1. 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

2. 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!

3. 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.

4. 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

5. 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

6. 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
eng.pdf 6

7. 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
aliment/print_eatwell_bienmang-eng.pdf

8.
aliment/print_eatwell_bienmang-eng.pdf

9. 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

10. Distribution of Macronutrients
EXAM!
MACRONUTRIENT DISTRIBUTION
MACRONUTRIENT
% OF TOTAL CALORIES
Carbohydrate
45-60%
Fat
20-35%
Protein
15-20%

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

12. 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)

13. 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 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 •

14. 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). •

15. 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.

16. Stevia
Per these guidelines, it would be acceptable for a 70 kg man can ingest up to 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.

17. 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.

18. 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 •

19. 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. •

20. The Canadian Diabetes Association Reference Tool:•

21. Distribution of Macronutrients
MACRONUTRIENT DISTRIBUTION
MACRONUTRIENT
% OF TOTAL CALORIES
Carbohydrate
45-60%
Fat
< 35%
Protein
15-20% •

22. 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 •

23. Good Fat, Bad Fat

24. 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)

26. 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

27. HANDY
PORTION GUIDE

28. Other common objects

29. 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

30. Distribution of Macronutrients
EXAM!
MACRONUTRIENT DISTRIBUTION
MACRONUTRIENT
% OF TOTAL CALORIES
Carbohydrate
45-60%
Fat
20-35%
Protein
15-20%

31. 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

32. 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 = round to 17
17 CHO choices per day divided in meals and snacks
20-35% FAT
(Avg = 30%)
Step 1: 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: 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

33. 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

34. 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

35. 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

36. 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

37. 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.

38. For the exam – understand and memorize the BTB Poster!
Order your copy here:
desc

39. 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

40. Other Choices (sweet foods and snacks)

41. Add favourite foods -

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

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

44. Fats do not contain CHO

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

46. 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

47. 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

48. 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.

49. 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

50. 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

51. 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

52. 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

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

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

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

56. Sample Exam Questions
Nutrition Focus

57. 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

58. 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

59. 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

60. 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

61. Question 3 What are the CHO recommendations for
the Type I diabetes patient?
A % of calories from CHO source
B % of calories from CHO source
C % of calories from CHO source
D % of calories from CHO source

62. ANSWER What are the CHO recommendations for
the Type I diabetes patient?
A % of calories from CHO source
B % of calories from CHO source
C % of calories from CHO source
D % of calories from CHO source

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

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

65. 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

66. 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

67. Popsicles
~1 CHO Choice

68. 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

69. 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

70. 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

71. 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

72. 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

73. 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

74. 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

75. 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

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

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

78. 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)

79. 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)

80. 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?”

81. 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.

82. 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

83. 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

84. 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

86. 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…

87. A PICTURE IS WORTH…

88. 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

89. 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”)

90. 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

91. 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

92. 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