Canadian Diabetes Association Clinical Practice Guidelines
Nutrition Therapy
Dr.Saeid Khezer Family physician Kurdistan / Duhok
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Nutrition Checklist
REFER 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
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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
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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
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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
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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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Choose low glycemic index carbohydrates
www.guidelines.diabetes.ca
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Clinical assessmentLifestyle 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
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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 DisadvantagesHi-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
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Properties of Dietary PatternsDietary 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
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Recommendations 1 and 2
1. 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]
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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
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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
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Recommendations 7 and 8
7. 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]
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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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
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Recommendations 11 and 12
11. 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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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].
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients