Dietary Guidelines for the Treatment of Diabetes

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Dietary Guidelines for the Treatment of Diabetes

• l
• Nutrition Dietetic Service
• Selly Oak Hospital

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Aims of Nutritional Advice

• The aim is to provide those who need advice with
  the information requirement to make appropriate
  choices on the type and quantity of food which
  they eat.
• It must take into account the individuals
• Specific needs
• Personal and cultural preferences
• Beliefs and lifestyle
• Wishes and willingness to change

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The goals of dietary advice

• Are
• To maintain or improve health through the use of
  appropriate and healthy food choices
• To achieve and maintain optimal metabolic and
  physiological outcome
• (Diabetic medicine 2003, Pan Birmingham
  Guidelines for the management of Diabetes 2004)

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Role of the dietitian

• The role of the dietitian is to translate
  nutritional objectives into practice in a way
  which is realistic and practical for the
  diabetic.
• Focussing on modifying the patients existing
  eating habits, food choice and timing of meals.
• To facilitate appropriate dietary modification
  the dietitian needs to assess diet for
• Food choices
• Meal plan
• Nutritional adequacy and overall dietary
  balance
• Alcohol consumption
• Beliefs or misconceptions held about diet and
  diabetes
• Physical activity, personal information
  ethnicity, occupation, literacy, economic
  circumstances , etc
• Body weight
• Other medical conditions Coeliacs, visual
  handicap, nephropathy, etc

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Background

• Historically advice given on carbohydrate
  exchanges or portions
• In 1980s carbohydrate restriction found to be
  unnecessary advice changed to healthy eating
  plate model
• DAFNE trial / Carbohydrate Counting

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The Balance of Good Health For a balanced diet
have a variety of food from the five groups
below, in the portions shown.
Bread, other cereals, pasta, rice, potatoes,
chapattis Starchy foods. Base meals and snacks on
these. Encourage low GI, high fibre foods.
Fruit and Vegetables To provide vitamins
antioxidants. No evidence for use of supplements
except in special situations.
Milk and dairy foods Choose lower fat varieties.
Advise ½ pint milk or equivalent/day.
Protein Foods Aim not more than 1g/kg
bodyweight. Encourage oily fish 1-2 portions/week.
Advise a decrease in saturated fat. Choose fats
high in MUFA, eg olive oil, rapeseed oil.
Foods containing fats, oils and sugar Cut down
on fatty foods and sugary food. Avoid diabetic
foods and nutritive sweeteners.
Image reproduced with the kind permission of the
Food Standards Agency
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What is Glycaemic Index (GI)?

• Ranking of individual foods according to the
  effect they have on blood glucose levels
• The GI is a measure of how quickly foods that
  contain carbohydrate raise blood glucose levels.
  Some carbohydrate foods (with a high GI) cause a
  rapid rise in blood glucose and others (with a
  low GI) a gradual rise.
• It is the combination of foods that matters, eg
  Corrnflakes (high GI) and milk (low GI) medium
  GI

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The glycaemic index is a ranking of foods from 0
to 100 based on their effect on blood glucose
levels
High GI eg White bread
Blood glucose level
Low GI eg legumes
Time
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Average Glycaemic Index of some food groups
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Meal Planning

• Some suggestions for lower GI meals
• Breakfast Porridge, Special K with milk
• Snack Meal Lentil soup with bread
• Baked beans on toast
• Pitta bread with salad or meat sandwich
  and fruit yoghurt
• Main Meal Chilli beans with baked potato
• Basmati rice with vegetable curry
• Dessert Slice of fruit loaf
• Oatcakes

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Summary

• A low GI food will have a lower Glycaemic effect
  than a high GI food only if consumed in
  equivalent carbohydrate loads
• It allows for occasional sweet food after a low
  GI meal
• High GI foods can be appropriate at certain
  times, eg to treat hypos and for exercise

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Diet Insulin

• Carbohydrate
• Consistency of starchy carbohydrate is important
  for individuals who are on fixed insulin regimens
• The total carbohydrate content of meals is
  important for individuals who adjust their own
  insulin

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Diet and Insulin

• Considerations
• Timing of meals/insulin
• Snacks?
• Treatment of Hypoglycaemia
• Effects of alcohol
• Activity
• Illness

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Diet History

• 8am 2-4 slices of toast or Porridge made
  
• with semi skimmed milk
• Mid morning fruit or 3 digestives
• 1-2pm sandwich 2 slices bread or salad
• Yoghurt
• 7-9pm Meat (8oz) 4 small potatoes
• and vegetables
• Before Bed nothing or 2 crackers
• occasional chinese
  takeaway

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Meal Plan not recommended for b.d insulin
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Meal plan recommended for bd insulin
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Carbohydrate Counting

• Advantages
• Stabilise blood glucose levels with less
  fluctuations
• Glycaemic Index CHO counting allows individuals
  to predict their glucose response to different
  foods
• Increase variety of foods with dose adjustment

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Carbohydrate Counting contd

• Disadvantages
• Takes time and practice
• Increase in blood glucose testing and need to
  keep detailed records of blood sugars/foods
  consumed
• Possible weight gain if high calorie foods are
  eaten
• Diet may become unbalanced

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Carbohydrate Counting Steps

• Identify which foods contain carbohydrate
• Calculate or estimate the carbohydrate content of
  the meal
• Calculate insulin dose needed to cover
  carbohydrate eaten (insulin to CHO ratio)
• Need to Consider
• Other factors that may influence blood glucose
  response, ie Glycaemic Index
• Pre-meal blood glucose
• Activity levels

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Issues related to Asian diets

• Food Advice
• Chapattis Use medium brown or wholemeal flour
• Avoid spreading fat or use margarine high
  in monounsaturated fat
• but sparingly
• Keep fried breads for special occasions, eg
  poori, parathas
• Rice Choose basmati as lower GI
• Best to have plain boiled rather than pilau,
  buriyani which are high fat
• Meat, fish, paneer Remove all visible fat on
  meats , avoid frying use minimal vegetable
• (curd cheese), eggs oil or try baking
• Encourage all varieties of pulses
• Vegetables Aim to include 2 to 3 portions daily
  of any vegetables cooked or raw
• Fruit Beware of portion sizes especially for
  tropical fruits, but no fruit is taboo
• Spices All spices , chillies, herbs are allowed
• Milk Avoid full cream milk
• Snacks Keep to a minimum Chevra (Bombay mix),
  samosas, pakoras, rusks
• (Pakistani salted biscuit)
• Suggest Fruit , fruit yoghurt, rich tea
  biscuit.
• Fats and oil Use margarine high in
  monounsaturated fat or poly unsaturated fat
• For cooking choose vegetable oil, rapeseed
  oil, olive oil but use sparingly

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Issues related to African-Caribbean Diets

• Food Advice
• Fritters, dumplings Have boiled dumplings
  (fritters only occasionally)
• Rice Brown or white try Basmati
• Rice and peas is excellent but avoid or cut
  down on coconut cream
• Starchy vegetables Yam, sweet potato, green
  banana, plantain bread fruit are all good
  starches but avoid adding fat or oil in
  cooking
• Fish Soak salt fish in large volume of water to
  remove some of the salt
• Bake or steam fish without added fat
• Fruits and juices Beware of portion sizes
  especially for tropical fruits but no fruit
  is taboo
• Avoid sweetened juices
• Have 1 small glass unsweetened fruit juice a
  day at meal times
• Pick me up drinks No glucose drinks, energy
  drinks e.g. nutriment, fruit punches with
  condensed milk
• Avoid tinned milk in tea and coffee
• Use semi skimmed or skimmed milk

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• Lamb Curry (170g)
• 57g fat 640 kcal
• Lentil Curry (170g)
• 6g fat 140 kcal
• Almond sweetmeat
• 32g fat 22g sugar 430kcal

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Obesity

• 90 individuals with Type 2 Diabetes are
  overweight (Davies et al, 2003)
• It is well recognised that it is obesity with an
  abdominal distribution of fat which is associated
  with insulin resistance (Diabetic Medicine 2003)
• Ideal weight is not always realistic evidence
  suggests to aim for 10 weight loss in obese
  individuals. 10kg weight loss results in
• Fall of 50 in fasting glucose
• Fall of 10 in total cholesterol

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Weight Management

• Advise a loss of 0.5-1kg per week by a sustained
  energy deficit of approximately 500kcal/day
• The skill of the Dietitian is in determining the
  most appropriate strategy for the individual
  patient
• Successful long term weight loss depends on the
  ability to maintain a low energy, low fat diet
  with an average of 25 energy being derived from
  fat (Management of Obesity in Patients with Type
  2 Diabetes Diabetic Medicine 2001 18)
• Exercise is helpful in maintaining weight loss

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WHO (1998) BMI Classification
Co-morbidity risks associated with waist
circumference in adults
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Weight Management

• Very low calorie diets (VLCDs lt800kcal/day)
• Slimming clubs
• Pharmacological treatment
• - Orlistat (low fat diet 50g/day
• - Reductil
• Gastric reduction surgery

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Obesity

• 1 digestive biscuit (73kcal) eaten twice per day
  for one year (365 days) is 53,290kcal
• There are 3,500kcal in 1lb of body fat, which
  means that in 1 year these 2 biscuits could (in
  theory) account for 15.2lbs of fat

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CASE STUDY
Mr X is a 70 year old male with Type II Diabetes.
He has recently started on insulin. During his
hospital admission he reports a poor appetite and
is not managing to eat all his meals. Some
weight loss is also reported. What do you
do? Also think about what a Dietitian may advise.
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Practical suggestions to increase dietary intake

• High calorie snacks between meals
• Nourishing drinks
• Food fortification
• Increase fat intake
• supplements

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New ways of working

• Weight management group sessions
• Carbohydrate counting group sessions
• Multidisciplinary insulin pump clinics
• Insulin group starts

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DAFNE

• Dose adjustment for normal eating
• 5 day structured teaching programme
• Improve diabetes control by matching insulin to
  carbohydrate. (Not based on healthy eating).
• Evidence shows improved HbA1c, reduced severe
  hypos and less hospital admissions from DKA

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• The DAFNE approach enables individuals to eat the
  amount of carbohydrate they choose and learn how
  to match it with an appropriate dose of insulin
• 10g carbohydrate 1 carbohydrate portion (1CP)
  which increases blood glucose levels by 2-3mmols
• The training programme teaches individuals to
  learn how many units of quick acting insulin they
  need for 1 CP and how to give corrective doses of
  insulin/alter background insulin as needed.
• 1unit quick acting insulin increases blood
  glucose by 2-3mmols

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Summary

• It is recommended that every person with
  Diabetes must have a dietary consultation within
  4 weeks of diagnosis of Diabetes and Dietary
  review annually
• (Diabetes UK, Pan Birmingham Diabetes Dietitians)