Dietary Guidelines for the Treatment of Diabetes

1. Dietary Guidelines for the Treatment of Diabetes l Nutrition & Dietetic Service Selly Oak Hospital

2. 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

3. 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)

4. 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 patient�s 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

5. 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

7. 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

10. 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

11. 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

12. 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

13. Diet and Insulin Considerations Timing of meals/insulin Snacks? Treatment of Hypoglycaemia Effects of alcohol Activity Illness

14. 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

15. Meal Plan not recommended for b.d insulin

16. Meal plan recommended for bd insulin

18. 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

20. Carbohydrate Counting cont�d 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

21. 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

23. 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 Butter, ghee for special occasions Dispel myths regarding spices and avoiding particular fruits

24. 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

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

26. 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

27. 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

28. WHO (1998) BMI Classification

29. Weight Management Very low calorie diets (VLCDs <800kcal/day) Slimming clubs Pharmacological treatment - Orlistat (low fat diet 50g/day - Reductil Gastric reduction surgery

31. CASE STUDY

32. Practical suggestions to increase dietary intake High calorie snacks between meals Nourishing drinks Food fortification Increase fat intake supplements

33. New ways of working Weight management group sessions Carbohydrate counting group sessions Multidisciplinary insulin pump clinics Insulin group starts

34. 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 hypo�s and less hospital admissions from DKA

36. 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

37. 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)