NUTRITIONAL INTERVENTION IN DIABETES: … · • Patients’ common presentation • Importance of nutritional intervention in diabetes management ... high glycemic index (GI) food

NUTRITIONAL INTERVENTION IN DIABETES:

BARAKATUN NISAK MOHD YUSOF

Ph.D (UKMalaysia)

Senior Lecturer and Dietitian Department of Nutrition & Dietetics

Faculty of Medicine & Health Sciences Universiti Putra Malaysia

1 MJM-UPM 8 NOV 2012

Translating Scientific Evidence into Practice

SIZE of the PROBLEM

2

• The Size of the problem

• Patients’ common presentation

• Importance of nutritional intervention in diabetes management

• Translating the evidences into practices

• Summary

Where is Malaysia in the midst of Asian Epidemic of Diabetes?

3

Estimated prevalence of diabetes among adults aged 20-79

years old in 11 Asian countries

IDF Diabetes Atlas 2009

DIABETES: The SIZE of The PROBLEM

4

09

165%

Common Presentations

1. Poor Glycemic Control

5

Proportion of patients achieving target HbA1c

Mafauzy et al. 2011 DiabCare 2008

Common Presentations

2. Overweight and Obesity with prominent

abdominal obesity

6

BMI Category Waist Circumference

Barakatun Nisak et al 2009 - 2011

Collaborative Management

Diabetes Management

Nutrition Therapy

Physical Activity

Monitoring Blood Glucose

Medication – Insulin or oral

agents

7

+ Intensive

Education +

Self-

Management

Nutrition Intervention for the Management of Diabetes

DOES NUTRITION INTERVENTION REALLY HELP?

Ranging from 1-2% reduction in AIc 0.4% (p<0.05)

0.4kg (NS)

Barakatun Nisak et al. 2012

Patients’ Self Perception on

Treatment Adherence

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Treatment Adherence +ve RESPONSES

Diet 85%

Exercise 57%

Taking medication as prescribed

96%

SMBG 52%

Come for appointments with HCP

97%

Mafauzy et al. 2011 DiabCare 2008

HOW MANY OF THEM WERE ACTUALLY

ADHERED TO THE TREATMENT?

11

55

39

27

87

3427

59

79

0

20

40

60

80

100

Diet Exercise SMBG Prescribed Mx (OAD)

2003 2008

Mafauzy et al. 2011 DiabCare 2008

Malaysian Diet

• We experience

more postprandial

hyperglycemia and

this could be due

to frequent

consumption of

high glycemic

index (GI) food (ie,

“glutinous”)

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Country Fasting Postprandial

Indonesia 7.9 11.6

Bangladesh 8.4 8.6

Singapore 7.6 7.5

Malaysia 8 12.7

Taiwan 8 10.6

Thailand 7.9 11

Philippines 7.2 9.4

1. Mohamed M et al. Curr Med Res Opin 2008; 24: 507-514

Malaysian Style

75 – 90 g of CH0 (5-6 exch CHO)

1 exch = ½

cup of rice

OR 1pc

bread

Risk Reduction with 1% decline

in annual mean A1c

UKPDS 1998 15

Goals of Diabetes Management

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• Achieve and maintain:

– Good Metabolic Control (Blood glucose, Lipid

profile, Blood pressure)

• Prevent or slow down complications of diabetes

• Individualized diets according to lifestyle and culture and willingness to change

• Limit food choices based on scientific evidence and maintain pleasure of eating

MNT MDA 2005

Diabetes and Cardiovascular Disease

• CVD: is a major cause of death in patient with DM1

• Independent risk factor –hyperglycemia2,3

(1) Node & Inoue 2009 Cardio Diab 8:23; (2) Nagakami et al.

2004 Diabetologia 47:385-394 (3) Huxley et al. 2006 BMJ 332:73-78

Cum

ula

tive I

ncid

ence o

f CVD

Mort

ality

0 2 6 4

CVD Mortality

DM

NGT

Barr EL, et al. Circulation. 2007;116:151–157

AusDiab = Australian Diabetes, Obesity, and Lifestyle Study

17

Achieving Good Metabolic Control thru Nutrition Intervention

• First Line Treatment-

Amount of carbohydrate (CHO exch or CHO counting) is the main option of treatment

18 MNT MDA 2005

CHO in Diabetes MNGT

• The component of diet that has the greatest influence on blood glucose

CARBOHYDRATE

*(85-94% variability of mean glc and insulin

responses)

• Carbohydrate has been the focus of management

First step of CHO recommendations

• Control the amount of carbohydrate

CHO prescription

• Carbohydrate should be consistently distributed throughout the day

• Avoid excessive intake at one

meal

• Distribute evenly through out

the day

The Helping Hands

American Diabetes Association 2005

Choose foods in the

correct amounts

Starch Fat Protein

The Helping Hands

American Diabetes Association 2005

Choose foods in the

correct amounts

Vegetables: choose as much as you can hold in both hands. These should be green leafy vegetables –

For fruit use one fist.

Common Presentations

2. Overweight and Obesity with prominent abdominal obesity

24

BMI Category Waist Circumference

How to achieve reduce energy diet of 1200-

1500kcal/d?

1. Conventional reduced energy diet (Self-selected Diet)

2. Meal Replacements

25

Weight loss strategy

Overweight/Obesity

1.Physical activity consistent

with guidelines

2.Weight loss consistent with

guidelines

3.MNT consistent with

guidelines

4.Formula/Caloric

replacement consistent

with options and

strategies

5.Consider bariatric surgery

26

Malaysia – food heaven!

NUTRITION INTERVENTION AND WEIGHT LOSS?

0.4% (p<0.05)

0.4kg (NS)

Barakatun Nisak et al. 2012

Intervention Weight changes in T2DM Weight changes in non-DM

6-mo 12-mo

Weight loss diet (n=532)

- 2.4kg - 2.6 - 4.6 to 7.6

Orlistat (n= 574) - 4.9 - 5.1 - 8.2

Sibutramine (n=152)

- 7.5 - 7.2 - 8.2

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Wk 0

Wk 12

Wk 24

Schedule

Tatti P and Di Mauro P, 2010

Tatti P and Di Mauro P. Mediterr J Nutr Metab. 2010. In press.

Baseline

Weight, blood glucose, A1C, lipids and blood pressure

Weight, blood glucose, A1C, lipids and blood pressure

> 5% wt loss < 5% wt loss

Weight, blood glucose, A1C, lipids and blood pressure

Diabetes Meal

Replacement

Subjects Enrolled (n=96) and informed

consent obtained

30

31

Look AHEAD Trial

(Action for Health in Diabetes)

The Look AHEAD Research Group. Diabetes Care 2007. 30;6:1374-1383.

Objective To determine the effectiveness of intentional weight loss in reducing cardiovascular disease events in type 2 diabetes. 13.5 year follow up

Methods 5,145 men and women with type 2 diabetes who were 45 – 74 years of age and had a BMI ≥25kg/m²

Randomly assigned to Intensive Lifestyle Intervention (ILI) or a control condition, Diabetes Support and Education (DSE)

Weight loss goal of 10% (study goal = 7%)

Physical activity goal of 175 minutes per wk

Ongoing group and individual sessions

Portion-controlled diet including liquid meal replacements

Invited to three group sessions each year

Information on behavioral strategies presented but not implemented in sessions

Information focused on diet, physical activity, or social support

ILI Group included: DSE Group included:

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34

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What is Meal Replacement Program

(MRP)

• To help achieve reduced energy diet by controlling energy

and portion size.

• For people who have difficulty with self selection and/or

portion control, meal replacements (e.g., liquid meals,

meal bars, calorie-controlled packaged meals) may be

used as part of the diet component for a comprehensive

weight management program.

• Substituting one or two daily meals or snacks with meal

replacements is a successful weight loss and weight

maintenance strategy (Level A)

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Ref : ADA Evidence Based Library 2011

WHAT FORMULA/

PRODUCTS TO USE IN

MRP?

Quick Guide of Selecting The Right MRP

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Meal-Replacement Products for People with Diabetes

Quick Guide for Selecting the Right MRPs

Calories 190 to 250

For MRPs fewer than 200 calories, add an extra 15 to 20 grams of carbohydrates (about 100 calories) by including fat-free light yogurt,

low-fat whole-grain crackers, fresh fruit or fat-free milk. Raw or

cooked non-starchy vegetables (which are low in calories but contribute extra fiber, vitamins and minerals) may be eaten with any

of the MRPs.

Protein 10 to 15 grams Adequate protein promotes health and mealtime fullness.

Carbohydrate 14 to 34 grams

To slow the rate blood glucose (sugar) rises after a meal, look for the first carbohydrate listed in the ingredients to be maltodextrin or

tapioca dextrin rather than refined sugars, such as sucrose, corn

syrup, high-fructose corn syrup or brown rice syrup.

Dietary Fiber 3 to 6 grams

Total Fat 5 to 8 grams The primary fat source should be unsaturated fat from vegetable oils rather than saturated fat, such as partially hydrogenated oil, palm oil

or coconut oil. All MRPs should be trans-fat free.

Cholesterol 0 to 20 milligrams

Sodium 100 to 300 milligrams

Vitamins and Minerals

Look for 50 to 100 percent of the Dietary Reference Intake.

Avoid products containing stimulants, such as caffeine, ginseng, guarana and ephedra.

MRPs are effective for weight loss for a variety of reasons other than reducing calories. MRPs:

· Offer a structured calorie-controlled plan without having to count calories or choose what to eat for one or two meals and/ or one to two snacks a day

· Help establish a routine for eating meals and snacks at regular times · Help satisfy a craving for sweets (and help reduce the amount eaten), as many MRPs

have a sweet taste · Save time and require no preparation or refrigeration if unopened (Most fit easily into a

purse or briefcase for times when you cannot eat a regular meal.) · Save money when compared to many other commercial diet plans

"Use of meal replacements once or twice daily to replace a usual meal

can result in significant weight loss, but meal-replacement therapy must be continued if weight loss is

to be maintained."

- The American Diabetes Association

Meal-replacement products (MRPs) provide a meal or snack alternative for people with diabetes. MRPs may help:

· Stabilize blood glucose (sugar) levels · Assist with weight loss

MRPs include multi-flavored and ready-to-go drinks, powdered shakes, soups, bars, and puddings. Most are lactose and gluten-free and many offer non-nutritive sweeteners as replacements for some sugars. Adding regular aerobic exercise most days of the week will not only help with weight loss, but also help maintain a healthy weight long term. Ask your registered dietitian, diabetes educator or health care provider about using MRPs to optimize your health goals.

Eat Move Live A nutrition resource for living well with diabetes

Meal replacement products should provide at least 50-100% of the RNI for vitamins and minerals and low in fat and sodium. MNT 2012

Unpublished

MEAL REPLACEMENT

Characteristics Glycemic Targeted Products

Commercialized Low Calorie Diet

Energy /Serving 200-300 kcal/serving 80-160 kcal/serving

Protein 15-25% 25-40%

Carbohydrate 45-55% 50%

Fat 25-35% (MUFA) 15-20%

Fibre Added fibre (15g/serv) Nil - 3g

Vit/Mineral 50-100% Dietary Reference Intake

Products Liquid form and snack bar Liquid, milk shake, snack bar, soup

Glycemic Index LOW NA

Meal Replacement using Glycemia

Targeted Specialized Nutrition (GTSN)

• GTSN – diabetes specific formula

• Role of GTSN

– To provide proper nutrition (Complete Balance Meal)

(vs. Complete But Not Balance) – improve overall nutritional status

– To promote effective weight management suitably to patients with diabetes

– Maintained better glycemic control than standard formulas

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LUNCH

TEA TIME BREAKFAST

DINNER

1200 kcal/day

Considerations before

starting MRP

• Patients should undergo at least 3 to 6 months of individualized conventional low calorie diet

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Meal Replacement vs. Reduced Energy

Diet on Calories Intake/day

% c

han

ges i

n c

alo

ries i

nta

ke

Ditschuneit and Marion 2001; Obesity Research

Life examples..

• Without prior knowledge on self-selected diet of low caloric diet, may

– Promotion of eating disorder (Binge eating)

– Fostering poor eating habit

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Considerations before

starting MRP

• Patients should undergo at least 3 to 6 months of individualized conventional low calorie diet

• MRPs as weight loss strategy are not recommended for persons with complications such as chronic kidney disease Stage 3 onwards, recent myocardial infarction and other severe complications.

• Risk of hypoglycemia should be assessed and monitored

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Disadvantages of using MRP as part

of weight loss strategy

• Boredom with use of MRP over time

• Limitation of outcomes and evidence for ‘off the shelf’

– Research in MRP often involve provision of MRP products free of charge and ongoing support to develop their skills which are likely to increase their compliance

– There is a need to evaluate the real life outcomes of using MRP within our healthcare setting with limited resources and time that are usually evident

• Cost implication – May not be considered a viable option for lower SES groups

• Satiety Issues

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INTENSIVE LIFESTLE DIABETES MANAGEMENT

Look AHEAD Trial

Intervention format Individual + Group

Frequency of Follow up for

the first 6 mo

4 /mo

Refresher Group/ campaigns 2-3 times/year after 2 years

Supervised activity Periodically in campaigns

P<0.001

Lifestyle Intervention Can Produce Long Term

Benefits: Results After 4 Year

Arch Intern Med. 2010;170(17):1566-1575

Some factors for success:

Ongoing intensive contact

Meal replacements

Diet and physical activity

MONITORING AND EVALUATION

• Individuals on meal replacements for weight loss should be followed-up by a dietitian within 1-3 mo.

• Dietitian should help to progress to low calorie diets for weight maintenance where appropriate. However, continued use of meal replacements may be needed to maintain weight (Grade A).

• Risk of hypoglycemia should be assessed and monitored.

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Summary

• Nutrition Intervention is important in managing diabetes and delaying diabetes complications

• Nutrition Intervention: – Focus on the total amount of carbohydrate

– Avoid excessive portion size (dietary CHO)

– Consider Meal Replacement Program using Glycemic Targeted Specialized Nutrition

• Add exercise most days of the week

• Self-monitoring and frequent follow-ups 50

Summary

• More information is needed about

– Which patients do best with MRP approaches?

– How to integrate MRP within Malaysia health care and community setting?

• Individuals on MRP should be followed-up by a dietitian

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Red vs green apple

15 g CHO 58 g CHO

Thank you.. [email protected]

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