Ty Lecture 4d 3 February 2014 Type 2 Diabetes Pathology Nutritional Intervention-pre- and post-onset.

Ty

Lecture 4d

3 February 2014 Type 2 Diabetes

•Pathology•Nutritional Intervention-pre- and post-onset

Ty

Type 2 diabetes-causes

-genetics including genetically driven diabetes-obesity-caused by poor diet (high fat, high simple sugars or glycaemic index foods), lack of exercise and/or genetics-obesity leads to metabolic syndrome and pre-diabetes (still time to recover before becomingtype 2 diabetic)-obesity leads to insulin resistance which ultimately leads to reduced pancreatic insulin production-metabolic syndrome and pre-diabetes can leadto type 2 diabetes (type 2 diabetes is permanent)

Metabolic syndrome

Prevent and in part manage by Canada’s food guide and exercise (150 minutes per week ofmoderate to vigourous exercise)exercise)

-Type 2 diabetes

Post onset management in part by diet and exercise and if need be oral medications and/or insulin

Canadian Diabetes Association Clinical Practice Guidelines

Nutrition Therapy Chapter 11

Paula D. Dworatzek, Kathryn Arcudi, Réjeanne Gougeon, Nadira Husein,

John L. Sievenpiper, Sandi Williams

Nutrition ChecklistREFER for nutrition counseling by a registered

dietitian

FOLLOW Eating Well with Canada’s Food Guide

INDIVIDUALIZE dietary advice based on

preferences and treatment goals

CHOOSE low glycemic index carbohydrate food

sources

2013

Nutrition Checklist (continued)

KNOW alternative dietary patterns for type 2

diabetes

ENCOURAGE matching of insulin to

carbohydrate in type 1 diabetes

ENCOURAGE nutritionally balanced,

calorie-reduced diet in overweight or obese

patients

2013

Encourage patients to follow Eating Well with Canada’s Food Guide in order to meet their nutritional needs

http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php

Macronutrient Distribution (% Total Energy)

Carbohydrates Protein Fat

% of total energy

45-60% 15-20%(or 1-1.5g / kg BW)

20-35%

Calories per gram

4 4 9

Grams for 2000 calorie/day diet

225-300 75-100 44-78

BW = body weight

Choosing Foods Using % Daily Value

http://www.hc-sc.gc.ca/fn-an/label-etiquet/nutrition/cons/fact-fiche-eng.php

Daily Values > 15% = a lot Daily Value < 5% = a little

For Patients with BMI ≥25 kg/m2…

Nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight

Weight loss of 5-10% of initial body weight

Improved insulin sensitivity, glycemic control, blood pressure control, lipid levels

Choose low glycemic index carbohydrates

www.guidelines.diabetes.ca

Clinical assessment

Lifestyle intervention by Registered Dietitian

Initiate intensive lifestyle intervention or energy restriction + increased physical activity to achieve/maintain a healthy body weight

Provide counselling on a diet best suited to the individual based on preferences, abilities, and treatment goals using the advantages/disadvantages listed below

If not at target

Figure 1 – Nutritional management of hyperglycemia in type 2 diabetes

Continue lifestyle intervention and add pharmacotherapy

Timely adjustments to lifestyle intervention and/or pharmacotherapy should be made to attain target A1C within 2 to 3 months for lifestyle intervention alone or 3-6 months for

any combination with pharmacotherapy

2013

A1C = glycated hemoglobinCRP = C reactive proteinTC = total cholesterol

CHO = carbohydrateMUFA = monounsaturated fatty acidLDL = low-density lipoprotein

BP = blood pressureTG = triglyceridesFPG = fasting plasma glucose

GI = gastrointestinal = <1% decrease in A1CHDL = high-density lipoprotein

Properties of Macronutrients

Dietary interventions A1C Advantages Disadvantages

Hi-CHO (low-glycemic index [GI])

HDL-C, CRP, hypoglycemia

-

Hi-CHO (high fibre)

TC, LDL-C HDL-C, GI side effects

Hi-MUFA TG -

Lo-CHO TG Micronutrients, renal load

Hi-protein BP, TG, preserve lean mass

Micronutrients, renal load

Long chain omega 3 fatty acids

TG Methyl-Hg exposure, environmental impact

2013

Properties of Dietary Patterns

Dietary Pattern A1C Advantages Disadvantages

Vegetarian Diet LDL-C, HDL-C Vitamin B12

Mediterranean Diets BP, CRP, TC, HDL-C, TC:HDL-C, TG

none

DASH Weight, BP, CRP, LDL-C, HDL-C

none

Atkins diet Weight, TC, HDL-C, TC:HDL-C, TG

LDL-C, micronutrients, adherence

Protein Power Plan Weight Micronutrients, adherence, renal load

Ornish - Weight, LDL-C:HDL-C FPG, adherence

Weight Watchers - Weight, LDL-C:HDL-C FPG, adherence

Zone Diet - Weight, LDL-C:HDL-C FPG, adherence

Dietary Pulses TC, LDL-C GI side effects

Nuts LDL-C, apo-B, apo-B:apo-A1 none

Meal Replacements weight Temporary intervention

2013

Recommendations 1 and 21. People with diabetes should receive nutrition counseling by a

registered dietitian to lower A1C levels [Grade B, Level 2, for type 2

diabetes; Grade D, Consensus, for type 1 diabetes], and reduce

hospitalization rates [Grade C, Level 2]

2. Nutrition education is effective when delivered in either a small group

or one-on-one setting [Grade B, Level 2]. Group education should

incorporate adult education principles, such as hands-on activities,

problem solving, role-playing, and group discussions [Grade B, Level 2]

Recommendations 3 and 4

3. Individuals with diabetes should be encouraged to follow

Eating Well with Canada’s Food Guide in order to meet

their nutritional needs [Grade D, Consensus]

4. In overweight or obese people with diabetes a

nutritionally balanced, calorie reduced diet should be

followed to achieve and maintain a lower, healthier body

weight [Grade A, Level 1A]

2013

Recommendations 5 and 6

5. In adults with diabetes, the macronutrient distribution as a percentage

of total energy can range from 45-60% carbohydrate, 15-20%

protein, and 20-35% fat to allow for individualization of nutrition

therapy based on preference and treatment goals [Grade D, consensus]

6. Adults with diabetes should consume no more than 7% of total daily

energy from saturated fats [Grade D, Consensus] and should limit

intake of trans fatty acids to a minimum [Grade D, Consensus]

2013

2013

Recommendations 7 and 87. Added sucrose or added fructose can be substituted for other

carbohydrates as part of mixed meals up to a maximum of

10% of total daily energy intake, provided adequate control

of BG and lipids is maintained [Grade C, Level 3]

8. People with type 2 diabetes should maintain regularity in

timing and spacing of meals to optimize glycemic control

[Grade D, Level 4]

Recommendation 9

9. Dietary advice may emphasize choosing

carbohydrate food sources with a low glycemic

index to help optimize glycemic control [type 1

diabetes: Grade B, Level 2; type 2 diabetes:

Grade B, Level 2]

Recommendation 10

10. Alternative dietary patterns may be used in people

with T2DM to improve glycemic control,

(including):• Mediterranean-style dietary pattern [Grade B, Level 2]

• Vegan or vegetarian dietary pattern [Grade B, Level 2]

• Incorporation of dietary pulses (e.g., beans, peas, check

peas, lentils) [Grade B, Level 2]

• Dietary Approaches to stop Hypertension (DASH) dietary

pattern [Grade B, Level 2]

2013

Recommendations 11 and 1211. An intensive lifestyle intervention program combining dietary

modification and increased physical activity may be used to

achieve weight loss and improvements in glycemic control, and

cardiovascular risk factors [Grade A, Level 1A]

12. People with type 1 diabetes should be taught how to match

insulin to carbohydrate quantity and quality [Grade C, Level 2];

or should maintain consistency in carbohydrate quantity and

quality [Grade D, Level 4]

Recommendations 13

13. People using insulin or insulin secretagogues

should be informed of the risk of delayed

hypoglycemia resulting from alcohol consumed with

or after the previous evening’s meal [Grade C, Level

3] and should be advised on preventive actions such as

carbohydrate intake and/or insulin dose adjustments,

and increased BG monitoring [Grade D, Consensus].

CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

Type 2 diabetes

Post-onset management in part exercise

Canadian Diabetes Association Clinical Practice Guidelines

Physical Activity and DiabetesChapter 10

Ronald J Sigal, Marni J Armstrong, Pam Colby,

Glen P Kenny, Ronald C Plotnikoff, Sonja M Reichert, Michael C Riddell

Physical Activity Checklist

DO a minimum of 150 minutes of moderate-to vigorous-

intensity aerobic exercise per week

INCLUDE resistance exercise ≥ 2 times a week

SET physical activity goals and INVOLVE a multi-

disciplinary team

ASSESS patient’s health before prescribing an exercise

regimen

2013

Physical Activity: Bridging the Gap

Problems Solutions

Lack of knowledge of resources

Increase awareness among health care professionals of community resources

Time constraints during physician-patient encounter

Involve a multi-disciplinary team of Physical Therapists, Diabetes Educators and Case Workers who can help motivate patients

Pre-existing or suspected heart disease

If patient wishes to take on activity more vigorous than walking, evaluate with a history and physical, resting ECG and possibly exercise ECG stress test.

Know your Community Resources and Advertise Them

Speak to your patients about community

resources:

Community pools, gyms, safe walking

trails, weight loss smart phone apps etc.

Pre-exercise Assessment

• Assess for conditions that can predispose to injury before prescribing an exercise regimen:– Neuropathy (autonomic and peripheral)

– Retinopathy

– Coronary artery disease – resting ECG +/- exercise stress test (see CPG Chapter 23)

– Peripheral arterial disease

www.guidelines.diabetes.ca

Recommendation 1

1. People with diabetes should accumulate a

minimum of 150 minutes of moderate to vigorous

intensity aerobic exercise each week, spread over

at least 3 days of the week, with no more than 2

consecutive days without exercise [Grade B,

Level 2, for T2DM; Grade C, Level 3 for T1DM]

Recommendation 2

2. People with diabetes (including elderly people)

should perform resistance exercise at least

twice a week, and preferably 3 times per week

[Grade B, Level 2] in addition to aerobic

exercise [Grade B, Level 2]. Initial instruction

and periodic supervision by an exercise

specialist are recommended [Grade C, level 3]

Recommendations 3 and 4

3. People with diabetes should set specific physical activity goals,

anticipate likely barriers to physical activity (e.g. weather, competing

commitments), develop strategies to overcome these barriers [Grade B,

Level 2], and keep records of their physical activity [Grade B, Level 2]

4. Structured exercise programs supervised by qualified trainers should

be implemented when feasible for people with type 2 diabetes to

improve glycemic control, CVD risk factors, and physical fitness

[Grade B, Level 2]

2013

2013

Recommendation 55. People with diabetes with possible cardiovascular disease or

microvascular complications of diabetes, who wish to

undertake exercise that is substantially more vigorous than

brisk walking, should have medical evaluation for conditions

that might increase exercise-associated risk. The evaluation

would include history, physical examination (including

fundoscopic exam, foot exam, and neuropathy screening),

resting ECG, and, possibly, exercise ECG stress testing [Grade

D, consensus]

2013

Diet and exercise type 1 and type 2 diabetes

Along with relevant medications including insulin as appropriate,

diet and exercise are meant to protect the vasculature, damage to

which is the major cause of disability (heart attack and stroke) and

death (heart attack and stroke) in all diabetics

See -Donohoe et al (2007) JAMA 298:765-end of article

-Booth et al (2006) Lancet 368:29-end of article

-Lloyd-Jones et al (2006) 113:791-end of article

CDA Vascular Protection ChecklistA A1C – optimal glycemic control (usually ≤ 7%)

B BP – optimal blood pressure control (< 130/80 mmHg)

CCholesterol – LDL-C ≤ 2.0 mmol/L if decision made to treat(http://guidelines.diabetes.ca/VascularRisks/RiskAssessment/)

D

Drugs to protect the heart (even if the baseline blood pressure or LDL-C is already at target) (http://guidelines.diabetes.ca/VascularRisks/RiskAssessment/)

EExercise / Eating – Regular physical activity, healthy eating, achievement and maintenance of healthy body weight

s Smoking cessation

CDA Vascular Protection Checklist

glycaemic control is best for microvascular disease-gives

decreased nephropathy and decrease retinopathy(both are

microvascular) but gives mixed results for macrovascular

disease

Note book “Heart Health for Canadians’-by Dr. Beth

Abramson-talks in part about health eating.

CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients