nutrition IN Diabetes Clinical Practice Guidelines

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


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

http://www.guidelines.diabetes.ca/


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


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


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

2013


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]



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



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



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]


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



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]


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

http://guidelines.diabetes.ca/

http://diabetes.ca/

nutrition IN Diabetes Clinical Practice Guidelines

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