1. Ty Lecture 4d 3 February 2014 Type 2 Diabetes Pathology Nutritional Intervention-pre- and post-onset

2. Ty Type 2 diabetes-causes -genetics including genetically driven diabetes -obesity-caused by poor diet (high fat, high simple sugars or glycaemic index foods), lack of exercise and/or genetics -obesity leads to metabolic syndrome and pre- diabetes (still time to recover before becoming type 2 diabetic) -obesity leads to insulin resistance which ultimately leads to reduced pancreatic insulin production -metabolic syndrome and pre-diabetes can lead to type 2 diabetes (type 2 diabetes is permanent)

3. Metabolic syndrome Prevent and in part manage by Canada’s food guide and exercise (150 minutes per week of moderate to vigourous exercise)exercise)

4. -Type 2 diabetes Post onset management in part by diet and exercise and if need be oral medications and/or insulin

5. Canadian Diabetes Association Clinical Practice Guidelines Nutrition Therapy Chapter 11 Paula D. Dworatzek, Kathryn Arcudi, Réjeanne Gougeon, Nadira Husein, John L. Sievenpiper, Sandi Williams

6. Nutrition Checklist 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 2013

7. Nutrition Checklist (continued) 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 overweight or obese patients 2013

8. Encourage patients to follow Eating Well with Canada’s Food Guide in order to meet their nutritional needs http://www.hc- sc.gc.ca/fn- an/food-guide- aliment/index- eng.php

9. Macronutrient Distribution (% Total Energy) CarbohydratesProteinFat % of total energy 45-60%15-20% (or 1-1.5g / kg BW) 20-35% Calories per gram 449 Grams for 2000 calorie/day diet 225-30075-10044-78 BW = body weight

10. Choosing Foods Using % Daily Value http://www.hc-sc.gc.ca/fn-an/label- etiquet/nutrition/cons/fact-fiche-eng.php Daily Values > 15% = a lot Daily Value < 5% = a little

11. For Patients with BMI ≥25 kg/m 2 … Nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight Weight loss of 5-10% of initial body weight Improved insulin sensitivity, glycemic control, blood pressure control, lipid levels

12. Choose low glycemic index carbohydrates www.guidelines.diabetes.ca

13. 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 Figure 1 – Nutritional management of hyperglycemia in type 2 diabetes 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 2013

14. A1C = glycated hemoglobin CRP = C reactive protein TC = total cholesterol CHO = carbohydrate MUFA = monounsaturated fatty acid LDL = low-density lipoprotein BP = blood pressure TG = triglycerides FPG = fasting plasma glucose GI = gastrointestinal  = <1% decrease in A1C HDL = high-density lipoprotein Properties of Macronutrients Dietary interventionsA1CAdvantagesDisadvantages Hi-CHO (low-glycemic index [GI])   HDL-C,  CRP,  hypoglycemia - Hi-CHO (high fibre)   TC,  LDL-C  HDL-C, GI side effects Hi-MUFA   TG - Lo-CHO   TG  Micronutrients,  renal load Hi-protein   BP,  TG, preserve lean mass  Micronutrients,  renal load Long chain omega 3 fatty acids   TG Methyl-Hg exposure, environmental impact 2013

15. Properties of Dietary Patterns Dietary PatternA1CAdvantagesDisadvantages Vegetarian Diet   LDL-C,  HDL-C  Vitamin B12 Mediterranean Diets   BP,  CRP,  TC,  HDL-C,  TC:HDL-C,  TG none DASH   Weight,  BP,  CRP,  LDL-C,  HDL-C none Atkins diet   Weight,  TC,  HDL-C,  TC:HDL-C,  TG  LDL-C,  micronutrients,  adherence Protein Power Plan   Weight  Micronutrients,  adherence,  renal load Ornish -  Weight,  LDL-C:HDL-C  FPG,  adherence Weight Watchers -  Weight,  LDL-C:HDL-C  FPG,  adherence Zone Diet -  Weight,  LDL-C:HDL-C  FPG,  adherence Dietary Pulses   TC,  LDL-C GI side effects Nuts   LDL-C,  apo-B,  apo-B:apo-A1 none Meal Replacements   weight Temporary intervention 2013

16. Recommendations 1 and 2 1.People with diabetes should receive nutrition counseling by a registered dietitian to lower A1C levels [Grade B, Level 2, for type 2 diabetes; Grade D, Consensus, for type 1 diabetes], and reduce hospitalization rates [Grade C, Level 2] 2. Nutrition education is effective when delivered in either a small group or one-on-one setting [Grade B, Level 2]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role-playing, and group discussions [Grade B, Level 2]

17. Recommendations 3 and 4 3.Individuals with diabetes should be encouraged to follow Eating Well with Canada’s Food Guide in order to meet their nutritional needs [Grade D, Consensus] 4.In overweight or obese people with diabetes a nutritionally balanced, calorie reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A] 2013

18. Recommendations 5 and 6 5.In adults with diabetes, the macronutrient distribution as a percentage of total energy can range from 45-60% carbohydrate, 15-20% protein, and 20-35% fat to allow for individualization of nutrition therapy based on preference and treatment goals [Grade D, consensus] 6.Adults with diabetes should consume no more than 7% of total daily energy from saturated fats [Grade D, Consensus] and should limit intake of trans fatty acids to a minimum [Grade D, Consensus] 2013

19. Recommendations 7 and 8 7.Added sucrose or added fructose can be substituted for other carbohydrates as part of mixed meals up to a maximum of 10% of total daily energy intake, provided adequate control of BG and lipids is maintained [Grade C, Level 3] 8. People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4]

20. Recommendation 9 9.Dietary advice may emphasize choosing carbohydrate food sources with a low glycemic index to help optimize glycemic control [type 1 diabetes: Grade B, Level 2; type 2 diabetes: Grade B, Level 2]

21. Recommendation 10 10. Alternative dietary patterns may be used in people with T2DM to improve glycemic control, (including): Mediterranean-style dietary pattern [Grade B, Level 2] Vegan or vegetarian dietary pattern [Grade B, Level 2] Incorporation of dietary pulses (e.g., beans, peas, check peas, lentils) [Grade B, Level 2] Dietary Approaches to stop Hypertension (DASH) dietary pattern [Grade B, Level 2] 2013

22. Recommendations 11 and 12 11. An intensive lifestyle intervention program combining dietary modification and increased physical activity may be used to achieve weight loss and improvements in glycemic control, and cardiovascular risk factors [Grade A, Level 1A] 12. People with type 1 diabetes should be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2]; or should maintain consistency in carbohydrate quantity and quality [Grade D, Level 4]

23. Recommendations 13 13. People using insulin or insulin secretagogues should be informed of the risk of delayed hypoglycemia resulting from alcohol consumed with or after the previous evening’s meal [Grade C, Level 3] and should be advised on preventive actions such as carbohydrate intake and/or insulin dose adjustments, and increased BG monitoring [Grade D, Consensus].

24. CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients

25. Type 2 diabetes Post-onset management in part exercise

26. Canadian Diabetes Association Clinical Practice Guidelines Physical Activity and Diabetes Chapter 10 Ronald J Sigal, Marni J Armstrong, Pam Colby, Glen P Kenny, Ronald C Plotnikoff, Sonja M Reichert, Michael C Riddell

27. Physical Activity Checklist DO a minimum of 150 minutes of moderate-to vigorous-intensity aerobic exercise per week INCLUDE resistance exercise ≥ 2 times a week SET physical activity goals and INVOLVE a multi- disciplinary team ASSESS patient’s health before prescribing an exercise regimen 2013

28. Physical Activity: Bridging the Gap ProblemsSolutions Lack of knowledge of resources Increase awareness among health care professionals of community resources Time constraints during physician-patient encounter Involve a multi-disciplinary team of Physical Therapists, Diabetes Educators and Case Workers who can help motivate patients Pre-existing or suspected heart disease If patient wishes to take on activity more vigorous than walking, evaluate with a history and physical, resting ECG and possibly exercise ECG stress test.

29. Know your Community Resources and Advertise Them Speak to your patients about community resources: Community pools, gyms, safe walking trails, weight loss smart phone apps etc.

30. Pre-exercise Assessment Assess for conditions that can predispose to injury before prescribing an exercise regimen: –Neuropathy (autonomic and peripheral) –Retinopathy –Coronary artery disease – resting ECG +/- exercise stress test (see CPG Chapter 23) –Peripheral arterial disease

31. www.guidelines.d iabetes.ca

33. Recommendation 1 1.People with diabetes should accumulate a minimum of 150 minutes of moderate to vigorous intensity aerobic exercise each week, spread over at least 3 days of the week, with no more than 2 consecutive days without exercise [Grade B, Level 2, for T2DM; Grade C, Level 3 for T1DM]

34. Recommendation 2 2.People with diabetes (including elderly people) should perform resistance exercise at least twice a week, and preferably 3 times per week [Grade B, Level 2] in addition to aerobic exercise [Grade B, Level 2]. Initial instruction and periodic supervision by an exercise specialist are recommended [Grade C, level 3]

35. Recommendations 3 and 4 3.People with diabetes should set specific physical activity goals, anticipate likely barriers to physical activity (e.g. weather, competing commitments), develop strategies to overcome these barriers [Grade B, Level 2], and keep records of their physical activity [Grade B, Level 2] 4. Structured exercise programs supervised by qualified trainers should be implemented when feasible for people with type 2 diabetes to improve glycemic control, CVD risk factors, and physical fitness [Grade B, Level 2] 2013

36. Recommendation 5 5.People with diabetes with possible cardiovascular disease or microvascular complications of diabetes, who wish to undertake exercise that is substantially more vigorous than brisk walking, should have medical evaluation for conditions that might increase exercise-associated risk. The evaluation would include history, physical examination (including fundoscopic exam, foot exam, and neuropathy screening), resting ECG, and, possibly, exercise ECG stress testing [Grade D, consensus] 2013

37. Diet and exercise type 1 and type 2 diabetes Along with relevant medications including insulin as appropriate, diet and exercise are meant to protect the vasculature, damage to which is the major cause of disability (heart attack and stroke) and death (heart attack and stroke) in all diabetics See -Donohoe et al (2007) JAMA 298:765-end of article -Booth et al (2006) Lancet 368:29-end of article -Lloyd-Jones et al (2006) 113:791-end of article

38. CDA Vascular Protection Checklist AA1C – optimal glycemic control (usually ≤ 7%) BBP – optimal blood pressure control (< 130/80 mmHg) C Cholesterol – LDL-C ≤ 2.0 mmol/L if decision made to treat(http://guidelines.diabetes.ca/VascularRisks/RiskAsse ssment/) D Drugs to protect the heart (even if the baseline blood pressure or LDL-C is already at target) (http://guidelines.diabetes.ca/VascularRisks/RiskAssessme nt/) E Exercise / Eating – Regular physical activity, healthy eating, achievement and maintenance of healthy body weight sSmoking cessation

39. CDA Vascular Protection Checklist glycaemic control is best for microvascular disease-gives decreased nephropathy and decrease retinopathy(both are microvascular) but gives mixed results for macrovascular disease Note book “Heart Health for Canadians’-by Dr. Beth Abramson-talks in part about health eating.

40. CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients