1. Slides current until 2008 Nutritional needs of people with type 1 diabetes and type 2 diabetes

2. Nutrition in diabetes Curriculum Module III-5 Slide 2 of 59 ACTIVITY Slides current until 2008 Identify factors that need to be considered before developing an individual dietary plan.

3. Nutrition in diabetes Curriculum Module III-5 Slide 3 of 59 Slides current until 2008 Diabetes nutrition therapy Aims to help people with diabetes attain a quality of life and life expectancy similar to that of the general population. This is achieved through reducing diabetes complications.

4. Nutrition in diabetes Curriculum Module III-5 Slide 4 of 59 Slides current until 2008 Behaviours which contribute positively to improved glycaemic control: Adherence to meal plan Consistent snacking behaviour Adjusted food and insulin when hyperglycaemia detected Appropriate treatment of hypoglycaemia Type 1 diabetes – Diabetes Control and Complications Trial DCCT Research Group, 1993 Delahanty and Halford, 1993

5. Nutrition in diabetes Curriculum Module III-5 Slide 5 of 59 Slides current until 2008 Type 2 diabetes - United Kingdom Prospective Diabetes Study Trial outcome: Tight control of blood glucose and blood pressure in people with type 2 diabetes reduces the risk of long-term micro- and macrovascular complications. UKPDS 1998

6. Nutrition in diabetes Curriculum Module III-5 Slide 6 of 59 Slides current until 2008 Type 2 Diabetes – Diabetes Prevention Program Trial outcome: Lifestyle changes such as weight loss and moderate daily exercise reduced the risk of developing type 2 diabetes by 58% (over 3 years) in people with impaired glucose tolerance. DPP 1999

7. Nutrition in diabetes Curriculum Module III-5 Slide 7 of 59 Slides current until 2008 Dietary approaches to stop hypertension (DASH) First trial: DASH diet significantly lowered blood pressure Second trial: DASH diet lowered blood pressure at high, intermediate and low levels of sodium Sacks 1997, 2001

8. Nutrition in diabetes Curriculum Module III-5 Slide 8 of 59 Slides current until 2008 Dietary advice to control blood pressure DASH diet: High in fruit and vegetables Low-fat dairy products Nuts Fish/chicken in preference to red meat Small amounts of red meat Sacks 1997, 2001

9. Nutrition in diabetes Curriculum Module III-5 Slide 9 of 59 Slides current until 2008 Aims of diet therapy Attain and maintain metabolic outcomes through: Good blood glucose levels Optimum lipid profile Controlled blood pressure levels Optimum body weight

10. Nutrition in diabetes Curriculum Module III-5 Slide 10 of 59 Slides current until 2008 Aims of diet therapy To prevent and treat obesity, dyslipidaemia, cardiovascular disease, hypertension and nephropathy through modification of diet and lifestyle To consider the person’s nutritional needs while taking into account personal and cultural preferences and lifestyle issues Respect the individual’s rights, decisions and willingness to change Optimize quality of life

11. Nutrition in diabetes Curriculum Module III-5 Slide 11 of 59 Slides current until 2008 Person-centred approach to diet therapy Education/advice needs to be individualized and holistic Individual assessment of the person with diabetes is vital Diabetes is a progressive condition requiring regular review

12. Nutrition in diabetes Curriculum Module III-5 Slide 12 of 59 Slides current until 2008 Achieving optimum glycaemic control in type 1 diabetes Insulin action profiles selected to suit the person’s meal pattern with particular attention to CHO intake and distribution High intake of soluble fibre preferred Education for healthy food choices should be given Low glycaemic index should be encouraged

13. Nutrition in diabetes Curriculum Module III-5 Slide 13 of 59 Slides current until 2008 Insulin action profiles Rapid-acting analogue insulin Onset: <0.5 hr Peak: 1 hr Duration: 3-4 hr Soluble insulin Onset: 1/2 hr Peak: 1-3 hr Duration: 6-8 hr Lente insulin Onset: 2 1/2 hr Peak: 7-15 hr Duration: 24 hr NPH insulin Onset: 1 1/ 2 hr Peak: 4-12 hr Duration: 24 hr Biphasic insulin Onset: 1/2 hr Peak: 2-8 hr Duration: 24 hr Biphasic analogue insulin Onset: <0.5 hr Peak: 1-4 hr Duration: 24 hr Long-acting analogue insulin Onset: 2-3 hr Peak: none Duration: 24 hr

14. Nutrition in diabetes Curriculum Module III-5 Slide 14 of 59 Slides current until 2008 Selecting insulin to suit the individual and meal pattern Meal patternNumber of injections and insulin type Two large mealsTwice a day: mixture of short- and intermediate- acting before meals Three meals: breakfast, light lunch and dinner Twice a day: mixture of rapid-/short- and intermediate-acting before breakfast and before dinner

15. Nutrition in diabetes Curriculum Module III-5 Slide 15 of 59 Slides current until 2008 Selecting insulin to suit the individual and meal pattern Meal patternNumber of injections and insulin type 3/4 meals: breakfast, light lunch, mid- afternoon and evening meal 2-3 per day: mixture of rapid- /short- and intermediate-acting before breakfast; rapid/short for the afternoon snack and mixture of rapid-/short- and intermediate-acting before the evening meal; or long-acting analogue 1-2/day and 3-4 rapid acting 3 meals; 3 snacks4-6: rapid-/short-acting before meals and snacks, NPH or long- acting analogue 1-2 per day

16. Nutrition in diabetes Curriculum Module III-5 Slide 16 of 59 Slides current until 2008 Achieving optimal glycaemic control in type 2 diabetes Type 2 diabetes is progressive Glycaemic control will deteriorate with time Most people will require polypharmacy including: –glucose lowering medicines –insulin –anti-hypertensive, anti- thrombolytic and lipid-lowering drugs UKPDS 1995, Gaede 1999, Gaede 2003

17. Nutrition in diabetes Curriculum Module III-5 Slide 17 of 59 Slides current until 2008 Achieving optimal glycaemic control in type 2 diabetes Regular carbohydrate intake essential Low glycaemic index Assessment of total energy requirements Healthy eating principles

18. Nutrition in diabetes Curriculum Module III-5 Slide 18 of 59 Slides current until 2008 Dyslipidaemia in type 1 diabetes and type 2 diabetes An abnormal lipid profile Three out of four deaths are caused by cardiovascular disease DCCT 1995, J Am Med Assoc 1997, Laing et al 2000, Larsen et al 2002, DCCT 2003

19. Nutrition in diabetes Curriculum Module III-5 Slide 19 of 59 Slides current until 2008 Dietary influences on dyslipidaemia High fat intake reduces insulin sensitivity Saturated and trans fats increase LDL cholesterol Monounsaturated lower LDL cholesterol and triglycerides High carbohydrate intake may exaggerate the post-meal triglyceride response

20. Nutrition in diabetes Curriculum Module III-5 Slide 20 of 59 Slides current until 2008 National cholesterol education programme recommendations Energy distribution and recommendations Total fat25-35% of total energy Saturated fat<7% total kcal Polyunsaturated fatUp to 10% total kcal Monounsaturated fatUp to 15% total kcal Carbohydrates50-60% total kcal ProteinApprox 15% of total energy Total caloriesTo achieve and maintain healthy weight Fibre (pref soluble)10 – 25 g/day Plant stanols/sterols (2 g/day) Cholesterol<200 mg/day National Cholesterol Education Program 2004

21. Nutrition in diabetes Curriculum Module III-5 Slide 21 of 59 Slides current until 2008 Practical advice Decrease total fat, particularly saturated and trans fatty acids Increase monounsaturated fats Include two portions of fish in the weekly diet (omega-3 fatty acids) Ensure adequate sources of antioxidants - flavonoids, soluble fibre and potassium (five portions of fruit and vegetables daily)

22. Nutrition in diabetes Curriculum Module III-5 Slide 22 of 59 ACTIVITY Slides current until 2008 Identify foods in the local diet that contribute to intake of saturated, total and trans fats. Discuss ways of modifying diet to decrease total dietary fat and improve the fatty acid profile.

23. Nutrition in diabetes Curriculum Module III-5 Slide 23 of 59 Slides current until 2008 Weight management A weight management programme includes: Dietary change Increased physical activity Behaviour modification Support and monitoring

24. Nutrition in diabetes Curriculum Module III-5 Slide 24 of 59 Slides current until 2008 Benefits of weight loss Diabetes related deaths  by 30% to 40% Risk of developing diabetes  by 50% Systolic and diastolic BP  by 10 mmHg Fasting glucose by 30% to 50% (improved insulin sensitivity) HbA 1c  by 15% Total cholesterol  by 10% LDL by 15% Triglycerides by 30%  HDL by 8% Jung 1997, Goldstein 1992 10% weight loss Decreased insulin requirements

25. Nutrition in diabetes Curriculum Module III-5 Slide 25 of 59 Slides current until 2008 Associated weight gain with some glucose-lowering medicines UKPDS showed: On metformin, weight gain of 1 kg over a 6-year period On sulphonylurea, weight gain of 4 kg over a 6-year period On insulin, weight gain of 6 kg over a 6-year period

26. Nutrition in diabetes Curriculum Module III-5 Slide 26 of 59 Slides current until 2008 Assessing the patient for weight management Assess the person’s agenda and lifestyle, particularly: Motivation Cultural issues Importance of weight loss Opportunities for increased physical activity

27. Nutrition in diabetes Curriculum Module III-5 Slide 27 of 59 Slides current until 2008 Dietary modification Practical advice Avoid fatty foods Do not add fat Use low-fat cooking methods Decrease sugary foods Do not add sugar Portion size Use easy measures for descriptions of food quantity Negotiate acceptable portion sizes for all foods

28. Nutrition in diabetes Curriculum Module III-5 Slide 28 of 59 Slides current until 2008 Dietary recommendations Practical evidence-based dietary recommendations European Association for the Study of Diabetes (1999) Diabetes UK (2003) American Diabetes Association (2004) Canadian Diabetes Association (2004)

29. Nutrition in diabetes Curriculum Module III-5 Slide 29 of 59 Slides current until 2008 Dietary recommendations Weight reduction for overweight/obese people Regular starchy meals Low sugar diet  Total fat intake by 30%  Intake of fruit and vegetables  Protein intake by 15% to 20%  Salt to 6 g per day (1 teaspoon) Alcohol in moderation Diabetic products are not advised

30. Nutrition in diabetes Curriculum Module III-5 Slide 30 of 59 Slides current until 2008 Education tools Glycaemic index: Ranks carbohydrate-rich foods according to the increase in blood glucose levels they cause in comparison with a standard food (white bread/glucose).

31. Nutrition in diabetes Curriculum Module III-5 Slide 31 of 59 Slides current until 2008 Advanced education tools Glycaemic index and load Food exchanges Carbohydrate counting

32. Nutrition in diabetes Curriculum Module III-5 Slide 32 of 59 Slides current until 2008 Glycaemic response of glucose and lentils Blood glucose level GlucoseLentils © Reprinted with permission from Canadian Diabetes Association 2004

33. Nutrition in diabetes Curriculum Module III-5 Slide 33 of 59 Slides current until 2008 Type of sugar –glucose, fructose, galactose Nature of starch –amylose, amylopectin Starch-nutrient interactions –resistant starch Cooking/food processing Factors affecting the glycaemic index

34. Nutrition in diabetes Curriculum Module III-5 Slide 34 of 59 Slides current until 2008 Processing/form of the food –gelatinization –particle size –cellular structure Presence of other food components –fat and protein –dietary fibre Factors affecting the glycaemic index Brand Miller J 1998

35. Nutrition in diabetes Curriculum Module III-5 Slide 35 of 59 Slides current until 2008 Glycaemic index of foods Low glycaemic index foods Intermediate glycaemic index High glycaemic index Lentils/dahlRye breadGlucose Most fruit and vegetables Some rice (long grain) Mashed and baked potatoes YogurtBananasProcessed breakfast cereal MilkPastaWhite bread OatsGrapesWhite rice

36. Nutrition in diabetes Curriculum Module III-5 Slide 36 of 59 Slides current until 2008 Practical advice Eat more vegetables, fruit, whole grains, and low-fat milk One low GI food at each meal Mix high and low GI food = intermediate GI meal Substitute high GI cereals/breads/rice with low GI cereals/bread/rice Eat low GI snacks instead of high GI snacks (remember to choose lower fat snacks)

37. Nutrition in diabetes Curriculum Module III-5 Slide 37 of 59 Slides current until 2008 Promotes healthy eating Increases fibre intake Helps control appetite Helps control blood glucose levels Helps lower blood lipid levels Assists weight loss Offers a more comprehensive approach for type 2 diabetes Reduces risk of type 2 diabetes and heart disease Low glycaemic index diet – advantages

38. Nutrition in diabetes Curriculum Module III-5 Slide 38 of 59 Slides current until 2008 Mixed meal is a combination of the glycaemic effect of all the foods Does not include guidance on fat intake May reduce choice and flexibility Difficult to maintain a low glycaemic index diet for long periods Requires an effort to remember which foods have high or low glycaemic index Low glycaemic index diet – disadvantages

39. Nutrition in diabetes Curriculum Module III-5 Slide 39 of 59 Slides current until 2008 Food exchanges Carbohydrate exchange Cereal and pulse exchange Fat/oil exchange Protein exchange Milk exchange Fruit exchange Vegetable exchange

40. Nutrition in diabetes Curriculum Module III-5 Slide 40 of 59 Slides current until 2008 Food exchanges Similar food types placed in exchange groups Within groups, a single food based on weight/measure/size has the same carbohydrate or kcal value as another and can be interchanged In the case of cereal exchanges: 1 slice of bread can be exchanged for 1/3 cup rice Foods from different groups cannot be interchanged – 1 slice of bread cannot be exchanged for 1½ tsp of butter

41. Nutrition in diabetes Curriculum Module III-5 Slide 41 of 59 Slides current until 2008 Carbohydrate counting – Level 1 Assesses only CHO not protein or fat Goal –carbohydrate consistency with food intake and blood levels Advantage –flexible food choices Useful for –all types of diabetes

42. Nutrition in diabetes Curriculum Module III-5 Slide 42 of 59 Slides current until 2008 Carbohydrate counting – Level 2 Goal –adjust medication/food/activities based on blood glucose patterns from daily records Advantage –lifestyle flexibility Useful for –people taking part in diets, using glucose-lowering medicines and insulin who can implement Level 1

43. Nutrition in diabetes Curriculum Module III-5 Slide 43 of 59 Slides current until 2008 Carbohydrate counting – Level 3 Goal –to be able to adjust insulin dose using a carbohydrate/insulin ratio Advantage –flexibility of food and insulin regimen with tight glucose control Useful for –people on intensive insulin therapy –people who have mastered insulin adjustment and supplementation

44. Nutrition in diabetes Curriculum Module III-5 Slide 44 of 59 Slides current until 2008 Carbohydrate exchanges Amount and type influences blood glucose levels Sucrose can be substituted for equal amounts of another carbohydrate without adverse effect Carbohydrate rich foods are –grains/potatoes/legumes –fruit –milk ADA 2004

45. Nutrition in diabetes Curriculum Module III-5 Slide 45 of 59 Slides current until 2008 Carbohydrate exchanges 1 carbohydrate exchange = 10-15 g carbohydrate 1 starch/cereal exchange (10-15 g) 1 small potato/legume exchange (10-15 g) 1 fruit exchange (10-15 g) 1 milk exchange (10-15 g) Example: ½ cup pasta = 1 cup milk = 1 small banana = 1/3 cup rice

46. Nutrition in diabetes Curriculum Module III-5 Slide 46 of 59 Slides current until 2008 Carbohydrate exchanges Use exchange lists to count carbohydrate –1 carbohydrate exchange = 15 g = 1/3 cup rice –1 cup rice = 45 g carbohydrate Calculate carbohydrate amount for each meal –count carbohydrate as above for each food item in the meal

47. Nutrition in diabetes Curriculum Module III-5 Slide 47 of 59 Slides current until 2008 Carbohydrate counting Information sources Prepared carbohydrate exchange lists for meal planning Food labels Nutrient reference books Computerized, pre-programmed food scales Internet websites

48. Nutrition in diabetes Curriculum Module III-5 Slide 48 of 59 Slides current until 2008 Carbohydrate counting Food diary Type of food Portion size Record amount of carbohydrate in each food Time of food intake eg 1 cup rice (45 g carbohydrate) for lunch at 13.00 hr

49. Nutrition in diabetes Curriculum Module III-5 Slide 49 of 59 Slides current until 2008 Counting recipes Moroccan chicken stew (serves 4) Carb (g) 2 cups chicken broth0 ¼ cup tomato paste6 1 tsp cummin0 1 tsp salt0 1/8 tsp cinnamon0 ½ cup dark raisins58 1 medium onion, finely sliced16 1 tblsp mince garlic4 1 can (440 g) of chick peas108 8 chicken thighs0 Total carbohydrate192 Per person48

50. Nutrition in diabetes Curriculum Module III-5 Slide 50 of 59 ACTIVITY Slides current until 2008 Examine a carbohydrate exchange list Discuss how useful they would be in meal planning Are carbohydrate exchanges suitable for all people? What are the advantages and disadvantages of carbohydrate counting?

51. Nutrition in diabetes Curriculum Module III-5 Slide 51 of 59 Slides current until 2008 Carbohydrate counting – advantages Focus on nutrient with greatest impact on blood glucose Permits flexible food choices Food and insulin can be adjusted easily and accurately Offers potential for improved blood glucose, especially for those on insulin People become skilled and feel more in control Improves quality of life

52. Nutrition in diabetes Curriculum Module III-5 Slide 52 of 59 Slides current until 2008 Need for arithmetic agility and understanding Requires accurate and detailed food records Difficult to estimate portion sizes initially –requires weighing and measuring Does not consider amount of fat, protein or type of carbohydrate Carbohydrate counting – disadvantages

53. Nutrition in diabetes Curriculum Module III-5 Slide 53 of 59 Slides current until 2008 Does not specify fibre content Requires frequent blood glucose estimations Difficult and expensive to record blood glucose Depends on people being motivated May be too complicated for some people and detract from pleasure of eating Carbohydrate counting – disadvantages

54. Nutrition in diabetes Curriculum Module III-5 Slide 54 of 59 ACTIVITY Slides current until 2008 Identify local carbohydrate foods (staples) Identify local foods that may be discouraged due to diabetes Discuss myths and appropriate educational strategies

55. Nutrition in diabetes Curriculum Module III-5 Slide 55 of 59 Slides current until 2008 Summary Diabetes dietary management requires: Individual assessment Regular dietetic review Weight management HbA 1c control Lipid management Control of hypertension Tailoring medication and/or insulin around food patterns

56. Nutrition in diabetes Curriculum Module III-5 Slide 56 of 59 Slides current until 2008 Summary The behavioural/counselling approach to diet management includes identifying barriers to change and includes: Dietary management/food preferences and patterns Lifestyle Culture Social issues Physical activity

57. Nutrition in diabetes Curriculum Module III-5 Slide 57 of 59 Slides current until 2008 References 1.Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336(16): 1117- 24. 2.Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M; American Diabetes Association. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2003; 26 Suppl 1: S51-61. 3.Bailey CJ, Feher MD. Therapies for diabetes including oral agents and insulins. Sherbourne Gibbs Ltd, 2004. ISBN 1.905036.00.0 4.Brand Miller J, Foster-Powell K, Colagiuri S, Leeds A. The GI factor. Hodder 1998. 5.Franz M, Montz A, Bergenstal R, et al. Outcomes and Cost-effectiveness of Medical Nutrition Therapy for non-insulin dependent diabetes mellitus. Diabetes Spectrum 1996; 2: 122-27. 6.DCCT Research Group. Effect of intensive diabetes management on macrovascular events and risk factors in the Diabetes Control and Complications Trial. Am J Card 1995; 75(14): 894-903. 7.DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329(14): 977-86. 8.Gillespie SJ, Kulkarni KD, Daly AE. Using carbohydrate counting in diabetes clinical practice. J Am Diet Assoc 1998; 98(8): 897-905.

58. Nutrition in diabetes Curriculum Module III-5 Slide 58 of 59 Slides current until 2008 References 9.Diabetes Prevention Research Group. Reduction in the evidence of type 2 diabetes with life-style intervention or metformin. N Engl J Med 2002; 346: 393-403. 10.Gaede P, Vedel P, Parving HH, Pedersen O. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet 1999; 353(9153): 617-22. 11.Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348(5): 383-93. 12.Glycemic Index Explained (cited 2004 Nov 14) (23 pages) Available from URL: http://www.diabetes.ca/Files/Glycemic%20Index%20Presentation.pdfwww.diabetes.ca/Files/Glycemic%20Index%20Presentation.pdf 13.Goldstein DJ. Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord 1992; 16(6): 397-415. 14.Jung RT. Obesity as a disease. British Medical Bulletin 1997; 53(2): 307-21. 15.Laing SP, Swerdlow AJ, Slater SD, Burden AC, Morris A, Waugh NR, Gatling W, Bingley PJ, Patterson CC. Mortality from heart disease in a cohort of 23,000 patients with insulin- treated diabetes. Diabetologia 2003; 46(6): 760-5. 16.Larsen J, Brekke M, Sandvik L, et al. Silent coronary atheromatosis in type 1 diabetic patients and its relation to long-term glycemic control. Diabetes 2002; 51(8): 2637-41. 17.Multiple Risk Factor Intervention Trial. Risk factor changes and mortality results. Multiple Risk Factor Intervention Trial Research Group. JAMA 1997; 277(7): 582-94.

59. Nutrition in diabetes Curriculum Module III-5 Slide 59 of 59 Slides current until 2008 References 18.Nathan DM, Lachin J, Cleary P, et al. Diabetes Control and Complications Trial. Epidemiology of Diabetes Interventions and Complications Research Group. Intensive diabetes therapy and carotid intima-media thickness in type 1 diabetes mellitus. N Engl J Med 2003; 348(23): 2294-303. 19.Powers MA. Medical Nutrition Therapy for Diabetes, Handbook of Diabetes Medical Nutrition Therapy, Aspen Publication. 1996. 20.Sacks FM, Svetkey LP, Vollmer WM, et al. DASH-Sodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001; 344(1): 3-10. 21.UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). [erratum appears in Lancet 1999 Aug 14; 354(9178): 602]. Lancet 1998; 352: 837-53. 22.UKPDS Group. Overview of 6 years' therapy of type II diabetes: a progressive disease. U.K. Prospective Diabetes Study Group.(UKPDS 16). [erratum appears in Diabetes 1996; 12; 45(11):1655]. Diabetes 1995; 44(11): 1249-58. 23.UKPDS Group. Efficacy of atenolol and captropril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998; 317: 713-20.