Dietary Management in Diabetes Flashcards
List some goals of diet therapy
- Encourage the attainment or maintenance of a healthy body weight
- To achieve the best possible metabolic control without seriously compromising quality of life
- Delay or prevent complications
- Provide specific guidelines for different stages in lifecycle
- promote self-care
- encourage overall health by providing nutrition instruction
What goal of diet therapy is very important?
Promoting self-care by providing the necessary knowledge, skills resources and support - as the patient must be able to care fo their own condition
In order to achieve the best possible metabolic control without seriously compromising quality of life, which targets are we focusing on?
- Glucose
- Lipid profile (LDL <2 mmol/L)
- BP <130/80
What are the first 4 points of the nutrition checklist? (RFIC)
- Refer to nutrition counselling by an RD
- Follow Eating Well with CFG
- Individualize dietary advice based on preferences and treatment goals
- Choose low GI CHO foods
What are the next 3 points of the nutrition checklist? (KEE)
- Know alternative dietary patters for T2DM
- Encourage matching of insulin to CHO for T1DM
- Encourage nutritionally balances, calorie-reduced diet in patients overweight or obesity
What is a clinical assessment?
- Healthy behaviour interventions by an RD
- Always the first step in management of hyperglycemia in T2DM
In management of hypergylcemia in T2DM, after consult with RD we will usually inititiate intensive healthy behaviour interventions/energy restriction and increased PA to achieve HBW. What happens next?
Provide counselling on a diet best suited to individual needs, preferences and treatment goals based on advantages and disadvantages
If after diet counselling, patient is still not at target, what is the protocol?
Continue healthy behaviour interventions and add pharmacotherapy
When should timely adjustments to healthy behaviour interventions be made to attain A1C?
2-3 months for healthy behaviour alone
When should timely adjustments to healthy behaviour AND pharmacotherapy interventions be made to attain A1C?
3 to 6 months when healthy behaviour is combined with pharmacotherapy
When should a 5-10% weight loss of initial body weight be recommended? Why?
BMI >/= 25
We know that modest weight loss can greatly improve insulin sensitivity, and 5-10% is an achievable target
What are the other benefits to a 5-10% moderate weight loss?
- Improved insulin sensitivity
- Glycemic control
- Blood pressure control
- Lipid levels
What is the SINGLE action that will help insulin and glycemic control the most?
Moderate weight loss of 5-10%
Target CHO diabetes?
45-60%
Target protein diabetes?
15-20%
Target fat diabetes?
20-35%
Minimum intake of ____ of CHO is recommended to sustain brain and glucose dependent organs
130 g/day
Explain the rationale of providing a >45% intake of CHO with diabetes
This amount of CHO, when complex, will prevent the high intake of saturated fat which will lead to a higher risk of CVD
What kinds of CHOs should be recommended?
- Low GI
- High fibre
- Complex
____of added sugar (sucrose) is recommended
<10%
What is important to consider when evaluating the response of the blood glucose curve?
The area unde the curve
What is the glycemic index?
Area under the curve (AUC) in blood glucose response of a given food compare to a standard of the same content of CHO (g) - based on a scale of 0-100
How is GI calculated?
AUC food / AUC standard x 100
What is the glucose load?
Accounts for available CHO in a portion
Pasta has a high glycemic load, does this mean that is automatically has a high GI?
NO - recall that GI is based on the blood glucose response it elicits, and NOT the amount of CHO per portion
What is important when making recommnedations about GI and GL?
- Must explain in lay terms
- Must give recommendations for similar food groups
Watermelon has a high/low GI and a high/low GL
High GI
Low GL
-Watermelon is 98% water, but due to “simple sugars” within the melon will cause a spike in blood glucose
Low GI?
= 55
Medium GI?
56-69
High GI?
> /= 70
Low GL?
= 10
Medium GL?
11-19
High GL?
> /= 20
What else should be considered about Gl and GL accuracy?
That these foods are not usually consumed in isolation, and when combined with other foods may alter the glycemic response
What are some dietary factors that affect the glycemic response?
- Dietary fibres
- Food form
- Cooking and processing
- Digestibility
- Nutrients such as fat/protein present
- Inter-prandial differences
- Fast/slow eater
- Individual glucose tolerance
How can food forms affect glycemic response?
Smaller forms of the same foods may be digested faster
How can cooking and processing affect glycemic response?
Overly cooked foods, such as pasta, will have a higher GI than if cooked al-dente
How can inter-prandial differences affect glycemic response?
Time between meals can affect how we respond to different foods
Glycemic indexes are determined in ___
healthy individuals with normal glucose tolerance
Examples of Low GI breads, grains and cereals?
100% stone-ground whole wheat, pasta, all bran
Examples of other low GI foods?
Sweet potato, yam, legumes
Medium GI breads, grains and cereals?
Whole wheat, rye, pita, oatmeal, couscous, basmati rice
Other Medium GI foods?
White potato, sweet corn, stoned wheat thins, popcorn, bean/pea soups
High GI breads, cereals, grains?
White brea, bran flakes, short-grain rice
Other High GI foods?
Russet potato, pretzels, rice cake
What have studies shown regarding replacing high GI with low GI?
- Improvement in glycemic control in diabetes
- Suggested of increased HDL, decrease CRP
Disadvantage of high GI foods?
Some studies showed hypoglycaemic events with T1DM combined with meds
____ total intake of fibres recommended in DM
HIGHER
g/d fibre diabetes?
30-50 g/day
g/1000 kcal fibre diabetes?
15-15 g/1000 ckal
How does fibre improve glycemic control in diabetes?
Evidence in SOLUBLE fibres, which will slow gastric emptying and glucose absorption as it forms a gel
___ of total fibre intake should be soluble, viscous fibre
1/3
~10-20 g/day
Explain to a patients why it is still OK to consume sugars as a diabetic
We want to minimize intake of aded sugar to minimize spiking blood sugar, but this does NOT mean that we need to eliminate CHOs, in fact, 45-60% of low GI, high fibre CHO are recommended to improve blood sugar control and reduce CVD risk
Bottom line recommendation on CHOs and diabetes
Focus on minimal added sugars, and high quality, high soluble fibre complex carbohydrates
Sucrose recommendation?
<10% total energy
Added fructose?
In place of sucrose may help lowerA1c, likely unharmful BUT may increase TGs
Does intake of HFCS worsen cardiometabolic outcomes compared to sucrose? What is the exception?
- No
- sugar-sweetened beverages
Risk with sugar-sweetened beverages?
High intake associate with HTN and increased ris of CHD, could have huge impact if these are cut out
(T/F) High GI fruits, such as pineapple mango, papaya and melons should be consumed in unlimited amounts in diabetics, as their fibre will decrease glycemic response
False, high GI and should be consumed with caution and in smaller portion sizes
(T/F) High GI fruits, such as pineapple mango, papaya and melons are harmful due to high fructose content
False, could never consume enough fructose from whole fruits to cause harm
Could replacing sucrose with honey and maple syrup be beneficial?
On a weight-weight comparison, contain less sucrose, however contains fructose and glucose therefore not the best substitution
Considerations about low-CHO diets and diabetes?
- Low CHO means a larger amount of lipids, and recall that diabetics are at the highest risk of heart disease
- T1 and T2 DM on Insulin Tx are more prone to ketosis, and severe concern of acidosis
What may compound the risks of keto-acidosis in diabetic patients?
- Insulin therapy or SGLT2 inhibiters
- Low-CHO diets
key concept of developing an adverse metabolic profile?
Excess energy
Low CHO diet range?
4-45%
(T/F) Low CHO diets have shown consistent improvements in A1C, blood lipid profile and maintenance of weight-loss in the long-term
False
What is a concern with low CHO diet and treatment of hypoglycemia in diabetes?
There will be a a blunted response of glucagon injection
Role of glucagon?
Stimulate glycogenolysis and gluconeogenesis in the liver to re-establish blood glucose
Explain the dangerous situation that may arise if a diabetic is following a low CHO diet and experiences a hypoglycaemic episode
If low intake of CHO, glycogen will be depleted, which means that there will be no glycogen reserves to undergo hydrolysis and re-establish blood glucose after injection of glucagon (blunted response)
What is an advantage of low CHO intake?
Less CHOs consumes, less insulin injected
Fat recommendation diabetes?
20-35% of energy
Diabetes recommendations due to high risk of CVD?
- Avoid trans fat
- Sat fat <9%E
- Limit animla sar fat
AI linoleic women and men?
12 g
17 g
AI linolenic acid women and men?
- 1 g
1. 6 g
How should sat and trans fats be replaces?
-PUFAs, MUFAs, whole grains or low-GI CHOs
(T/F) Omega-3 supplements are never recommended, including in severe TG
False, may be recommended for severe HyperTg
Omega-3 supplementation potential effect?
-Decrease TG, platelet aggregation
Higher intake of fish associated with what? Recommendation?
- Red. CAD and kidney disease in T2DM, less albuminemia in T1DM
- 2-3 servings of fish/week
Protein recommendation diabetes?
- 15-20% (1.0-1.5 g/kg/day)
- Replacement of animal with plant protein sources
Effect of replacing animal with plant protein?
Improved A1c, fasting BG, insulin
Concern of CKD and protein?
- No more than 0.8 g/kg/da
- monitor protein status to avoid malnutrition
- CAUTION with plant protein (increase in K+)
Is increasing plant protein recommended in CKD?
NO - as it increased K+ and must consume more volume to get same protein amount, and also we have a limited “budget” for protein, may be better to consume animal proteins
Effects of replacing MUFA with CHO?
- benefits
- Improved fasting BG, systolic BP, Tg and HDL-C
- No effect an A1C
What are the 3 key cardiometabolic benefits related to macronutrient substitutions in diabetes?
1) High CHO with MUFA
2) Fat with low-GI CHO
3) High GI CHO w/ High protein (weight-loss)
Which dietary patterned may be recommended in diabetes?
- Mediterranean diet
- Vegetarian diet
- DASH diet
- Portfoliodiet
- Nordic diet
What is the MOST important consideration when evaluating the benefit of a certain diet in diabetes?
Glycemic control, indicate by A1C
What may help in glycemic control?
Non nutritive sweetners
Are non-nutritive sweeteners included in CHO counting? is there an acceptable daily intake?
No
What may limit intake of non-nutritive sweeteners?
GI disturbances
(T/F) Sorbitol, xylitol and Maltitol are artificial sweeteners
False, are sugar alcohols (non-nutritive sweetners)
No adverse effect of non-nutritive sweeteners with consumption of ___ g/day
10
Alcohol recommendation diabetes?
= 2 drinks/day or 10/week (women)
= 3 drinks/day or 15/week for men
Does moderate intake of alcohol impact BG?
Little effect
Light to moderate intake on BG?
Inverse association with A1C, lower risk of fatal CHD in T2DM
What is a major risk of alcohol intake?
MASKS the symptoms of hypoglycemia and increases ketones
What may delay hypoglycemia?
Moderate alcohol intake with a meal or intake 2-3 hours later
What is a cultural consideration for diabetic patients
fasting and ramadan, risk of hypoglycemia if insulin Tx
What are some key, special concerns for patients on insulin Tx?
- Regularity in meal-spacing and CHO content
- Snacks to avoid hypoglycemia
- Bedtime snacks of CHO and protein –> Avoid nocturnal hypoglycemia
Targeted strategies for pre-diabetes?
-Weight loss/maintenance
-Portion control
Low GI, reduce refined CHO
-PA
Targeted strategies for early type 2 DM
- Same as pre-diabetes, plus:
- CHO distribution, high fibre and dietary pattern of choice
Targeted strategies for DM not on insulin?
Same as early type-2 DM
Targeted strategies when on basal insulin only?
Same, but CHO consistency (since on insulin)
Targeted strategies on basal-bolus insulin?
Same, but CHO consistency initially then learn CHO counting (more flexibility)
Considerations during illness?
Take DM medications as perscribes, and SMBG often
Illness and episode’s of N/V?
Replace usual CHO w liquid or semi-liquid containing CHO (fruit juice, jello, gatorade)
Hydration during illness?
250-370 ml/hr
When should a patient consult MD in illness?
- Cannot tolerate illness
- Glycemia >20 mmol/l
- > 38.5 C for 48 hr
- Ketonuria
- Persistant diarrhea, general deterioration
In hospital glycemic targets in non-critically ill?
Fasting: 5-8
Random: <10
Therapy of choice in non-critically ill?
Pre-hospital regimen or basal-bolus correction
In hospital glycemic targets in critically ill?
8-10
Therapy of choice in critically ill?
IV insulin infusion
In hospital glycemic target of CABG intra-op?
5.5-10
Therapy of choice in CABG intra-op?
IV insulin infusion
In hospital glycemic target for other peri-op?
5-10
Therapy of choice in other peri-op?
As appropriate
No ____ are proven to treat diabetes, and may be harmful
No natural health products
Compare & contrast decreasing kcal in T1Dm and T2DM
T1: No
T2: yes
Compare & contrast importance of improving insulin action in T1Dm and T2DM
T1: Impossible, not important
T2: Very urgent
Compare & contrast the increase frequency of feedings in T1Dm and T2DM
T1: Yes for conventional Tx, but no fo intensive Tx
T2: Not usually
Compare & contrast the importance of consistent intake of kcal and macronutrients kcal in T1Dm and T2DM
T1: Important (conventional Tx), not critical (intensive Tx)
T2: Better, but not critical
Compare & contrast the consistent ratio of CHO, pro and fat/meal in T1Dm and T2DM
T1: Very important (conventional Tx), not critical (intensive Tx)
T2: Not crucial
Compare & contrast consistent timing of meals in T1Dm and T2DM
T1: important
T2: Not crucial
Compare & contrast significance of extra food for unusual exercise in T1DM and T2DM
T1: Yes (conventional Tx) variable (intensive Tx)
T2: Not usually
Compare & contrast recommendation on providing CHO with meals during illness in T1Dm and T2DM
T1: To prevent ketosis
T2: To prevent HHS
Compare & contrast the use of food to treat, and prevent hypoglycemia in T1Dm and T2DM
T1: Important
T2: Less important, but could be used to treat
Discuss important consideration when on conventional Tx (T1DM)
- Increase frequency of feedings
- Consistent intake and ratio of kcal, CHO, pro and fat
- Account for extra food for unusual exercise
Key recommendations (1/7)
- Nutrition counselling by RD to lower A1C and red. hospitalization rates
- Deliver education in small groups or one-on-one
Key recommendations (2/7)
- Follow CFF
- if overweight/obese, follow a nutritionally/balanced, calorie reduced diet
- Dietary modification and increased PA
Key recommendations (3/7)
- 45-60% CHO, 15-20% pro, 20-35% fat
- Regularity in timing and spacing of meals
Key recommendations (4/7)
-Avoid TFA, <9% E from SFA, –> replace with MUFA, PUFA, whole grains and low GI CHO
Key recommendations (5/7)
-Substitute added sugars with other CHOs as part of mixed meals to a max of 10% total energy intake
Key recommendations (6/7)
- 30-50 g/day fibre, where 10-20g/day from soluble
- Low GI CHOs
- Med, veg, DASH, legumes, F&V and nuts recommended
Key recommendations (7/7)
- T1DM match insulin to CHO, or maintain consistency
- Insulin Tx should be education on risk of hypoglycemia alcohol
Key messages ? (4)
- Replace high GI with low GI in mixed meals
- Consistency/spacing of CHO intake
- Intensive healthy behaviour interactions
- Choose the dietary pattern that best aligns with their values, preferences and treatment goals
