1. Dr. S. Nishan Silva (MBBS)

2. Diabetes- What is it? Body is not producing or has lost sensitivity to insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy. Insulin is produced in the body by the pancreas.

3. Types of Diabetes There are several types of diabetes: Type I - body does not produce any insulin. Type II- body is not making enough or is losing sensitivity to insulin made.

4. Types of Diabetes Secondary - a consequence from another disease. For example, pancreatitis or cystic fibrosis. Gestational Diabetes- diabetes during pregnancy. Impaired Glucose Tolerance- an intermediate between normal and diabetes.

5. Insulin from the pancreas Vad happens to the carbohydrates from the food? - - - Fat/muscle cell Stored sugar in the liver (glycogen) Carbohydrates from food

6. A healthy cell Insulin O2O2O2O2 CO 2 WaterEnergy Urine test shows Glucose Ketones 0 0 0 0 Bloodvessel Cell

7. Starvation (Insulin) in liver Fatty acids Ketones Urine test shows Glucose Ketones 0 + 0 + Bloodvessel Cell

8. Diabetes - lack of insulin Cell in liver Fatty acids Ketones Urine test shows Glucose Ketones +++ +++ +++ +++ Bloodvessel

9. Type I Usually diagnosed in children and young adults. Must take daily insulin shots to stay alive. Type I accounts for 5-10% of the population with diabetes.

10. Type II The most common form of the disease. Approximately 50% of men and 70% of women are obese at the time of diagnosis. Nearing epidemic proportions, due to increase # of older Americans, greater occurrence of obesity and sedentary lifestyles.

11. Gestational Diabetes Pregnant women have a higher insulin level. If woman has hyperglycemia, her blood glucose crosses the placenta but her insulin does not. This can cause a high birth weight for baby.

12. Pathophysiology Genes Obesity Sedentary Lifestyle Aging

13. Pathology of Diabetes Age % Insulin resistance Beta cell activity Point of Diabetes

14. Pathology of Diabetes Age % Insulin resistance Beta cell activity Reduced beta cell activity New Point of Diabetes Causes for Beta cell exhaustion 1.Pancreatic damage 2.Pancreatic insufficiency 3. Other?

15. Pathology of Diabetes Age % Insulin resistance Beta cell activity Increased Insulin resistance New Point of Diabetes Causes for Insulin Resistance 1.Increased skin fat 2.Reduced muscle use of glucose 3. Other?

16. Pathology of Diabetes Age % Insulin resistance Beta cell activity Reduced beta cell activity Increased Insulin resistance New Point of Diabetes

17. Pathology of Gestational Diabetes Age % Insulin resistance Beta cell activity Point of Diabetes Ges. Diabetes

18. Who’s at risk? Obesity First degree relative with diabetes Belongs to a high-risk ethnic group Was diagnosed with gestational diabetes or delivered a baby whose birth weight >9 lbs. Hypertension

19. Who’s at risk? HDL level 250 Found to have impaired glucose tolerance or impaired fasting on a previous test.

20. Treatment Goals for Type I Match insulin to food intake. Type I’s are encouraged to be precise and regular from day to day with food intake, insulin regimen, and activity.

21. Exercise and Type I’s Increases flexibility, muscular strength, and well being. Must monitor insulin and food intake to match exercise regimen. Increases insulin effectiveness and sensitivity in the body.

22. Treatment Goals for Type II Achieve normal or near-normal blood glucose levels. Provide adequate calories for reasonable body weight. Prevent, delay or treat nutrition related complications. Improve health through optimal nutrition.

23. Exercise and Type II Especially beneficial in type II diabetes. Promotes weight loss Increases insulin sensitivity. Must also be aware of medication and intake to prevent hypoglycemia.

24. Treatment of Diabetes Diet plays a major role. Carbohydrates are the component of food that causes an increase in blood sugar. Diabetics are encouraged to keep track of the amount of CHO they eat.

25. Nutrition Nutrition Therapy – The Most Fundamental Component of the Diabetes Treatment Plan Goals: –Near Normal Glucose Levels –Normal Blood Pressure –Normal Serum Lipid Levels –Reasonable Body Weight –Promotion of Overall Health

26. Nutrition Consult Conduct Initial Assessment of Nutritional Status Diet History, Lifestyle, Eating Habit Provide Patient Education Regarding –Basic principles of diet therapy –Meal planning –Problem solving –Developing individualized meal plan –Emphasize one or two priorities –Minimize changes from the patient’s usual diet

27. Nutrition Therapy Provide Follow-up assessment of the meal plan to –Determine effectiveness in terms of glucose and lipid control and weight loss –Make necessary changes based on weight loss, activity level, or changes in medication –Provide ongoing patient education and support

28. Methods of Carbohydrate Control There are many new methods of controlling diabetes, these are still the two most common. Exchange Lists Carbohydrate counting- Very basic, allows a little more freedom and variety.

29. Blood Glucose Monitoring All diabetics must keep track of blood glucose levels. This is the only way to know if the treatment is effective. Gives the diabetic a good indication of what affects their blood sugar level. Must check at least 2 times a day and four times a day for at least 3 days a week.

30. Hemoglobin A1c A good indicator of blood glucose control. Gives a % that indicates control over the preceding 2-3 months. Performed 2 times a year. A hemoglobin of 6% indicates good control and level >8% indicates action is needed.

31. Nutrition Assessment Type of diabetes, any complications Blood sugar control Past medical history Anthropometrics- height, weight, BMI, body composition Biochemical- labs Medications, including supplements Dietary 24 hour recall (meals, snacks, and beverages) Favorite foods Food allergies Eating patterns and habits Physical activity Readiness to change Attitude

32. Diabetes and Co-morbidities Screening Parameters Body weight assessmentBody weight assessment –BMI –Waist circumference Blood Glucose – RBS, FBS, PPBSBlood Glucose – RBS, FBS, PPBS Blood PressureBlood Pressure HbA1cHbA1c LipidsLipids Compliance with nutrition planCompliance with nutrition plan Other – Renal functions, ECG, USS abdomen ?Other – Renal functions, ECG, USS abdomen ?

33. The Glycemic Index

34. Definition : Glycemic Index 0 0.5 1 1.5 2 2.5 Time (h) Evaluation of the incremental rise of blood glucose (area under curve) after ingestion of a food that contains 50g of carbohydrates, as a percentage of the same amount of carbohydrate from a reference food (white bread or glucose) and absorbed by the same person 4 6 8 Plasma glucose (mmol/l)

35. The glycaemic index is a ranking of foods from 0 to 100 based on their effect on blood glucose levels High GI eg: White bread Low GI eg: legumes Time Blood glucose level

36. Glycemic Index in ‘Simple English’ The amount of glucose released into blood by a certain type of food with the same amount of carbohydrates found in 50grams of glucose. So it’s a rate/ a ratio a percentage. Making simpler:- “How quickly does a certain type of food release glucose in to blood”

37. Glycemic Index (GI) This is what matters! Food items with a higher glycemic index releases glucose faster into the blood. Food items with lower GI; vice versa. One gram of bread will release glucose faster than one gram of red rice (although the amount of glucose in both types of food might be the same; the speed of release is what matters!)

38. Definition : Glycemic Index Depends upon the rapidity of digestion and absorption of the carbohydrate (physical and chemical properties) Depends on the fibre content of the food (More fibre in food means that type of food releases glucose slowly)

39. Definition : Glycemic Index Examples :- Glycemic Index (Glucose) = 100% Low Glycemic Index  55% Medium glycemic index 56-69% High glycemic index  70%

40. Foods and their Glycemic Index values

41. Effects of Low GI Foods  Satiety (You will feel ‘full’ quicker! But the amount of glucose that goes in to the blood is limited.)  Hunger (Because the food releases glucose slowly over a long time and stays in the stomach longer. So you don’t feel hungry often)  Weight

42. Diseases reduces by low Glycemic Index Food Diabetes Heart Disease High levels of Cholesterol in blood Cancers in Large bowel Metabolic syndrome (Diabetes/Obesity/High cholesterol and so many more) Alzheimer’s disease

43. What does this mean?? The Glycemic index gives you a ROUGH idea of what to eat to prevent mainly Diabetes and a whole lot more. That doesn’t mean the amount is not important. For example; although red rice is ‘healthy’, you shouldn’t eat loads of it. Of course in addition to the Glycemic index you MUST consider the fat content in your food. Else you will prevent Diabetes but die of High blood pressure!!!!

44. Choose what you eat!!! There are several factors you have to consider before selecting what you eat. Glycemic index is just one of them ; a very important aspect recognized internationally and proven by many researches as the mainstay in diabetic diets. The concept of ‘food pyramid’ gives you just a glimps of what you might want to fill your plate with.

46. The Plate Method http://www.tops.org/images/plate.gif

47. Dietary recommendations for diabetes Eat starchy foods regularly Eat more fruit and vegetables Reduce animal or saturated fat Cut down on sugar Reduce salt

48. Nutrition Intervention options for Diabetes Reduce energy and fat intakeReduce energy and fat intake Carbohydrate countingCarbohydrate counting Simplified meal plansSimplified meal plans Healthy food choicesHealthy food choices Individualized meal planning strategiesIndividualized meal planning strategies Exchange listsExchange lists Insulin-to-carbohydrate ratiosInsulin-to-carbohydrate ratios Physical activity and behavioral strategiesPhysical activity and behavioral strategies

49. Breakdown of Macronutrients Total carbohydrate: 45-65% of total calories Total Protein: 10- 35% of total calories Total fat: 20-35% of total calories

50. Eat starchy foods regularly Bread Potatoes Rice Pasta Cereals Plantain Chapatis

51. Eat more fruit and vegetables Fresh Frozen Tinned Dried Juice

52. Choose more high fibre foods To help maintain blood glucose levels and cholesterol levels Fruit Vegetables Pulses Oats Helps to maintain a healthy gut Wholegrain cereals Wholemeal bread Wholewheat pasta Brown rice

53. Reduce animal or saturated fat intake Use low fat milk Use low fat spread instead of butter Use oil high in unsaturated fat, eg olive oil, rapeseed oil

54. Use less fat in cooking Grill Dry-roast Microwave Steam

55. Choose the right sort of fat SATURATED Full fat dairy produce (eg cheese, butter, full cream milk) Pies Biscuits Savoury snacks Lard Hard vegetable fat MONO- UNSATURATED Olive oil Rapeseed oil Groundnut oil POLY- UNSATURATED Sunflower oil (products) Oily fish

56. Cut down on sugary foods Not a sugar free diet Cut out sweets Cut out sugary drinks

57. Choose low sugar products Use diet or low calorie, sugar free drinks

58. Intense sweeteners Tablet Liquid Granulated

59. Reduce salt intake Cut down on added salt Use alternative seasonings Look out for reduced/low sodium foods, eg bread Avoid salt substitutes

60. Eat regular meals based on carbohydrate: Breakfast

61. Lunch or snack meal

62. Main meal

63. Drink alcohol in moderation That’s 2 units a day for women 3 units a day for men

64. Portion Control http://www.snacksense.com/files/u1/portions_v4.jpg

65. Insulin regimens

67. Outcome Measures for Nutrition Interventions Maintain blood glucose levels (80-130)Maintain blood glucose levels (80-130) HbA1c (≤ 7%)HbA1c (≤ 7%) Achieve recommended blood lipid levelsAchieve recommended blood lipid levels Optimize blood pressure (120/80)Optimize blood pressure (120/80) Maintain BMIMaintain BMI Weight loss, if obese (10% weight loss from initial)Weight loss, if obese (10% weight loss from initial)

68. Types of exercise Walking Biking and stationary cycling Lap swimming and water aerobics Weight lifting At least 3-4 times a week, 30-40 minutes per session, 50 to 70% of maximum oxygen uptake

69. Each Person With Diabetes is Different! Every person with diabetes should receive medical nutrition therapy based on his/her medical needs Your dietitian may suggest very specific goals for your weight, diet, and exercise depending on your health status

70. Modern treatment of childhood diabetes Traditional approach - Insulin, diet, and exercise Diabetes treatment today -Insulin, love and care ”It is no fun having diabetes - but you must be able to have fun even if you have diabetes” It is our job to adjust the diet to the child, not the other way around