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NUTR 344 > Diabetes nutritional approach > Flashcards

Diabetes nutritional approach Flashcards

1
Q

Goals of diet therapy

A
  • 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
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2
Q

Since diabetes is a risk factor for __ we also want to control __ (mostly __)

A

Since diabetes is a risk factor for CVD we also want to control lipid profile (mostly LDL-C)

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3
Q

What are the components of metabolic control and targets for each

A
  • Glycemic control: near-normal or targets
  • Lipid profile: primary target LDL-C ≤2.0 mmol/L
  • Blood pressure <130/80
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4
Q

Nutrition checklist (7)

A
  • 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
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5
Q

Nutritional management of hyperglycaemia in t2Dm

A
  1. Clinical assessment
    Healthy behaviour interventions by Registered Dietitan
  2. Initiate intensive healthy behaviour interventions or energy restriction and increased physical activity to achieve/maintain a healthy body weight
  3. Provide counselling on a diet best suited to the individual based on values, preferences, and treatment goals using the advantages/disadvantages
  4. 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
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6
Q

What is the main marker for hyperglycaemic control

A

A1c

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7
Q

What should be advised to people with BMI>25? Why?

A

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

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8
Q

Macronutrient Distribution (% Total Energy) for diabetes

A

Carbohydrates: 45-60%
Protein: 15-20% (or 1-1.5g /kg BW)-> should be maintained or increased in energy reduced diets.
Fat: 20-35%

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9
Q

What is the minimum intake of CHO

A

Minimum intake of 130 g/d

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10
Q

Why would it be advised to consume >45% of CHO?

What should it include/ not include

A

> 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)

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11
Q

Glycemic index vs glycemic load

A

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

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12
Q

What is the formula for glycemic load? How would you calculate GL of 200g of pasta that has 50g of cho?

A

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

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13
Q

Glycemic index vs load scales cut-offs

A

Glycemic index (GI)
Low: ≤ 55
Medium: 56-69
High: ≥ 70

Glycemic load (GL)
Low: ≤ 10
Medium: 11-19
High: ≥ 20

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14
Q

Dietary factors affecting the glycemic response

A 
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
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15
Q

What are the benefits of replacing high Gi foods with low GI foods? Should all patients be advised to do so?`

A

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.

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16
Q

What are the fiber intake recommendations for DM?

A

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

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17
Q

benefits of fiber intake in diabetes

A

Evidence for more benefits from soluble fiber:

  • slows gastric emptying and glucose absorption
  • Improvement in A1C, Fasting BG and lipid profile
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18
Q

How to increase fiber intake?

A

Consume more pulses, whole grains, fruits and veggies

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19
Q

Recommendations for added sucrose intake? Why is it so?

A

<10% of total energy is acceptable

>10% increases BG and TG in some

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20
Q

Added sucrose vs added fructose

A

Added fructose

in place of sucrose may help lower A1C and unlikely harmful

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21
Q

What does excess fructose lead to?

A

> 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
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22
Q

Natural fructose from fruits consensus

A

Natural fructose from fruits: no harm

Caution with high GI fruits: pineapple, mango, papaya, melons

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23
Q

What is the amount of CHO in low CHO diets?

A

CHO of 4% to 45% of total energy

24
Q

Are low CHO diets beneficial in DM?

A

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

25
Q

Recommendations for fat intake

A

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

26
Q

What should saturated fats be replaced with?

A

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

27
Q

Should DM patients take omega-s supplements? What might they take instead

A

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

28
Q

Benefits of replacement of animal with plant protein sources

A

improved A1C, fasting BG and insulin

29
Q

Protein and chronic kidney disease

A
  • 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
30
Q

Substitution of MUFA for carbohydrates

A

may have benefits in T2DM, over ≅20 weeks:
Improved fasting BG, systolic BP, TG and HDL-C
But no reduction in A1C

31
Q

Macronutrient substitutions cardiometabolic benefits shown in T2DM

A

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

32
Q

Atkins

A

low carb

33
Q

Best diets (most benefit vs least disadvantages)

A

Mediterranean (improved, a1c, decrease CVD risk, BP, CRP, increased HDL-c improved retinopathy; no disadvantages)

34
Q

Why don’t weight loss diets show no benefit on a1c?

A

Weight loss diets are usually not adhered to for a long period -> no a1c benefit

35
Q

benefits of meal replacement

A

useful for temporary intervention for rapid weight decease (e.g. for a surgery)
someone who lacks cooking skills

36
Q

Benefits of vegetarian diet vs vegan

A

Vegan or vegetarian dietary pattern to improve glycemic control, body weight, and blood lipids including LDL-C, and reduce myocardial infarction

37
Q

benefits and risks of non-nutritive sweeteners

A
  • May help in glucose control
  • Recent study shows impact of saccharin, sucralose and aspartame on glucose tolerance through alteration of gut microbiome
38
Q

Adverse effects, recommended intake of sugar alcohols

A

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
39
Q

Risks and benefits of alcohol intake

A

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

40
Q

How is delayed hypoglycaemia related to T2DM?

A

T1DM and insulin-treated T2DM: moderate alcohol intake with meal or 2-3 hours later -> delayed hypoglycemia

41
Q

What can help to avoid nocturnal hypoglycemia

A

bed-time snacks

42
Q

Pre-diabetes treatment

A

Weight loss or maintenance*
Portion control
Guidance to include low GI CHO and reduce refined CHO
Physical activity

43
Q

Early type 2 diabetes treatment

A
  • 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
44
Q

Strategies when on basal insulin only

A 
Portion control
Weight loss or maintenance*
CHO consistency
Low GI CHO
High fibre
Dietary pattern of choice **
Physical activity
45
Q

Strategies when on basal insulin + bolus

A 
Portion control
Weight loss or maintenance*
CHO consistency initially then learn CHO counting
Low GI CHO
High fibre
Dietary pattern of choice **
Physical activity
46
Q

Adjustments to strategies during illness

A
  • 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
47
Q

why do we want to control glucose during surgery

A

hyperglycaemia is associated with worse surgery outcomes-> use insulin infusion

48
Q

Type 1 vs Type 2 DM

do we decrease calories

A

Type 1- no as these patients are usually not overweight/obese
Type 2 DM- yes

49
Q

Type 1 vs Type 2 DM - Improve insulin action

sensitivity

A

Type 1- Seldom important: β-cells are inactive and no IR

Type 2 DM- Very urgent

50
Q

Type 1 vs Type 2 DM

Increase frequency of feedings

A

Type 1- Yes (conventional Tx)
No (intensive Tx)
Type 2- Not usually

51
Q

Type 1 vs Type 2 DM

Consistent intake of kcal, CHO, pro, fat

A

Type 1- Important (conventional Tx)
Not critical (intensive Tx)
Type 2- Better but not critical

52
Q

Type 1 vs Type 2 DM

Consistent ratio of CHO, pro, fat/meal

A

Type 1- Very important (conventional Tx); Not critical (intensive Tx)
Type 2- not crucial

53
Q

Type 1 vs Type 2 DM

Consistent timing of meals

A

Type 1- important

Type 2- not crucial

54
Q

Type 1 vs Type 2 DM

Extra food for unusual exercise

A

Type 1- Yes (conventional Tx); Variable (intensive Tx)

Type 2- not crucial

55
Q

Type 1 vs Type 2 DM

During illness, provide CHO (with meds and close monitoring)

A

Type 1- To prevent ketosis (insulin needs may be higher than usual)
Type 2- to prevent HHS

56
Q

Type 1 vs Type 2 DM

Use of food to treat, prevent hypoglycemia

A

Type 1- important

Type 2- less important (yes, to treat)

57
Q

Benefits of DASH

A
  • improved glycemic control
  • BP
  • LDL-C
    and reduces major CV events

NUTR 344 (22 decks)

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