Nutrition and Diabetes How to be an effective resource for patients behind the counter…And pass the CDE Exam! Diabetes Smart Program March 20, 2016

OBJECTIVES To review the principles of nutrition therapy for diabetes management To review some practice exam questions To provide some real-life examples, teaching tips and survival tools!

Table of Contents (90 slides) Nutrition therapy and recommendations Carbohydrates Sweeteners Glycemic Index Distribution of CHO, Fat and Protein Meal Planning Basic Advanced Carb Counting The BTB Poster Nutrition Labels Sample Exam Questions Useful Tools behind the Counter Anything in RED – know for the Exam.

NUTRITION THERAPY Clinical Practice Guidelines Integral part of the treatment and self- management of diabetes Goals To maintain or improve quality of life and nutritional and physiological health To prevent and treat acute and long-term complications of diabetes, associated comorbid conditions and concomitant disorders

NUTRITION THERAPY Can reduce A1C by 1.0 to 2.0% When used with other components of diabetes care, can further improve clinical and metabolic outcomes Can have significant impact on postprandial blood glucose levels in particular

NUTRITION RECOMMENDATIONS Nutrition recommendations for people with diabetes are generally the same as for all Canadians Based on the principles of Canada’s Guidelines for Healthy Eating: Enjoy a variety of foods Emphasize cereals, breads and other whole grain products, vegetables and fruits Choose lower-fat dairy products, leaner meats and foods prepared with little or no fat Achieve and maintain a healthy body weight by enjoying regular physical activity and healthy eating Limit salt, alcohol and caffeine http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/print_eatwell_bienmang- eng.pdf 6

EATING WELL WITH CANADA’S FOOD GUIDE Summarizes nutrient needs and nutritional guidelines for all healthy Canadians Daily serving recommendations by age and gender Can be used by people with diabetes to make healthy food choices Foods should be low in energy density to: promote satiety and discourage overconsumption Help achieve and maintain a healthy body weight Ensure an adequate intake of CHO, fibre, essential fatty acids, proteins, vitamins and minerals http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide- aliment/print_eatwell_bienmang-eng.pdf

http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide- aliment/print_eatwell_bienmang-eng.pdf

BALANCED APPROACH Moderate carbohydrate Protein choice at meals Small serving of heart healthy fat Include together at all meals Mixed meals have the slowest BG response

Distribution of Macronutrients EXAM! MACRONUTRIENT DISTRIBUTION MACRONUTRIENT % OF TOTAL CALORIES Carbohydrate 45-60% Fat 20-35% Protein 15-20% http://guidelines.diabetes.ca/executivesummary/ch11

WHAT IS CARBOHYDRATE (CHO)? TOTAL CHO = SUGAR + STARCH + DIETARY FIBRE

WHY IS CHO IMPORTANT ? Total amount of carbohydrate (CHO) eaten is the main factor that increases blood glucose (BG) levels Self-monitoring of blood glucose (SMBG) two hours after meals allows you to observe the connection between CHO and BG levels To best control CHO intake: control the total amount from sugars and starches choose foods of medium and low glycemic index (GI)

CARBOHYDRATE RECOMMENDATIONS 2013 CPGs suggest: Include vegetables, fruit, whole grains and milk Within the same food category, consume low glycemic index foods in place of high glycemic index foods Increase dietary fibre to 25-50 g/day from a variety of sources, including soluble and cereal fibre Sucrose (table sugar) intake of up to 10% of total daily energy is acceptable Up to 60g of added fructose (e.g. fructose- sweetened beverages and foods) in place of an equal amount of sucrose is acceptable •http://guidelines.diabetes.ca/Browse/Chapter11.aspx

Artificial Sweeteners and Sugar Alcohols –Intake of < 10 g/day of sugar alcohols is acceptable –Use of artificial sweeteners is acceptable Need to memorize the guidelines for how much artificial sweetener is acceptable (based on mg/kg/day). •http://guidelines.diabetes.ca/Browse/Chapter11.aspx

Memorize… Per these guidelines, it would be acceptable for a 70kg man to ingest up to 2800mg of aspartame per day. What does this mean to the 70kg man? 22.4 cans of diet coke per day.

Stevia Per these guidelines, it would be acceptable for a 70 kg man can ingest up to 70000 mg (70 g) of erythritol per day 1 pkg of Truvia = 3 g (3000 mg) of Erythritol. 70 g is allowed divided by 3 g is a pkg of Truvia = 23.3 packets per day.

GLYCEMIC INDEX (GI) Scale that ranks CHO-rich foods by how much they raise blood glucose levels compared to a standard food Standard used can be glucose or white bread Eating foods with a low glycemic (GI) can: Decrease postprandial BG levels Improve glycemic control Improve lipid profile and emerging CVD factors Have a role in the prevention and management of obesity because of a satiety factor •Canadian Diabetes Association.

GLYCEMIC INDEX (GI) GI > 70 GI < 55 White bread Pumpernickel White bagel Bran Flakes /CF / RK Minute Rice Potato French Fries Pretzels Rice cakes Pumpernickel All Bran / Bran Buds / Oat Bran Parboiled or converted rice Pasta/noodles Sweet potato Legumes •http://guidelines.diabetes.ca/Browse/Chapter11.aspx

FACTORS THAT AFFECT GLYCEMIC INDEX Cooking increases GI of food: Cooking swells the starch molecules and makes them easier to digest. Al-dente pasta has lower GI. Processing: More refined a product is, the higher the GI Fat Content: Higher the fat content, the lower its GI because fat tends to slow down digestion of these foods Acid Content Acid present in food slows down digestion of foods consumed at the same meal. Adding lemon juice or vinegar to a salad will help lower GI of meal. •http://guidelines.diabetes.ca/Browse/Chapter11.aspx

The Canadian Diabetes Association Reference Tool: •http://guidelines.diabetes.ca/Browse/Chapter11.aspx

Distribution of Macronutrients MACRONUTRIENT DISTRIBUTION MACRONUTRIENT % OF TOTAL CALORIES Carbohydrate 45-60% Fat < 35% Protein 15-20% •http://guidelines.diabetes.ca/Browse/Chapter11.aspx

FAT AND PROTEIN RECOMMENDATIONS 2013 CPGs suggest: Restrict saturated fats to < 7% of total daily energy intake and restrict trans fat intake to a minimum Limit polyunsaturated fat to < 10% of energy intake and monounsaturated fats to < 20% of energy intake Consume monounsaturated fats instead of saturated fats more often Include foods rich in polyunsaturated omega-3 fatty acids and plant oils No evidence to suggest that usual recommended protein intake should be modified •http://guidelines.diabetes.ca/Browse/Chapter11.aspx

Good Fat, Bad Fat

DIABETES MEAL PLANNING Basic diabetes meal planning involves consistent amounts of CHO at meals Canada’s Food Guide Plate Method Handy Portion Guide More advanced diabetes meal planning allows for flexibility in meal planning Beyond the Basics Carbohydrate Counting (Basic and Advanced)

How does your plate look? Most people have a plate with ½ CHO and ½ PRO and NO veggies! And how big is your dinner plate? Usually a bread and butter plate is a better size for a full meal. VS

HANDY PORTION GUIDE

Other common objects

More advanced meal planning Need to know: Calorie requirements per day Recommended calorie distribution for CHO, Fat and Protein Amount of calories in 1 g of CHO, Fat, Protein and Alcohol 15 g of CHO = 1 CHO choice

Distribution of Macronutrients EXAM! MACRONUTRIENT DISTRIBUTION MACRONUTRIENT % OF TOTAL CALORIES Carbohydrate 45-60% Fat 20-35% Protein 15-20% http://guidelines.diabetes.ca/executivesummary/ch11

How many kcal per gram? 1g of Fat has 9kcal 1g of Protein has 4kcal 1g of CHO has 4kcal 1g of alcohol has 7kcal

Why is this important? % OF TOTAL CALORIES For a 2000 calorie diet … Advanced Meal Planning is MATH 45-60% CHO (Avg = 50%) Step 1: 2,000 cal x 50% CHO = 1000 cal from CHO/day Step 2: 1,000 CHO cal divided by 4 cal/g CHO= 250 g CHO /day Step 3: 250 g CHO/15 g of CHO = 16.67 round to 17 17 CHO choices per day divided in meals and snacks 20-35% FAT (Avg = 30%) Step 1: 2000 cal x 30% Fat = 600 calories/day from Fat Step 2: 600 fat calories divided by 9 cal/g Fat = 66.7 = 67 g FAT/day g 67 g of Fat is divided among meals and snacks/day 15-20% PRO Avg = 20% Step 1: 2000 cal x 20% PRO = 400 calories/day from Protein Step 2: 400 protein calories divided by 4 cal/ g PRO = 100 g PRO/day 100 g of PROTEIN is divided among meals ands snacks/day

THE CHO PRESCRIPTION Patient requires 2000 calories per day 50% of calories as CHO 2000 calories x 50% = 1000 calories 1000 ÷ 4 = 250 grams CHO per day 250 g ÷ 15 g of Cho = 17 CHO choices Distribute 17 CHO choices over meals and snacks

Small banana, ¾ c yogourt Meal CHO choices g of CHO Food Choices Breakfast 3 45 1 small bagel, ½ cup OJ Snack 2 30 Small banana, ¾ c yogourt Lunch 4 60 2 slices WW bread, 30 grapes 6 cups air-popped popcorn Dinner 1 cup rice, 1 cup peas 1 cup LF milk, 3 arrowroots Total 17 255 34

MEAL PLANNING CHO COUNTING Two Approaches: BASIC: CHO targets – particularly for those people not using meal time insulin 1. ADVANCED: matching insulin to carbohydrate intake – particularly for those people on rapid-acting insulin at meal time and those using insulin pump

BASIC CARBOHYDRATE COUNTING – CHO TARGETS Individual variation: 150g – 300g / day 45g – 60g per meal: Women 60g – 75g per meal: Men 15g – 30g at HS if needed

BEYOND THE BASICS Meal planning system based on 15 g carbohydrate choices 1 serving = 15 g CHO or 1 carbohydrate choice Minimum of 3-4 choices per meal 1-2 choices per snack •Canadian Diabetes Association. http://guidelines.diabetes.ca/PatientResources.aspx

For the exam – understand and memorize the BTB Poster! Order your copy here: https://orders.diabetes.ca/cda/product.asp?category=BEM&part_no=211505&find_category&find_description&find_3p8art_ desc

Left side of the Poster lists CHO containing food: Grains & Starches Fruits Milk & Alternatives Other Choices 1 serving = 15 g CHO or 1 CHO choice

Other Choices (sweet foods and snacks)

Add favourite foods -

Count the carbs in these vegetables: Parsnips, Peas and Winter Squash provide 15 g of CHO per cup

Count the carbs in legumes - peas and beans 1 cup provides 15 g of CHO

Fats do not contain CHO

CARBOHYDRATE- CONTAINING FOOD GROUPS Grains & Starches Fruits Milk & Alternatives Other Choices (Sweet Foods and Snacks) 1 Serving = 15 g CHO or 1 CHO choice

FOOD GROUPS THAT DO NOT CONTAIN CHO Vegetables (most) Meat & Alternatives Fats Parsnip, peas and winter squash provide 15 g of available CHO when 250ml (1 cup) is eaten

FRUITS CHOOSE MORE OFTEN CHOOSE LESS OFTEN 1 medium apple ½ cup unsweetened applesauce 1 small banana 2 cups blackberries, strawberries 1 cup blueberries 15 cherries 15 grapes 2 medium kiwi 1 medium orange ½ canned in fruit in juice CHOOSE LESS OFTEN ¼ cup mixed dried fruit ½ cup juice

CARBOHYDRATE- CONTAINING FOODS Should we eat all we want of the “choose more often” choices? NO – these foods still contain CHO Important to manage the total amount of carbohydrate that is consumed With regards to carbohydrate, the total quantity is important for day-to-day management of blood glucose, but the quality (GI) is important for long term health benefits.

DETERMINING INSULIN-TO- CARBOHYDRATE RATIO Need to determine how many grams of CHO one unit of insulin will cover • 500 ÷ TDD or 500 ÷ (weight in kg ÷2) Track pattern of insulin dosage, CHO intake and ac and 2 hr pc blood glucose levels

ADVANCED CHO COUNTING INSULIN-TO-CARBOHYDRATE RATIO CHO amounts can be varied with rapid insulin at meals (insulin : carbohydrate ratio) Matching insulin to carbohydrate intake Eg. 60 gram CHO meal / 10 units Rapid = 1 unit per 6 grams CHO OR Eg. 60 gram CHO meal / 6 units Rapid = 1 unit per 10 grams CHO

NUTRITION LABELS Nutrition label is the most accurate source of nutrition information Food labels can be used to estimate the size of one carbohydrate choice Important things to watch: Portion size Calorie content Fat content CHO content Fibre content

NUTRITION FACTS Total CHO indicated in grams This number includes sugar, starch and fibre Sugar and fibre might be shown separately Note portion size on label

NUTRITION FACTS Dietary fibre is not absorbed and, thus, does not increase BG levels Subtract fibre from total CHO to get available carbohydrate

AVAILABLE CARBOHYDRATE How much available carbohydrate is contained in 60g of this product? Answer = 22g • 24g – 13g = 11g x 2svg = 22g

AVAILABLE CARBOHYDRATE And how many carb- choices would this be for someone using the carb-counting method/ Answer = 22g / 15g = ~ 1.5 choices.

Sample Exam Questions Nutrition Focus

Question 1 A box of cereal has the following information on it’s label: Svg size: 2/3 cup (30g serving), Total Carb 25g, Sugars 8g, Starch 12g, Fibre 6g. If the patient has 2 cups of cereal, how many carb choices are they having? – A. 5 choices – B. 4 choices – C. 3 choices – D. 2.5 choices

ANSWER A box of cereal has the following information on it’s label: Svg size: 2/3 cup (30g serving), Total Carb 25g, Sugars 8g, Starch 12g, Fibre 6g. If the patient has 2 cups of cereal, how many carb choices are they having? – A. 5 choices – B. 4 choices – C. 3 choices – D. 2.5 choices

Question 2 The acceptable amount of added sugar intake for someone on a 2500kcal diet is: – A. 22.0g – B. 35g – C. 62.5g – D. 73g

ANSWER The acceptable amount of added sugar intake for someone on a 2500kcal diet is: – A. 22.0g – B. 35g – C. 62.5g – D. 73g

Question 3 What are the CHO recommendations for the Type I diabetes patient? A. 40-60% of calories from CHO source B. 30-50% of calories from CHO source C. 45-60% of calories from CHO source D. 40-50% of calories from CHO source

ANSWER What are the CHO recommendations for the Type I diabetes patient? A. 40-60% of calories from CHO source B. 30-50% of calories from CHO source C. 45-60% of calories from CHO source D. 40-50% of calories from CHO source

Question 4 Which of the following foods has the highest G.I.? A. Pumpernickel B. Corn flakes C. Oatmeal D. Sweet Corn

ANSWER Which of the following foods has the highest G.I.? A. Pumpernickel B. Corn flakes C. Oatmeal D. Sweet Corn

Question 5 Rita is ill. Her usual lunch consists of a ham sandwich, an apple and a diet pop. What clear fluids should she have instead during illness? A. 2 popsicles (75 ml each) B. 250ml 7-Up and 250ml orange juice C. 250ml apple juice and ½ C sweetened iced tea D. 250ml Jello and 250ml apple juice

ANSWER Rita is ill. Her usual lunch consists of a ham sandwich, an apple and a diet pop. What clear fluids should she have instead during illness? A. 2 popsicles (75 ml each) B. 250ml 7-Up and 250ml orange juice C. 250ml apple juice and ½ C sweetened iced tea D. 250ml Jello and 250ml apple juice

Popsicles ~1 CHO Choice

Question 6 Which of the following actions is advised to reduce the risk of cardiovascular disease in individuals with diabetes? A. Reduce saturated fat intake to less than 7% of energy intake B. Increase the consumption of trans fatty acids C. Increase egg and reduce meat consumption to reduce the amount of saturated fat in the diet D. Ingest food containing large amounts of animal fats

ANSWER Which of the following actions is advised to reduce the risk of cardiovascular disease in individuals with diabetes? A. Reduce saturated fat intake to less than 7% of energy intake B. Increase the consumption of trans fatty acids C. Increase egg and reduce meat consumption to reduce the amount of saturated fat in the diet D. Ingest food containing large amounts of animal fats

Question 7 Which of the following contains the greatest amount of carbohydrate? A. 1 cup orange juice B. 1 cup cranberry juice C. 1 cup grape juice D. 1 cup apple juice

ANSWER Which of the following contains the greatest amount of carbohydrate? A. 1 cup orange juice B. 1 cup cranberry juice - C. 1 cup grape juice - D. 1 cup apple juice

Question 8 Which of the following is NOT a guideline for someone with diabetes A. Eat at least 1 green and 1 orange vegetable per day. B. Encourage balanced exercise regime including resistance training, cardiovascular activity and stretching. C. Fat intake should be 20-35% of total daily kcal. D. Eat whole fruit and avoid juices

ANSWER Which of the following is NOT a guideline for someone with diabetes A. Eat at least 1 green and 1 orange vegetable per day. B. Encourage balanced exercise regime including resistance training, cardiovascular activity and stretching. C. Fat intake should be 20-35% of total daily kcal. D. Eat whole fruit and avoid juices

Question 9 How many carbohydrate choices does the following meal contain: 2 cups of salad made with lettuce, tomato and cucumbers, 5 olives, and 2 Tbsp of oil and vinegar dressing 2 cups of cooked Penne Pasta, with ½ cup tomato sauce 2x2 inch piece of chocolate cake with coffee, with a splash of 1% milk

ANSWER How many carbohydrate choices does the following meal contain: 2 cups of salad made with lettuce, tomato and cucumbers, 5 olives, and 2 Tbsp of oil and vinegar dressing (0g CHO) 2 cups of cooked Penne Pasta (60g CHO), with ½ cup tomato sauce (15g CHO) 2x2 inch piece of chocolate cake (15g CHO) with coffee, with a splash of 1% milk (negligible CHO) Total CHO = 90g 90g/15g/choice = 6 carb choices

Question 10 The maximum amount of aspartame a 70kg person should consume is: – A. 1500mg – B. 2800mg – C. 720mg – D. 350mg

ANSWER The maximum amount of aspartame a 70kg person should consume is: – A. 1500mg – B. 2800mg – C. 720mg – D. 350mg

Question 11 Which of the following foods contain the greatest amount of carbohydrate? A. 30g of chicken thigh meat B. 3 cups low-fat popcorn C. 1 cup unsweetened applesauce D. 1 cup of Gatorade Sports drink (original)

ANSWER Which of the following foods contain the greatest amount of carbohydrate? A. 30g of chicken thigh meat B. 3 cups low-fat popcorn C. 1 cup unsweetened applesauce D. 1 cup of Gatorade Sports drink (original)

Question 12 The Milk Calendar features a “Healthy Green Breakfast Smoothie that serves 4. A patient shows you’ the recipe and asks: “how many carbohydrates is in each serving?”

ANSWER 80g for entire recipe, divided by 4 = 20g cho per svg. The Milk Calendar features a “Healthy Green Breakfast Smoothie that serves 4. A patient shows you’ the recipe and asks: “how many carbohydrates is in each serving?” ¼ cup plain yogurt (5g) 1 cup low-fat milk (15g) 1 Tbsp honey (15g) 1 small banana (15g) 2 cup frozen peaches or 2 large peaches (30g) 1 cup spinach (0g) 1 Tbsp flax seed (0g) 2 Tbsp Almond Butter (0g) 80g for entire recipe, divided by 4 = 20g cho per svg.

Question 13 Jonathan’s Carbohydrate to Insulin ratio is 7:1. How many units of insulin should he take if eating a turkey and cheese sandwich on whole wheat bread (2oz meat and 2oz cheese), 2 cups of chocolate milk and an apple? – A. 15U – B. 13U – C. 6U – D. 20U

ANSWER Jonathan’s Carbohydrate to Insulin ratio is 7:1. How many units of insulin should he take if eating a turkey and cheese sandwich on whole wheat bread (2oz meat and 2oz cheese), 2 cups of chocolate milk and an apple? – A. 15U – B. 13U – C. 6U – D. 20U

USEFUL TOOLS TO KEEP BEHIND THE COUNTER Available from the CDA webesite The Glycemic Index Basic carbohydrate counting for diabetes management Sugar and Sweeteners Alcohol + diabetes Cholesterol + diabetes Eating away from home Managing weight and diabetes High blood pressure + diabetes Healthy Eating is in Store for You

HELPFUL HINTS – was there food equally divided among meals Ask the patient what they ate for yesterday – was there food equally divided among meals Ask them to measure their plate – keep a large and small plate behind the counter Your hands and every day objects can be very useful in estimating appropriate portions Make if fun…

A PICTURE IS WORTH…

SUMMARY Nutrition for people living with diabetes can seem very complex and overwhelming Need to simplify the messages and aim to provide consistent information: Regular, balanced meals Lower fat, higher fiber Focus is on controlling total CHO SMBG helps make the connection between food choices and BG levels

SUMMARY Pharmacists are uniquely positioned to provide basic nutritional counselling to their patients with diabetes: Reinforce importance of healthy eating to all patients to help with overall glycemic control Nutrition counseling by a Registered Dietitian is recommended for people with diabetes For patients who have yet to see a dietitian, survival nutrition skills information should be presented (i.e. “Just the Basics”)

Nutrition and Diabetes How to be an effective resource for patients behind the counter…And pass the CDE Exam! Monica Gray, RD Diabetes Smart Program March 20, 2016

Question 14 Which of the following combinations of food provide approximately 30g of carbohydrate? A. 125ml milk, ½ apple, 1 slice of white bread B. 200ml cooked oatmeal, 250ml strawberries, 250ml plain yogurt C. 4 melba toast, 1/2 banana, 250ml milk D. 125ml brussel sprouts, 125ml cooked macaroni

ANSWER Which of the following combinations of food provide approximately 30g of carbohydrate? A. 125ml milk, ½ apple, 1 slice of white bread B. 200ml cooked oatmeal, 250ml strawberries, 250ml plain yogurt C. 4 melba toast, 1/2 banana, 250ml milk D. 125ml brussel sprouts, 125ml cooked macaroni