Lecture 6bDiabetes Management

Chapter 19

Diabetes Management

• Type 1 diabetes – Managed by a coordinated regimen of nutrition therapy and insulin;

• Type 2 diabetes– Diet and exercise

• Gestational diabetes– Diet and exercise and perhaps insulin

• Goals and interventions are specified for three levels of prevention: – Primary prevention of diabetes among people with prediabetes or at high risk of

diabetes– Secondary prevention of managing existing diabetes– Tertiary prevention of slowing the rate of diabetes complications

Diabetes Management—(cont.)

• Calories, overweight, and obesity– Weight loss has traditionally been the focus of

nutrition intervention for overweight and obese people with prediabetes or type 2 diabetes.o No one proven strategy that can be uniformly

recommended to promote weight loss in all clientso Weight loss medicationso Bariatric surgery

Diabetes Management—(cont.)

• Preventing diabetes

– Weight loss through a combination of healthy eating and exercise is the primary focus of diabetes prevention.

– A low saturated fat intake may reduce the risk for diabetes by improving insulin resistance and promoting weight loss.

– Several studies show that an increased intake of whole grains and fiber lowers the risk of diabetes.

Diabetes Management —(cont.)

• Secondary prevention: managing diabetes – Primary goal of diabetes management is to keep blood

glucose levels as near normal as possible.

– Secondary goalso Attain and maintain control of blood lipid levels and blood

pressure.

o Prevent or delay the development of complications.

o Meet the individual’s cultural and personal needs.

o Maintain the pleasure of eating by not limiting any foods unless indicated by scientific evidence.

Diabetes Management—(cont.)

• Secondary prevention: managing diabetes—(cont.)

– Nutrition therapy is an essential component of diabetes management.

– Coronary heart disease (CHD) is the leading cause of death among people with diabetes.

Diabetes Management—(cont.)

Diabetes Management—(cont.)

Diabetes Management—(cont.)

• Secondary prevention: managing diabetes—(cont.)– Total carbohydrates—(cont.)

o Glycemic control depends on matching carbohydrate intake with the action of insulin or other medication.

o A low glycemic index diet may provide a modest benefit in controlling postprandial hyperglycemia.

Diabetes Management —(cont.)

• Secondary prevention: managing diabetes—(cont.)– Sweeteners—

o Use of fructose as an added sweetener is not recommended. May adversely affect serum lipid levels No reason for people with diabetes to avoid

naturally occurring fructose in fruit and vegetables

Diabetes Management—(cont.)

• Secondary prevention: managing diabetes—(cont.)– Sugar alcohols

o Provide fewer calories and cause a smaller increase in glucose

o Do not contribute to dental cavities o Nonnutritive sweeteners

Saccharin, aspartame, acesulfame, sucralose, and neotame

May safely be used by people with diabetes

Diabetes Management—(cont.)

• Secondary prevention: managing diabetes—(cont.)

– Fiber

o Recommendations for fiber are the same as for the general population.

o Foods rich in fiber provide other benefits such as increasing satiety; providing vitamins, minerals, and phytochemicals; and lowering serum cholesterol levels.

Diabetes Management—(cont.)

• Secondary prevention: managing diabetes—(cont.)– Fat

o People with diabetes are advised to limit their intake of saturated fat to less than 7% of total calories, minimize their intake of trans fat, and consume less than 200 mg of cholesterol daily.

Diabetes Management—(cont.)

• Secondary prevention: managing diabetes—(cont.)– Alcohol

o Moderate use of alcohol (1 drink/day or less in women and 2 drinks/day or less in men) by people who have well-controlled diabetes minimally affects blood glucose and insulin levels.

Diabetes Management—(cont.)

• Secondary prevention: managing diabetes—(cont.)– Vitamins and minerals

o Vitamin and mineral requirements of people with diabetes are not different from those of the general population.

o Uncontrolled diabetes is often associated with micronutrient deficiencies. Treatment is a balanced diet that supplies natural sources of nutrients.

o Chromium

Diabetes Management—(cont.)

• Tertiary prevention: controlling diabetes complications– Progression of microvascular diabetes complications may be

modified by improving glycemic control and lowering blood pressure.

• Meal planning approaches– Monitoring carbohydrate intake is key to controlling blood

glucose levels.

– Meal plan should reflect the individual’s lifestyle, preferences, and willingness/ability to make dietary changes.

Diabetes Management—(cont.)

• Meal planning approaches—(cont.)

– Exchange lists for meal planningo Choose Your Foods: Exchange Lists for Meal Planning is a

framework for choosing a healthy diet.o Group foods into lists that, per serving size given, are

similar in carbohydrate, protein, fat, and calories, based on rounded averages

o Three major categories are carbohydrates, meat and meat substitutes, and fats

Diabetes Management—(cont.)

• Meal planning approaches—(cont.)– Exchange lists for meal planning—(cont.)

o Sample meal pattern is designed for clients based on their usual pattern of eating.

o Clients are encouraged to eat a variety of foods within each list and to make healthy choices.

o Food should be weighed or measured until portion sizes can be accurately estimated.

o Eliminates the need for daily calculations

Diabetes Management—(cont.)

• Meal planning approaches—(cont.)– Exchange lists for meal planning—(cont.)o Some items on some lists are counted as more than just

one choice or one exchange.o Some items appear on more than one list and in different

amounts.o Best suited to people who want or need structured meal-

planning guidance and are able to understand complex details

Diabetes Management—(cont.)

• Carbohydrate counting

– Easier and more flexible alternative to using the exchange system

– Clients are given an individualized meal pattern that specifies the number of carbohydrate “choices” for each meal and snack.

– Carbohydrate choice lists

– Protein and fat cannot be disregarded.

Diabetes Management —(cont.)

• Carbohydrate counting—(cont.)– Appropriate for people who understand the

importance of consuming a consistent carbohydrate intake to match insulin or medication peaks

– Feel more in control and benefit from improved glucose control

– Keeping records of blood glucose tests and food intake helps

Diabetes Management—(cont.)

• Changing behaviors– Diagnosis of diabetes often triggers anxiety and uncertainty.– Before recommending dietary changes, it may be useful to

ask the client:o What are your goals for nutrition counselling?o What behaviors do you want to change?o What changes can you make in your present lifestyle?

Diabetes Management—(cont.)

• Changing behaviors—(cont.)– Before recommending dietary changes, it may be useful to

ask the client:—(cont.)o What obstacles may prevent you from making

changes?o What changes are you willing to make right now?o What changes would be difficult for you to make?

Diabetes Management—(cont.)

• Changing behaviors—(cont.)– Ideally, positive changes occur progressively. – Patient actively involved in goal setting, self-

monitoring, and record keeping. – Periodic and ongoing follow-up improves compliance.

Pharmacologic Management of Diabetes

• People with type 1 diabetes rely on exogenous insulin for survival.

• Due to the progressive nature of the disease, most people with type 2 diabetes eventually require oral agents, insulin, or a combination of both to manage blood glucose levels.

Pharmacologic Management of Diabetes—(cont.)

• Insulin therapy for people with type 1 diabetes – Insulin preparations vary in how quickly they act,

when their peak action occurs, and how long their effects last.– Intermediate- or long-acting insulin is used to meet basal

needs. – Rapid- or short-acting insulin is used before each meal.– Closely resembles how insulin is normally secreted– Nighttime hypoglycemia can be a problem with NPH peaking

during the night.

Pharmacologic Management of Diabetes—(cont.)

• Intensive insulin therapy for people with type 1 diabetes– Popular and dynamic insulin regimen for type 1 diabetes

– Algorithm gives formulas for clients to calculate the carbohydrate-to-insulin ratio for the anticipated carbohydrate content of a meal/snack.

– Requires more calculations at each meal but allows greater flexibility in when meals are eaten and how much carbohydrate is consumed

• Insulin therapy for people with type 2 diabetes– Approximately 30% of people with type 2 diabetes

eventually require insulin.– Often begins with a single injection of intermediate- or

long-acting insulin at bedtime – Another regimen uses a morning injection of rapid and

intermediate-acting insulin with an intermediate- or long-acting insulin at dinner or before bedtime.

– Self-monitoring of blood glucose levels

Pharmacologic Management of Diabetes—(cont.)

• Glucose-lowering medications

– Oral glucose-lowering medications vary in their mechanism of action and food concerns.

– Considered adjunct to nutrition therapy and exercise, not a sole mode of therapy

Pharmacologic Management of Diabetes—(cont.)

Exercise—(cont.)

• Exercise in insulin users

– Has not been shown to improve glycemic control in type 1 diabetics

– May worsen hyperglycemia

– Should occur within 2 hours of eating

– If exercise is unplanned, an additional 10 to 15 g of carbohydrate per hour of moderate activity is recommended.

Exercise—(cont.)

• Exercise in type 2 diabetes– Offers substantial benefits– Helps to maintain long-term weight reduction– Monitor blood glucose levels– Should occur within 2 hours after eating– Stop activity if signs and symptoms of hypoglycemia

develop

Sick-Day Management

• Acute illnesses can significantly raise blood glucose levels.

• Maintain normal medication schedule, monitor blood glucose levels every 2 to 4 hours, and maintain an adequate fluid intake

• A daily intake of 150 to 200 g of carbohydrates, approximately 45 to 50 g every 3 to 4 hours, is recommended.

Life Cycle Considerations

• Children and adolescents

– Children with diabetes appear to have the same nutrient needs as their age-matched peers

– Managing diabetes in children and adolescents is complicated by the impact of growth on nutrient needs, irregular eating patterns, and erratic activity levels.

– Failure to provide adequate calories and nutrients results in poor growth, as does poor glycemic control and inadequate insulin administration.

Life Cycle Considerations—(cont.)

• Children and adolescents—(cont.)– Individualized meal plans and intensive insulin

regimens can provide flexibility for erratic eating, activity, and growth.

– Weight control is key to preventing type 2 diabetes in children.

Life Cycle Considerations—(cont.)

• Diabetes in later life– Unique considerations related to aging that affect glycemic

control– Blood glucose levels rise with age for reasons that are

unclear.– Cognitive impairments may preclude self-management.– Older adults may be at greater nutritional risk for a variety

of reasons. – A fasting target level of 6.7 to 8.3 mmol/L may be

considered appropriate.

Diabetic Diets in the Hospital

• A consistent carbohydrate diet

• Appropriate modifications in fat intake are made.

• Consistent timing of meals and snacks is stressed.

• No one way to provide adequate nutrition for diabetics in the hospital

Functional foods

Health Canada definition

A functional food is similar in appearance to, or may be, a conventional food that is consumed as part of a usual diet, and is demonstrated to have physiological benefits and/or reduce the risk of chronic disease beyond basic nutritional functions, i.e. they contain bioactive compound.

Functional foods

Flaxseed- ground flaxseed may help with glycaemic control

Nutraceuticals

Health Canada definition

A nutraceutical is a product isolated or purified from foods that is generally sold in medicinal forms not usually associated with foods. A nutraceutical is demonstrated to have a physiological benefit or provide protection against chronic disease.

Nutraceuticals

Two examples

Flaxseed oil-high doses may worsen glycaemic control

Flaxseed lignan complex- 600 mg/day of secoisolariciresinol diglucoside lowered plasma glucose in older type 2 diabetes patients