g CHO.
Ex: 200 g cooked pasta (50 g CHO) vs. 50 g glucose or 100 g white bread (50 g CHO).
GI= AUC pasta / AUC glucose or white bread X 100= 46
What is glycemic load?
Accounts for available CHO in portion
GL= g CHO in normal serving x GI/100
GL pasta= 50 g X 46 /100 = 23
What are the ranges of glycemic index?
Low: ≤ 55
Medium: 56-69
High: ≥ 70
What are the ranges of glycemic load?
Low: ≤ 10
Medium: 11-19
High: ≥ 20
What are the dietary factors affecting the glycemic response?
¢ Dietary fibers ¢ Food form ¢ Cooking and processing ¢ Digestibility ¢ Other nutrients present (protein and fat) ¢ Interprandial differences ¢ Fast/ slow eater ¢ Glucose tolerance effect
What is the benefit of replacing high GI foods with low GI foods?
- better glycemic control
- increased HDL-C
- decreased CRP (reducing inflammation), hypoglycemia in T1DM, and medications
Recommended but teaching should be based on patient’s interest and ability.
What are the recommendations for dietary fiber intake in diabetes?
¢ Soluble fiber slows gastric emptying and glucose absorption
¢ Higher total intake recommended in DM: 25-50 g/d or 15-25 g/1000 kcal
What are the recommendations for added sucrose intake in diabetes?
<10% of total energy is acceptable
>10% increases BG and TG in some
What are the recommendations for added fructose intake in diabetes?
- in place of sucrose may help lower A1C and unlikely
harmful - > 10% increase TG in T2DM
- When excess energy: adverse metabolic profile
What are the recommendations for natural fructose intake in diabetes?
from fruits = no harm
Caution with high GI fruits: pineapple, mango, papaya, melons
What is the target fat for diabetic patients?
Fat: 20-35% of energy
Due to high risk of CVD:
- Saturated <7% of E
- Avoid trans fatty acids
- MUFAs up to 20%
- PUFAs up to 10%
What are the recommendations for Omega 3 fatty acids for diabetic people?
¢ No effect on blood glucose but decrease TG and platelet aggregation
¢ Higher intake of fish –> reduction in CVD in women with DM –> Recommendation: 2-3 servings fish/week
¢ Supplements: conflicting data –> Not recommended (except for severe hyperTG)
What is the target protein for diabetic patients?
¢ Protein: 15-20% (1.0-1.5 g/kg/day)
¢ Maintain 1.0-1.5 g/kg/d during weight-reduction
¢ Concern with chronic kidney disease (CKD)
- No more than 0.8 g/kd/d
What are the advantages and disadvantages of Hi-CHO (low-glycemic index [GI]) in diet?
Advantages:
decreased A1C, CRP, hypoglycemia
increased HDL-C
Disadvantages:
none
What are the advantages and disadvantages of Hi-CHO (high fibre) in diet?
Advantages:
decreased A1C, TC, LDL-C
Disadvantages:
decreased HDL-C
What are the advantages and disadvantages of Hi-MUFA in diet?
Advantages:
decreased A1C, TG
Disadvantages
none
What are the advantages and disadvantages of Lo-CHO diet?
Advantages:
decreased TG
Disadvantages:
decreased micronutrients
increased renal load
**no change in A1C
What are the advantages and disadvantages of Hi-protein diet?
Advantages:
decreased A1C, BP, TG
preserve lean mass
Disadvantages:
decreased micronutrients
increased renal load
What are the advantages and disadvantages of Long chain omega 3 fatty acids diet?
Advantages:
decreased TG
Disadvantages:
Methyl-Hg exposure, environmental impact
**no change in A1C
What are the considerations of non-nutritive sweeteners?
¢ May help in glucose control
¢ Acceptable daily intake: Table 2 in CDA Guidelines Nutrition
¢ Sugar alcohols (sorbitol, xylitol, maltitol,…)
- No acceptable daily intake determined
- GI symptoms limit intake
- Not counted in CHO counting
¢ Recent study shows impact of saccharin, sucralose and aspartame on glucose tolerance through alteration of gut microbiome
What are the recommendations for alcohol in diabetes?
¢ Limit to ≤2 drinks/d in women, ≤3 in men
¢ Moderate intake with meals has little effect on BG
¢ Moderate daily intake: lower risk of fatal CHD in T2DM
¢ Risks: alcohol may mask symptoms of hypoglycemia and increase ketones
¢ T1DM: moderate alcohol intake with meal or 2-3 hours later –> delayed hypoglycemia
What are the benefits of alcohol in T1DM?
moderate alcohol intake with meal or 2-3 hours later –> delayed hypoglycemia
What are the risks of alcohol in diabetes?
alcohol may mask symptoms of hypoglycemia and increase ketones
What are some special concerns with insulin Tx?
¢ Regularity in meal spacing and CHO content may help glycemic control
¢ Snacks may be useful to avoid hypoglycemia: balance against potential for weight gain
¢ Bed-time snacks containing protein may help avoiding nocturnal hypoglycemia
What are the extra precautions when a diabetes person is sick?
¢ Take DM medications as prescribed
¢ SMBG often: ≥ 4/d
¢ Episodes of N/V: replace usual CHO with liquid or semi-liquid containing CHO (fruit juice, yogurt, Gatorate, soft drinks, Jello, …)
¢ Hydrate: 250-370 mL per hour
¢ Consult MD if: cannot tolerate liquids, glycemia >20 mmol/L, To >38.5o C for 48 h, ketonuria, persistent diarrhea, general deterioration
What are in hospital glycemic targets and therapy choices for non-critically ill?
Fasting 5-8
Random <10
Pre-hospital regimen OR basal-bolus- correction
What are in hospital glycemic targets and therapy choices for critically ill?
8-10
IV insulin infusion
What are in hospital glycemic targets and therapy choices for CABG intraop?
5.5-10
IV insulin infusion
What are in hospital glycemic targets and therapy choices for Other periop?
5-10
As appropriate
Compare Type 1 and Type 2
- decrease calories
- Improve insulin action (sensitivity)
- Increase frequency of feedings
- Consistent intake of kcal, CHO, pro, fat
Type 1
- decrease calories: NO
- Improve insulin action (sensitivity) –> Seldom important:
β-cells are inactive and no IR
- Increase frequency of feedings –> Yes (conventional Tx) No (intensive Tx)
- Consistent intake of kcal, CHO, pro, fat –> Important (conventional Tx) Not critical (intensive Tx)
Type 2
- decrease calories: YES
- Improve insulin action (sensitivity) –> very important
- Increase frequency of feedings –> not usually
- Consistent intake of kcal, CHO, pro, fat –> Better but not critical
How important is consistent ratio of CHO, pro, fat/meal in T1DM and in T2DM?
T1DM
- Very important (conventional Tx)
- Not critical (intensive Tx)
T2DM
- not crucial
How important is consistent timing of meals in T1DM and in T2DM?
T1DM
- important (conventional Tx)
T2DM
- not crucial
How important is extra food for unusual exercise in T1DM and in T2DM?
T1DM
- Yes (conventional Tx)
- Variable (intensive Tx)
T2DM
- Not usually
How important is during illness, provide CHO (with meds and close monitoring) in T1DM and in T2DM?
T1DM
- To prevent ketosis (insulin needs may be higher than usual)
T2DM
- To prevent HHS
How important is use of food to treat, prevent hypoglycemia in T1DM and in T2DM?
T1DM
- important
T2DM
- Less important (yes, to treat)
Why is consuming plant protein better than animal protein in diabetes?
decreased albuminuria, LDC-C, TG, CRP
