Diabetes nutritional approach Flashcards
Goals of diet therapy
- long-term and short-term diet
- To encourage the attainment or maintenance of a healthy body weight
- To achieve the best possible metabolic control without seriously compromising quality of life
- 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
Since diabetes is a risk factor for __ we also want to control __ (mostly __)
Since diabetes is a risk factor for CVD we also want to control lipid profile (mostly LDL-C)
What are the components of metabolic control and targets for each
- Glycemic control: near-normal or targets
- Lipid profile: primary target LDL-C ≤2.0 mmol/L
- Blood pressure <130/80
Nutrition checklist (7)
- REFER for nutrition counselling 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
- ENCOURAGE matching of insulin to carbohydrate in type 1 diabetes
- ENCOURAGE nutritionally balanced, calorie-reduced diet in patients with overweight or obesity
Nutritional management of hyperglycaemia in t2Dm
- Clinical assessment
Healthy behaviour interventions by Registered Dietitan - Initiate intensive healthy behaviour interventions or energy restriction and increased physical activity to achieve/maintain a healthy body weight
- Provide counselling on a diet best suited to the individual based on values, preferences, and treatment goals using the advantages/disadvantages
- If not at target:
- Continue healthy behaviour interventions and add pharmacotherapy
- Timely adjustments to healthy behaviour interventions and/or pharmacotherapy should be made to attain A1C within 2 to 3 months for healthy behaviour interventions alone or 3 to 6 months for any combination with pharmacotherapy
What is the main marker for hyperglycaemic control
A1c
What should be advised to people with BMI>25? Why?
Nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight
because
Weight loss of 5-10% of initial body weight -> Improved insulin sensitivity, glycemic control, blood pressure control, lipid levels
Macronutrient Distribution (% Total Energy) for diabetes
Carbohydrates: 45-60%
Protein: 15-20% (or 1-1.5g /kg BW)-> should be maintained or increased in energy reduced diets.
Fat: 20-35%
What is the minimum intake of CHO
Minimum intake of 130 g/d
Why would it be advised to consume >45% of CHO?
What should it include/ not include
> 45% to prevent high intake of saturated fats and higher risk of CVD
Higher range should include low GI index and high fiber intake
<10% of added sugar (sucrose)
Glycemic index vs glycemic load
G index: scale 0-100 compared to glucose standard
Glycemic load: 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.
-> accounts for available CHO in portion
What is the formula for glycemic load? How would you calculate GL of 200g of pasta that has 50g of cho?
GI= AUC pasta / AUC glucose or white bread X 100= 46
GL= g CHO in normal serving x GI / 100
GL pasta= 50 g X 46 /100 = 23
Glycemic index vs load scales cut-offs
Glycemic index (GI)
Low: ≤ 55
Medium: 56-69
High: ≥ 70
Glycemic load (GL)
Low: ≤ 10
Medium: 11-19
High: ≥ 20
Dietary factors affecting the glycemic response
Dietary fibers Food form- e.g wheat flour vs bulgur Cooking and processing Digestibility Other nutrients present (protein and fat) Interprandial differences Fast/ slow eater Glucose tolerance effect- GI is determined in people with normal response and healthy weight
What are the benefits of replacing high Gi foods with low GI foods? Should all patients be advised to do so?`
Replacing high GI with low GI carbohydrates in mixed meals:
- improvement of glycemic control in type 1 and type 2 DM
- Studies showed increased HDL-C, decreased CRP, hypoglycemic events in T1DM, and medications
Recommended but teaching should be based on patient’s interest and ability.
What are the fiber intake recommendations for DM?
Higher total intake recommended in DM:
30-50 g/d or 15-25 g/1000 kcal
- 1/3 of total should be soluble viscous fibre (10-20 g/day) because of higher benefit
benefits of fiber intake in diabetes
Evidence for more benefits from soluble fiber:
- slows gastric emptying and glucose absorption
- Improvement in A1C, Fasting BG and lipid profile
How to increase fiber intake?
Consume more pulses, whole grains, fruits and veggies
Recommendations for added sucrose intake? Why is it so?
<10% of total energy is acceptable
>10% increases BG and TG in some
Added sucrose vs added fructose
Added fructose
in place of sucrose may help lower A1C and unlikely harmful
What does excess fructose lead to?
> 10% increase TG in T2DM
- High-fructose corn syrup (HFCS) shows not different than sucrose in cardiometabolic outcomes
- Sugar-sweetened beverages: high intake associated with hypertension and risk of CHD
- When excess energy: adverse metabolic profile
Natural fructose from fruits consensus
Natural fructose from fruits: no harm
Caution with high GI fruits: pineapple, mango, papaya, melons
What is the amount of CHO in low CHO diets?
CHO of 4% to 45% of total energy
Are low CHO diets beneficial in DM?
Systematic reviews have not shown consistent improvements in:
- A1C
- Blood lipid profile and BP
- Maintenance of weight loss in the long-term (>12 mo)
Concern of ketoacidosis with insulin therapy or SGLT2 inhibitors
Limited studies in type 1 DM: improved A1C in those who are adherent, but modest adherence overall
Concern with blunted response to glucagon injection in treatment of hypoglycemia
Recommendations for fat intake
Avoid trans fatty acids
Saturated <9% of E, replace with other sources
Which saturated fats to replace ?: from meats but perhaps not from dairy and plant sources
What should saturated fats be replaced with?
REPLACE with polyunsaturated fatty acids (PUFAs) from mixed n-3/n-6 sources (e.g. nuts, canola oil, soybean oil, flaxseed), monounsaturated fatty acids (MUFAs) from plant sources (e.g. extra virgin olive oil, high oleic oils, avocados), whole grains, or low-GI carbohydrates
Should DM patients take omega-s supplements? What might they take instead
Supplements: not recommended (except for severe hyperTG)
- no benefit on CV or mortality in people with prediabetes or diabetes from meta-analyses of RCT
- but may decrease TG and platelet aggregation
Higher intake of fish-> reduction in CAD and kidney disease in T2DM and less albuminemia in T1DM
Recommendation: 2-3 servings fish/week
Benefits of replacement of animal with plant protein sources
improved A1C, fasting BG and insulin
Protein and chronic kidney disease
- No more than 0.8 g/kd/d
- Monitor protein status in patients with DM and CKD to avoid malnutrition
- Optimize quality of protein, care with plant sources of protein rich in potassium
Substitution of MUFA for carbohydrates
may have benefits in T2DM, over ≅20 weeks:
Improved fasting BG, systolic BP, TG and HDL-C
But no reduction in A1C
Macronutrient substitutions cardiometabolic benefits shown in T2DM
Replacement of high-GI CHO with MUFA
Replacement of fat with low-GI CHO
Replacement of high-GI CHO with high protein diet, during weight loss
Atkins
low carb
Best diets (most benefit vs least disadvantages)
Mediterranean (improved, a1c, decrease CVD risk, BP, CRP, increased HDL-c improved retinopathy; no disadvantages)
Why don’t weight loss diets show no benefit on a1c?
Weight loss diets are usually not adhered to for a long period -> no a1c benefit
benefits of meal replacement
useful for temporary intervention for rapid weight decease (e.g. for a surgery)
someone who lacks cooking skills
Benefits of vegetarian diet vs vegan
Vegan or vegetarian dietary pattern to improve glycemic control, body weight, and blood lipids including LDL-C, and reduce myocardial infarction
benefits and risks of non-nutritive sweeteners
- May help in glucose control
- Recent study shows impact of saccharin, sucralose and aspartame on glucose tolerance through alteration of gut microbiome
Adverse effects, recommended intake of sugar alcohols
Sugar alcohols (sorbitol, xylitol, maltitol,…)
- No acceptable daily intake
- GI symptoms limit intake
- Not counted in CHO counting
- No adverse effects with consumption of 10 g/day
Risks and benefits of alcohol intake
Light to moderate intake-> inverse association with A1C and lower risk of fatal CHD in T2DM
Risks: alcohol may mask symptoms of hypoglycemia and increase ketones
People with diabetes using insulin and/or insulin secretagogues should be educated about the risk of hypoglycemia resulting from alcohol [Grade C, Level 3], and should be advised on preventive actions such as carbohydrate intake and/or insulin dose adjustments and increased BG monitoring
How is delayed hypoglycaemia related to T2DM?
T1DM and insulin-treated T2DM: moderate alcohol intake with meal or 2-3 hours later -> delayed hypoglycemia
What can help to avoid nocturnal hypoglycemia
bed-time snacks
Pre-diabetes treatment
Weight loss or maintenance*
Portion control
Guidance to include low GI CHO and reduce refined CHO
Physical activity
Early type 2 diabetes treatment
- Weight loss or maintenance*
- Portion control
- Low GI CHO
- High fibre
- CHO distribution
- Dietary pattern of choice: dietary patterns include Mediterranean, vegetarian, DASH, Portfolio and Nordic dietary patterns.
- Physical activity
Strategies when on basal insulin only
Portion control Weight loss or maintenance* CHO consistency Low GI CHO High fibre Dietary pattern of choice ** Physical activity
Strategies when on basal insulin + bolus
Portion control Weight loss or maintenance* CHO consistency initially then learn CHO counting Low GI CHO High fibre Dietary pattern of choice ** Physical activity
Adjustments to strategies during illness
- 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
why do we want to control glucose during surgery
hyperglycaemia is associated with worse surgery outcomes-> use insulin infusion
Type 1 vs Type 2 DM
do we decrease calories
Type 1- no as these patients are usually not overweight/obese
Type 2 DM- yes
Type 1 vs Type 2 DM - Improve insulin action
sensitivity
Type 1- Seldom important: β-cells are inactive and no IR
Type 2 DM- Very urgent
Type 1 vs Type 2 DM
Increase frequency of feedings
Type 1- Yes (conventional Tx)
No (intensive Tx)
Type 2- Not usually
Type 1 vs Type 2 DM
Consistent intake of kcal, CHO, pro, fat
Type 1- Important (conventional Tx)
Not critical (intensive Tx)
Type 2- Better but not critical
Type 1 vs Type 2 DM
Consistent ratio of CHO, pro, fat/meal
Type 1- Very important (conventional Tx); Not critical (intensive Tx)
Type 2- not crucial
Type 1 vs Type 2 DM
Consistent timing of meals
Type 1- important
Type 2- not crucial
Type 1 vs Type 2 DM
Extra food for unusual exercise
Type 1- Yes (conventional Tx); Variable (intensive Tx)
Type 2- not crucial
Type 1 vs Type 2 DM
During illness, provide CHO (with meds and close monitoring)
Type 1- To prevent ketosis (insulin needs may be higher than usual)
Type 2- to prevent HHS
Type 1 vs Type 2 DM
Use of food to treat, prevent hypoglycemia
Type 1- important
Type 2- less important (yes, to treat)
Benefits of DASH
- improved glycemic control
- BP
- LDL-C
and reduces major CV events
