Ev 192004

Recent clinical and epidemiological studies haveshown a relationship between oral diseases,particularly periodontal infection and systemicdiseases. The linkage between oral and systemicdiseases has ushered a new paradigm in oralhealth. Periodontal infections are nowrecognized as a risk factor for cardiovasculardisease, stroke,low birth rateweight offspring,more severed i a b e t e s ,pneumonia andbacteremia. Therecent U.S.Generals Report1of 2000 hashighlighted thatu n c o n t r o l l e ddiabetes is asignificant riskfactor in theetiology ofp e r i o d o n t a ldisease. Morei n t r i g u i n g ,however, is the suggestion that the link may bereciprocal and that severe periodontitis affectsglycemic control and exacerbates diabetes. Thesignificance of these findings is the subject ofthis brief.

Diabetes Mellitus encompasses several disorderswith the common characteristics of alteredglucose tolerance or impaired lipid andcarbohydrate metabolism. The primary cause ofdiabetes is a deficiency of insulin productionwhich gives rise to the type I insulin dependentdiabetes. Type 2 diabetes is causes by impairedutilization of insulin rather than insufficientinsulin production. Type2 diabetes is the most

F O R F R O N T L I N E D I A B E T E S E D U C A T O R S

VOLUME 19, AUTUMN 2004 WWW.DIABETESCAREGUIDE.COM

WHAWHAWHAWHAWHAT'S IT'S IT'S IT'S IT'S INNNNNSISISISISIDEDEDEDEDE

COVERDiabetes and Periodontal

Disease

PAGE 6Balance is Key in

Diabetes Diet

PAGE 9Oral Health

PAGE 10Diabetes and Nutrition

PAGE 14Ready, Set, Start Counting

Diabetes Care NewsDIABDIABDIABDIABDIABEEEEETES ANTES ANTES ANTES ANTES AND PD PD PD PD PERERERERERIODONTIODONTIODONTIODONTIODONTAL DIAL DIAL DIAL DIAL DISEASE SEASE SEASE SEASE SEASE

A CA CA CA CA COMOMOMOMOMPPPPPLEX TLEX TLEX TLEX TLEX TWWWWWOOOOO-W-W-W-W-WAAAAAY CY CY CY CY CONONONONONNNNNNEEEEECTIONCTIONCTIONCTIONCTIONBy Gordon Nikiforuk, DDS, MGordon Nikiforuk, DDS, MGordon Nikiforuk, DDS, MGordon Nikiforuk, DDS, MGordon Nikiforuk, DDS, MSc, FSc, FSc, FSc, FSc, FRCD, FCIRCD, FCIRCD, FCIRCD, FCIRCD, FCIDDDDD

common form accounting for about 80 90percent of diabetes. It is rapidly becoming anepidemic in Canada and is now considered apublic health problem. Statistics from theCanadian Diabetes Association indicate thattwo million Canadians are afflicted and thatanother 60,000 are estimated as having the

disease but remainundiagnosed. Dr. StewartHume from theUniversity of WesternOntario said. Were inthe midst of an epidemicthat is going to get worse,because the BabyBoomers are nowentering their 5th decadewhen the prevalence ratesof diabetes are high.While currently there isno cure for type 2diabetes it is treatable andsusceptible to basic lifestyles such as diet andexercise. It can beprevented or at least

delayed according to a study of over 3,000participants with impaired glucose tolerance bythe National Institute of Diabetes and Digestiveand KidneyDisease4. In this significant study,the key elements diet and exercise played acardinal role. Early diagnosis, aggressivetreatment by controlling blood glucose levels,blood pressure and lipids, have proven tosignificantly delay or even prevent damages thatuncontrolled diabetes causes to blood vessels.

Clinical Studies Linking Diabetes andPeriodontal DiseaseA number of clinical studies have shown asignificant relationship between diabetes and

2 Diabetes Care News

periodontal disease. Since 1990, a studyof Puma Indians, a population that has theworlds highest prevalence of type 2diabetes, showed a significant increase inthe prevalence of periodontal disease asmeasured by alveolar bone loss orattachment loss, indicating that diabetes isa risk factor for periodontal disease5,6. Afurther study found that destructiveperiodontal disease is higher in diabetespatients when compared to a group withnormal glucose tests7. In a longitudinalstudy of patients with non-insulin dependentdiabetes, it was found that a history ofperiodontal disease adversely affecteddiabetic control8. Grossi and Genco9proposed the model for two-wayrelationships between periodontal diseaseand diabetes based on the evidence thatperiodontal infections contribute toglycemic control. (See Figure: Etiology andConsequences of Gingivitis andPeriodontal Disease).

A major study of Greenstein et al10 indicatedthat the presence of infection, specificallyperiodontal disease, can affect the diabeticindividuals systemic condition. This studyconsisted of a one-stage non-surgicalperiodontal therapy consisting of full-mouth

scaling and root planing along with standardoral hygiene control and a reinstructionreview twice monthly. The non-surgicalperiodontal therapy resulted in a reductionof HBAC (glycated hemoglobin) levels,especially in patients with an elevateddegree of diabetes severity and periodontaldisease. This was corroborated by anotherstudy which also showed that effectiveperiodontal treatment results in lowerglycemic levels and a reduction of clinicalparameters of periodontal disease i.e.probing depth bleeding sites andsuppuration and improvement in biofilm(plaque) control11.

Oral Manifestation of DiabetesIt is important that dental practitionersunderstand the association betweendiabetes and periodontal disease. Inuncontrolled diabetes, there is an increasedrisk of both gingivitis and periodontaldisease. In patients with advanced stagesof diabetes, periodontal abscesses and lossof periodontal attachment may occur.While each patient may manifest differentsigns and symptoms, the following arecommonly observed in periodontal patients: Gingivitis red, swollen gum tissue Bleeding while brushing and/or flossing

Increased tooth mobility loose teeth Acute oral infections (recurrent herpes

simplex virus, periodontal abscess) Persistent mouth odour Increased periodontal pockets and in

depth of pocket Significant bone and tissue loss in

advanced periodontal disease

In addition to exacerbation of periodontaldisease, other oral manifestations ofdiabetes that have been reported inliterature12 include: diminished salivary flow (xerostomia) burning mouth or tongue syndrome enlarged parotid glands taste dysfunction

Medication that some diabetics take mayinduce an oral dryness state that contributesto xerostomia. This in turn may lead toincreased incidence of dental caries.Increased glucose levels have also beenobserved in gingival fluid which may affectplaque micro flora.

Oral Dental TherapyGeneral considerations:The initial oral-dental therapy for diabeticpatients is directed towards control of

Etiology and Consequences of Gingivitis and Periodontal Disease

Adapted from: Special Supplement. The Colgate Oral Care Report. 2003

infections. Communication with thepatients physicians is essential in order toobtain effective control of blood glucoselevels. It is important to advise thephysician of the presence of infectionsincluding advanced periodontal diseasesince infection increases insulin resistanceand aggravates glycemic control.

Dental Practitioners should discuss withpatients their blood glucose control,medication and diet regimen. For manypatients appointments can be scheduledearly in the day when the patient is restedand thus avoid peaks of insulin activity.Special instructions may include emphasison a proper diet, and taking appropriatemedication before appointment. Forpatients with uncontrolled diabetes a keyissue is that a dental treatment plan, otherthan emergencies, should be delayed. Thepatient should be referred to their physicianfor blood glucose testing and therapy.Patients with controlled diabetes can betreated for routine dental needs as any non-diabetic patient. The key precautions formany adults with type 2 diabetes includereducing factors that might cause stress,pain and apprehension.

In more severe periodontal disease, thepatient may be treated with advancedmechanical therapy. In one study, scalingand root planing, supplemented by oralirrigation, showed a significant improve-ment in the control of their diabetes and inthe level of pro-inflammatory substancessuch as indicated by cytokine analysis13.Some practitioners treat patients perquadrant current studies indicate thatwhole mouth treatment is more effectiveand should be encouraged.

Effective Oral HygieneOptimal oral hygiene is an integral part ofpre and post treatment of a patient withperiodontal diseases. Further, proper careof gums and teeth may also be effective inpreventing oral health problems associatedwith diabetes. The following oral hygieneprocedures are recommended:

Tooth brushing: Brush 2 3 times daily using a soft brush

with rounded bristles.

Diabetes Care News 3

Use short back-and-forth motion whilemoving the brush gingivally. Avoid harshmovement of the brush.

Brush the tongue frequently.Flossing: Dental floss should be about 18" long. Using a sawing motion press in-

between the control point of the tooth... Curve floss around each tooth and move

floss up and down several times frombelow gum to top of tooth.

Rinse: After flossing and/or brushing, use rinse

that has anti-plaque properties.

Guidelines for Selection of Oral CareProductsThe large array of dental products availableto the patient often results in a quandary.Choosing an effective toothbrush andtoothpaste is important in oral care. Thepatient can simplify this task by selectingproducts with the Canadian DentalAssociation seal of recognition. This sealis designed to help the public makeinformed choices and is awarded only ifthe products effectiveness and safety areevaluated by rigid clinical studies. Choosea dentifrice with the CDA seal of

All GLUCERNA products contain a unique blend of slowly digestedcarbohydrates to help make blood sugar control easier*

* When compared to standard snack bar and nutritional liquid.

www.abbott.ca1 800 361-7852

GLUCERNAComplete, balanced nutrition for people with diabetes

Available in pharmaciesRoss Nutritional Systems for Life

recognition that has been proven to reducegingivitis (Colgate Total*), plaqueformation, dental caries, supra gingivalcalculus, micro-flora and that hassubstantivity (long lasting). Similarly, usea non-prescription oral rinse with the sealof recognition for effective prevention ofgingivitis (Listerine). Effective oral careby reducing inflammation arising from oralinfections has significant systemicimplications.

SummaryDiabetes can significantly affect manytissues including the oral cavity. Clinicalresearch indicates that periodontitis is twiceas prevalent in diabetic individuals ascompared to non-diabetics. Recentevidence also suggests that periodontaldisease can adversely affect diabeticcontrol. In several longitudinal studies,periodontitis has been associated withincreased risk of inadequate glycemiccontrol.Periodontal treatment using mechanical andwhere necessary, surgical proceduresreduces periodontal pathogens andimproves glycemic control. Effective oralhygiene as recommended by thepractitioner is cardinal in the managementof periodontal disease. Practitioners needto have a good knowledge of the medicationand products used by diabetes patients andthis allows provision of periodontal therapywhile minimizing risk of complication.

Gordon Nikiforuk is a ProfessorEmeritus, University of Toronto:Professional Relationship Manager,Colgate-Palmolive Canada Inc. He isalso the author of Understanding DentalCaries. Volume 1. Etiology Volume 2.Prevention.

REFERENCES

1. U.S. Surgeon Generals Report 2000. Part IIIWhat is the relationship between oral health andgeneral health and well being, pp. 95 132

2. Position Paper: Diabetes and Periodontal Disease,J. Periodontal. 71:664-678,2000

3. Diabetes and Canadas Health System, Brief tothe Commission on the Future of Health Care inCanada, Submitted by the Canadian DiabetesAssociation, May 2002

4. Diet and Exercise Dramatically Delay type 2Diabetes: Diabetes Medication Metformin AlsoEffective. National Institute of Diabetes &Digestive & Kidney Diseases. www.niddk.nib.go/welcome/releases/8_8-01.htm

5. Shlossman M, Knowler WC, Pettit DJ, Genco RJ.Type 2 diabetes mellitus and periodontal disease.JADA 1990; 121:532-536

6. Emrich LJ, Shlossman M, Genco RJ. Periodontaldisease in non-insulin dependent diabetes mellitus.J Periodontal. 1991; 62(2):123-131

7. Taylor GW, Burt BA, Becker MP, Genco RJ,Shlossman M, Knowler WC, Petit DJ. SeverePerionditis and risk of poor glycemic control inpatients with non-insulin dependent diabetesmellitus. J Periodntal. 1996; 67(10): 1085-1093

8. Grossi SG, Skrepcinski FB, DeCaro T, Zambon JJ,Cummins D, Genco RJ. Response to periodontaltherapy in diabetics and smokers.J.Periodontal. 1996; 67(10): 1094-1102

9. Grossi SG, Genco R. Periodontal disease anddiabetes mellitus: A two-way relationship. AnnPeriodontal. 1998;3:51-61

10. Greenstein G, Lamster I. Changing periondonalparadigms: Therapeutic implication. Int JPeriodontics Restorative Dent 2000;20:337-357

11. Grossi SG. Treatment of periodontal disease andcontrol of diabetes: an assessment of the evidenceand need for future research.1:Ann Periodontal. 0201, Dec.6 (1), 138 45

12. Diabetes and Oral Health. New York UniversityCollege of Dentistry Global Health Nexus Summer2003. Vol. 5, No.2

13. Dbora C. Rodrigues, Mrio Taba Jr., Arthur B.Novaes Jr., Srgio L.S. Souza, and Mrcio F.M.Grisi. Effect of Non-Surgical PeriodontalTherapy on Glycemic Control in Patients withtype 2 Diabetes Mellitus J. of Periodontal. Vol.74, No.9 2003


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Balance is Keyin DiabetesDietPresented by LifeScan Canada Ltd

People with diabetes - type 1 or type 2 -can eat whatever foods and drink whateverdrinks they want, says Nina Hirvi, adding,importantly, that the issue is not what, itshow much.

People with diabetes are alwaysuncomfortable when I say that, says Hirvi,a dietitian at the Diabetes Education Centreat the Royal Columbian Hospital in NewWestminster, B.C. Usually, they just wantme to tell them what not to eat. But there isno food that a person with diabetes canteat.

The critical parts of the diabetes diet - reallyof everyones diet - are portion size andbalance.

The latter aspect is especially notable, giventhe current popularity of low-carbohydratediets such as the Atkins, Hirvi says. Thereason for Atkins popularity is obvious: itseasy to follow. You cut out two whole foodgroups - grains and fruits. In the short-term,Atkins also seems to work for many people,helping to reduce weight and, often,lowering lipid levels at the same time.

The long-term implications of the low-carbdiet, however, are less clear, especially for

people with diabetes. There are no long-term studies that demonstrate that lowerlipid levels can be sustained on a high-protein diet. The short-term improvementis likely more closely related to the weightloss than to the content of the diet itself,Hirvi says.

As well, if a person reduces their foodintake to low-carbohydrate vegetables andprotein, they risk overwhelming theirkidneys, which must work much harder toprocess the higher proportion of protein.Renal failure is, by itself, a potentialcomplication of diabetes, so it makes sensefor people with diabetes - or at risk ofdeveloping diabetes - to avoid stressingtheir kidneys in this way.

The nutritional recommendations from theCanadian Diabetes Association 2003Clinical Practice Guidelines for thePrevention and Management of Diabetesin Canada suggest that individuals withdiabetes should be encouraged to followCanadas Guidelines for Healthy Eating. They also suggest counselingby a registered dietitian.

(For the complete Clinical PracticeGuideline recommendations, seewww.diabetes.ca/cpg2003/ .)

Measuring the Glycemic IndexIt may be a bad long-term plan to try to cutcarbohydrates out of ones diet entirely, buteveryone can benefit by leaning towardcarbohydrates with a low Glycemic Index(GI), according to the CDA ClinicalPractice Guidelines.

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GI is a scale that ranks carbohydrate richfoods by how much they raise blood glucoselevels compared to a standard food. (Thestandard is glucose or white bread.) LowGI foods are less likely to cause blood-glucose spikes, so eating them may help tocontrol BG, cholesterol, and appetite, aswell as reducing the risk of developing heartdisease or type 2 diabetes.

In general, that means favouring vegetables,fruits, and low-fat milk products, as well asstarches with a low GI - barley, bulgar,couscous, or lentils, for example.

For a list of Low, Medium and HighGlycemic Index starches, look under theNutrition chapter, Appendices at

Zimbabwe Hand JiveThe CDA Clinical Practice Guidelines offera simple and surprisingly portablemeasuring system for establishing theappropriate portions of the four food groupsin your diet, a system called the ZimbabweHand Jive.

For carbohydrates (starches and fruits),you should choose an amount roughly equalto the size of your two fists.

For protein, choose an amount the size ofthe palm of one hand and the thickness ofyour little finger.

For vegetables, choose as much as you canfit in both hands combined; and

For fat, choose an amount equal to the sizeof the tip of your thumb.

when your patients finally see the big picture.

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Its simple. In fact, people told us OneTouch UltraSmart was easier to use than a paper logbook.

To give your patients the big picture, visit www.OneTouch.ca or call 1 888 534-9991.

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All Smuckers No Sugar Added Fruit Spreads are naturally sweetened with concentrated white grape juice and Sucralose. Theadvantage of Sucralose over artificial sweeteners is that it delivers a similar taste to that of sugar, Marketing Manager Leslie Gagepoints out. So our No Sugar Added Fruit Spreads match the wholesome fruit flavour of our regular jams.

Sucralose has other advantages for people with diabetes. The body does not recognize it as a sugar or carbohydrate, so it does notinfluence carbohydrate metabolism, insulin secretion, fructose absorption, glucose absorption, glucose utilization nor short- orlong-term blood glucose control.

Smuckers No Sugar Added Fruit Spreads are available in Strawberry, Orange, Blueberry, Raspberry and Apricot. They contain noartificial flavours. For anyone who is sacrificing sugar, its all sweet news indeed.

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Hold the Sugar, Keep the Taste


Kraft Canada has some exciting news for Dietitians and Diabetes Educators. In response to a growing de-mand, Kraft is developing a Healthy Shopping Solutions toolkit to assist educators in helping their clients be-come better informed food shoppers. While this material was prepared for people with diabetes and those atrisk, it also provides the ground rules for healthier eating for everyone. The Healthy Shopping Solutions toolkit consists of a PowerPoint presentation with a user manual, resources andproduct samples, as well as a consumer booklet. Written by the Kraft Dietitians, the toolkit translates dietaryinformation into easy to understand shopping strategies and delicious food ideas. Kraft Canada will send a follow-up package quarterly with a variety of food products to update your HealthyShopping Solutions toolkit. The updates are intended to be used in combination with the professional presenta-tion materials.


Oral health and diabetesAs a diabetes educator, you may want toremind your patients with diabetes about theimportance of their oral health in relationto their overall health. Research shows theremay be a link between oral disease anddiabetes confirming that people withdiabetes need to pay special attention totheir oral health.

How does oral health relate to diabetes?Complications caused by diabetes canactually affect the oral health of a personwith diabetes. Periodontal (gum) disease tends to

develop more easily and more severelydue to poor blood circulation caused bydiabetes.

Dry mouth caused by diabetes increasesthe risk of cavities and fungal infections.

Oral infections caused by periodontaldisease raises blood sugar levels andaffect insulin requirements.

What are the warning signs ofperiodontal disease?Also known as gum disease, periodontaldisease often develops slowly and withoutcausing any pain. This disease is the leadingcause of tooth loss in adults. Here are somewarning signs to share with your patients: Constant bad breath or bad taste in your

mouth Red, swollen or tender gums Bleeding gums when you brush or floss Gums that have pulled away from the

tooth Pus at the gums when you press them Teeth that are painful or loose

How can people with diabetes preventperiodontal disease?As part of a healthy lifestyle and to reducethe risk of periodontal disease, here aresome oral health care tips prepared by theCanadian Dental Association to share withyour patients.

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Brush properly with a soft toothbrush andfloss everyday. Clean dentures daily.

Check your gums regularly for warningsigns of periodontal disease and reportany of these signs to your dentist.

To keep your mouth moist, chewsugarless gum and drink plenty of water.

Dont smoke. Tobacco not only affectsblood circulation, but is also a majorcause of tooth loss through periodontaldisease and may lead to serious problemslike oral cancer.

Have your teeth and gums examinedregularly by your dentist to detect andprevent periodontal disease. Only yourdentist has the training, skills andexpertise to identify and address your oralhealth care needs.

To learn more about how diabetes affectsyour overall health, talk to your dentist.A healthy smile is an important part of ahealthy and enjoyable life.

Oral health - Good for Life!

Diabetes andNutrition:The role ofcarbohydratesand theglycemic index


By Serena Beber, RD, CDE

There are more than two million Canadiansdiagnosed with diabetes and, according tothe Canadian Diabetes Association (CDA),there are many more who don't know theyhave the disease.

Diabetes is a condition that requirespeople to provide their own care and selfmanagement, often in a home or communitysetting. To do this they require support.

In fact, the CDA identified accurateand detailed support and education from atrained and knowledgeable healthprofessional as one of the key criticalcomponents of successful diabetesmanagement.

Nutrition therapy is a vital aspect ofdiabetes management, and one that thefamily physician should be familiar with inorder to provide the proper care for his orher diabetic patients.

Appropriate dietary choices can helplower and stabilize blood sugars, helpingto minimize the highs and lows associatedwith many of the side effects andcomplications of diabetes. Canada'sGuidelines for Healthy Eating provides ahelpful roadmap towards effectivenutritional management of diabetes:* Enjoy a variety of foods.* Emphasize cereals, breads and other whole

grain products, vegetables and fruit.

* Choose lower-fat dairy products, leanermeats and foods prepared with little orno fat.

* Achieve and maintain a healthy bodyweight by enjoying regular physicalactivity and healthy eating.

* Limit salt, alcohol and caffeine.

Dietary components affecting bloodsugarsDietary carbohydrates are a major part ofour diet and should provide 50-60% ofenergy requirements. Carbohydrates are

chains of sugar molecules. Carbohydratesinclude simple sugars, starches and dietaryfibre. Simple sugars are monosaccharidesor disaccarides (chains of one or two sugarmolecules). Monosaccharides found in ourfood include glucose, fructose andgalactose. Starches are often referred to ascomplex carbohydrates. Starches are longchains of sugar molecules. When digested,they are broken down intomonosaccharides.

Monosaccharides are absorbed,enter the blood stream and are transported

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to the liver to become glucose. Glucose iseither used as energy or may be stored forlater use. Both the amount and the sourceof carbohydrates affect blood glucoselevels. There are several considerationswhen determining how a particular food willaffect the blood sugars. How quicklycarbohydrate is digested and affects yourblood glucose is different for every food.This is where the glycemic index comes intoplay.

The glycemic indexThe glycemic index (GI) is a method ofmeasuring the relative amount that acarbohydrate-containing food causes theblood sugar to increase. Somecarbohydrates are broken down quickly andcause quick rises in blood glucose. Thesefoods are considered to have a highglycemic index. Foods with alow GI cause the blood sugarto rise more slowly.

When a high GI food iseaten, the pancreas releases asurge of insulin, resulting in adecrease in blood glucose. Theinsulin spike can sometimescause the blood glucose to droptoo much. Foods with a lowerglycemic index cause the bloodsugar to rise slowly, resultingin a more appropriate releaseof insulin from the pancreas.This result is a more desirablesteady raising and lowering ofblood glucose levels.

GI food lists may useeither white bread or glucose asthe standard for comparison.Foods are compared against thestandard based on the relativerise in blood sugar that a foodwith the same amount ofcarbohydrate (50 grams) wouldcause. For example, whenwhite bread is given a glycemicindex of 100, table sugar(sucrose) has a glycemic indexof 83. This means that for thesame amount of carbohydrateseaten as sugar, white bread willraise the blood sugar morequickly. Most health careprofessionals used to think that

because bread is a complex carbohydrate,the body must break it down more slowlythan simple carbohydrates like table sugar,but research has shown us otherwise.

Factors which affect the rate atwhich a particular food causes the bloodglucose to rise include the amount ofcarbohydrate, the type of carbohydrate, theway the food is prepared and other foodsthat are eaten at the same time.Carbohydrates have different forms, sizesand chemical properties that affect bloodglucose response.

FibreThe fibre content of foods affects GI. Foodswith higher insoluble fibre content havelower GI, decreasing the blood glucoseresponse. Foods that are high in soluble


fibre also have lower GI. Soluble fibreslows down the interaction between starchand enzymes during digestion. Thisimproves blood sugar control in additionto lowering serum cholesterol. Allindividuals, especially those with diabetes,can benefit from increasing their totaldietary fibre intake.

Protein and fatIncluding protein and fat in a meal slowsdown digestion and absorption ofcarbohydrates, while, in turn, lowers the GI.People with diabetes have the same proteinrequirements as those without. Having abalanced meal which includes protein maystimulate insulin secretion and decreaseserum glucose response. Because high fatintake is associated with poor blood glucosecontrol, people with diabetes should follow

* Whenever possible, a Canadian product was given as an example.

Table 2.GI values of some common foods* (Reference Standard is glucose, GI=100)

Milk Products

Low GI (< 55) Intermediate GI (55-70) High GI (> 70)

skim milk 32whole milk 42

Fruits

apple 39apple juice 41banana 46grapes 43orange 40orange juice 53pear 33

cranberry juice 68

Vegetables peas 39sweet potato 48

Grains, Pasta

barley 22beans 40chick peas 31kidney beans 29spaghetti 40white rice 51whole wheat spaghetti37

Breads, Crackers,Cookies

oat bran bread 44rye bread 41

arrowroot cookies 63bran muffin 60 Bretons 67croissant 67digestive cookies 55Ryvita 69

Cereals

Sweeteners

Beverages

instant potatoes 88

bagle, white 72instant rice 87

white bread 71

Corn Flakes 80

glucose 100honey 87

Gatorade 78

Cream of Wheat 66quick oats 65sugar coated cornflakes55sucrose 60

Coca Cola 63

potato 60sweet corn 59

fructose 12

All-Bran 50

brown rice 55


Health Canada's recommendations ofdietary intake < 30% of Calories. Inaddition,

* Choose pasta, rice or sweet potatoesinstead of instant potatoes.

* When eating high glycemic index foods,combine with foods that have a lower GIor with protein and fat to achieve anoverall lower GI.

* Add beans to soups, salads and chilies.* Avoid high GI foods alone.

Some population groups have difficultymeeting their nutrient requirements. Forthese individuals, it is often helpful to takenutritional supplements either as a mealreplacement or to complement their currentintake. For people with Diabetes, anutritional supplement such as Glucerna, canbe used as a snack or as a meal replacement.It is geared towards individuals withDiabetes. Glucerna has a lowercarbohydrate content relative to standardsupplements. The fibre content is beneficialfor blood glucose control and highcholesterol levels often found in individualswith diabetes. In addition, the fibre can helpimprove poor bowel function that iscommon in those requiring supplements andin people with diabetes who havecomplications such as gastropareseis.Glucerna has a higher fat content than thestandard formula which may slow gastricemptying and minimize postprandialglucose increases in patients with abnormalglucose tolerance. The effect of Glucernaversus a standard nutritional supplement wascompared for the effect on blood sugarcontrol and lipoprotein profile in patientswith type 2 diabetes. Notwithstanding thehigh monounsaturated fat content ofGlucerna, the lipoprotein profiles were notsignificantly different from those consumingthe standard lower fat formula. As always,following a healthy meal plan developedwith a dietitian is the best way to controlblood sugars and promote optimal nutrition.The addition of supplements should bediscussed with the dietitian.

References

American Diabetes Association. PositionStatement. Evidence-Based NutritionPrinciples ands Recommendations for theTreatment and Prevention of Diabetes andRelated Complications. Diabetes Care2002;25:S50-S60.

Canadian Diabetes Association. Submissionto the Commission on the Future of HealthCare in Canada. May 2002.Beck, L. Leslie Becks NutritionEncyclopedia.Toronto: Prentice Hall Canada,2001.

Clips on Sugars, 2002. Canadian SugarInstitute

FAO/WHO Expert Consultation. Carbohy-drates in human nutrition: report of a jointFAO/WHO Expert Consultation (FAO Food


and Nutrition Paper 66) 1998.Foster-Powell, K. and Brand-Miller, J.International Tables of Glycemic Index andLoad Values: 2002. American Journal ofClinical Nutrition 2002;76:5-56.

Wolever, T at al. Guidelines for the Nutri-tional Management of Diabetes Mellitus inthe New Millennium: A Position Statementby the Canadian Diabetes Association.Canadian Journal of Diabetes Care1999;23:56-69


N U T R I T I O N N O T E Sa resource for living well with diabetes

READY, SET, START COUNTINGHOW TO USE CARBOHYDRATE COUNTING TO KEEP YOUR BLOOD GLUCOSE HEALTHY

1/3 cup

1/2 cup

1 cup

When you have diabetes, keeping your blood glucose in ahealthy range helps you feel your best today and in thefuture. Carbohydrate counting is a way to plan the amountof carbohydrate you eat and better manage your diabetes.Carbohydrate counting is not a diet. It is a meal planningtool that helps you understand how your food choicesaffect your blood glucose level.

CARBOHYDRATE AND BLOOD GLUCOSEMost of the carbohydrate you eat is digested to glucose.The right balance between carbohydrate and insulin (made by the pancreas or from injections) keeps yourblood glucose level normal. When you eat, how much youeat, and whether or not you have snacks should be based on your lifestyle, medications, and meal planning goals.A dietitian can help you choose, from the goals below,the one that is best for you.

CONSISTENCY For many people who use diabetesmedications or insulin, it is important to eat the sameamount of food at the same times. Planning the amountof carbohydrate you eat can keep your blood glucosefrom going too high or too low.

MAXIMUMS If you use a healthy lifestyle to controlyour diabetes, or medications that do not cause lowblood glucose, having a maximum limit forcarbohydrate at meals keeps your blood glucosefrom going too high, and allows you to choose lesscarbohydrate when you wish.

MATCHING Some insulin plans allow you to vary mealtimes or carbohydrate amounts. If you follow this type ofinsulin plan you need to know how to match yourinsulin to the amount of carbohydrate you eat.

TO COUNT CARBOHYDRATES YOU NEED TO KNOW: FOODS THAT CONTAIN CARBOHYDRATE- Grains, breads, cereals and dried beans- Starchy vegetables- Fruits- Milk and yogurt- Sweets and desserts(Nonstarchy vegetables contain small amounts ofcarbohydrate and will not affect blood glucose unlessyou eat large amounts.)

PORTION SIZES- A carbohydrate choice is a portion of

food that has 15 grams of carbohydrate.(11 carbohydrate choice = 1155 grams ofcarbohydrate)

- Carbohydrate from any food has thesame effect on blood glucose. Smallportions of sweets or sugar can be usedin place of other carbohydrate foods.

- Measure or weigh foods to learn whatcommon portion sizes look like. Whenyou cant, use these hand estimates.

HOW TO READ A FOOD LABEL

- Find the Serving Size.- Find the Carbohydrate in one serving. (Sugars are

included in this number, do not count them separately.)- Compare the serving size listed to your portion.- Calculate the amount of carbohydrate in your portion. - You can count grams of carbohydrate or

carbohydrate choices.

Nutrition FactsValeur nutritive2 cookies (28g)pour 2 biscuits (28g)

Calories 220

* % Daily Value / % valeur quotidienne: Vit A 0% Vit C 0 % Calcium 0 % Iron / Fer 6 %

Fat / Lipides 7g

Saturated / saturs 2g+ Trans / trans 0g

Cholesterol / Cholestrol 0mg

Sodium / Sodium 110mg

11%

10%

5%

Carbohydrate / Glucides 18g

Fibre / Fibres 1g

Sugar / Sucres 0g

Protein / Protines 2g

6%

3%

Amount/Teneur %DV / %VQ* Amount/Teneur %DV / %VQ*

For referral to a dietitian or for more information on meal planning contact your local registered dietitian or Dietitians of Canada at www.dietitians.ca

DEVELOPED BY

www.dce.orgwww.eatright.com

CARBOHYDRATE CHOICESWhen there is not a label, these food lists canhelp you.

Most women need about 3-4 carbohydrate choices(45 to 60 grams of carbohydrate) at each meal. Mengenerally need about 4-5 (60 to 75 grams ofcarbohydrate). If you eat snacks, 1-2 carbohydratechoices (15-30 grams of carbohydrate) is reasonable.How many carbohydrate choices you need will dependon your size and activity level.

Healthy eating is more than just carbohydrate counting.Eat a variety of foods, including 5 servings of fruits andvegetables, 6 servings of grains (3 whole grain), 2 servingsof low-fat dairy. Foods in the meat and fat groups do notdirectly affect blood glucose. Make heart healthy choicesfor optimal health.

Authored by:Belinda OConnell MS, RD, CDESusan Wang MS, RD, CDE

Sponsored by:An educational grant from Merisant, US, Inc.,makers of Equal sweetener

MY CARBOHYDRATE GOALS

Breakfast ______:______ (time)

_______________ carbohydrate choices or grams

Snack: _______________ carbohydrate choices or grams

Lunch ______:______ (time)



Dinner ______:______ (time)



Grains, Breads, Cereals

- 1 oz bread (1 slice bread,1/4 large bagel, 6 tortilla)

- 1/2 cup cooked dried beans- 1/3 cup pasta or rice- 1 cup soup- 3/4 cup cold cereal- 1/2 cup cooked cereal

Milk and Yogurt

- 1 cup milk- 2/3 cup

unsweetenedyogurt (6 oz)or sweetenedwith noncaloricsweetener

Fruits

- 1 small fresh fruit- 1/2 cup fruit- 1 cup melon or berries- 1/2 cup fruit juice- 1/4 cup dried fruit

Each portion is one carbohydrate choice (15 grams of carbohydrate).(Foods with less than 20 calories and 5 grams of carbohydrateare considered free. These include: sugar-free sodas andbeverages, sugar substitutes, spices and seasonings.)

Sweets and Snack Foods

- 3/4 oz snack food(pretzels, chips,4-6 crackers)

- 1 oz sweet snack(2 small sandwichcookies, 5 vanilla wafers)

- 1 Tbsp sugar or honey- 1/2 cup ice cream

Vegetables

- 1/2 cup potato, peas,or corn

- 3 cups raw vegetables- 1 1/2 cups cooked

vegetables

(Small portions ofnonstarchy vegetablesare free.)


Diabetes Care News is published quarterly by Sampling Canada for inclu-sion in the Canadian Diabetes Care Guide, Professional Pack. Address allcorrespondence to:

Alan DonaldsonPresident & PublisherCanadian Diabetes Care Guide33 Wheeler AvenueToronto, Ontario M4L 3V3

Diabetes CareNews

Magazine


Tel: 416.690.4871Fax: 416.690.3553

[email protected]

MULLED PEACH

TEA PUNCH

Just follow our 2 simple steps:

1.EMPTY 1 pouch CRYSTAL

LIGHT Peach Iced Tea Low

Calorie Drink Mix in heat-

proof pitcher.

2.ADD 5 whole cloves, 1 cinna-

mon stick, 4 cups boiling

water and 2 cups apple

juice. Stir to dissolve. Let

stand 10 min. Remove

spices. Serve warm.

Makes 8 (1 cup) servings.

Per Serving:

Calories 34

Protein 0.2 g

Fat 0.1 g

Carbohydrate 7.9 g

Canadian Diabetes Associa-

tion Food Choice Values

1 serving = 1

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