INFORM Diabetes and Nutritional Management

1. INFORMDiabetes and Nutritional Management Tiana Elba Diabetes Specialist Dietitian Guy’s & St Thomas’ September 2018

2. Aim of the session • Dietary guidelines for T2DM • NICE (2015) • Diabetes UK,(DUK)(2018) • Diet & lifestyle assessment & aims • Considerations when starting insulin • Meal pattern, carb portions, healthy eating • Weight gain • Alcohol & exercise

3. Type 2 Diabetes and Diet: Quiz Question 1: People with Type 2 diabetes should be advised to eat: A very low calories diet A low/no carbohydrate diet A sugar-free diet A healthy, balanced diet Question 2: Meal pattern - people with diabetes should eat: Frequent small meals and regular snacks Regular meals plus snacks if they are hungry One large meal per day

4. Type 2 Diabetes and Diet: Quiz Question 3: Can people with diabetes have…….? • Fruit juice? • Bananas? • Grapes? • Green banana, yam? • Rice, pasta, bread and potatoes? • Cakes and biscuits?

5. Type 2 Diabetes and Diet: Quiz Question 4: Which of these foods would affect your blood sugar the most?

6. Type 2 Diabetes and Diet: Quiz Question 5: Why might a patient with Type 2 diabetes be advised to lose weight if they are overweight?

7. What is the Evidence for Diet and Diabetes? Nice Guidelines: NG 28, Management of Type 2 Diabetes in Adult (2015) DUK 2018: Evidence based Nutrition Guidelines for the prevention and Management of Diabetes In more details…..

8. Nice Guidelines NG28, T2DM in adults(2015) Provide individualised and ongoing nutritional advice Advice sensitive to need, culture and beliefs, willingness to change and effects on QOL Emphasise healthy balanced eating applicable for the general population Encourage high fibre, low glycaemic index sources of carbohydrate: fruit, vegetable, wholegrains and pulses. Include low fat dairy products and oily fish Control the intake of food containing saturated and trans fatty acids Encourage lifestyle modification: increasing physical activity and weight loss Aim for initial weight loss of 5-10% if overweight Reduce risk of hypo for person using insulin or Sulphonylureas

9. DUK 2018: Nutrition Guidelines Focus on glycaemic control, weight loss and CVD Weight loss of at least 5% primary nutritional strategy for glycaemic control if overweight/obese Focus on total energy intake, overall diet composition and quality of the diet Mediterranean diet: effective in decreasing HbA1c, improves blood pressure & high density lipoprotein(HDL) levels Low carbohydrate diet: no consistent studies to support it, however seen reduction in diabetes medication and HbA1c Monitor carbohydrate consumed Increase low GI, high fibre and wholegrain foods Limit saturated fat and replace them by unsaturated fat ( monounsaturated) Limit trans-fats Aim for 2 portions of oily fish per week Limit intake of salt to less than 6g /day Limit alcohol to less than 14 units per week Aim for 150 minutes per week of moderate to vigorous physical activity

10. What are we aiming to do ? Individualised advice! Individualised aims and targets! Glycaemic control – improve to target – diet and lifestyle HbA1c target 48mmol/mol – 58mmol/mol (6.5% - 7.5%) 4 – 7 mmol/l before meals Blood pressure – optimise via diet and lifestyle Cholesterol levels - optimise via diet and lifestyle Weight loss if required

11. Glycaemic control Diet & Lifestyle Assessment & Aims Nutritional Deficiencies Weight/ BMI Dietary composition Physical activity Dietary advice Shift/meal patterns Lipids Religious / cultural Beliefs BP

12. What does a Healthy Diet look like?

13. In practice this means… • A balanced diet: low in fat, sugar, salt and high in fibre • A regular meal pattern • Include a starchy carbohydrate in each meal • Reduce total fat especially saturated fat and replace with monounsaturated fat • At least 5 portions of fruit & vegetable per day • Limit intake of sugar & sugary foods • Use less salt • Moderate alcohol (unless medically contradicted) • Include some exercise in your daily life • Reduction of energy intake where weight loss is required

14. Eat a low GI food at each meal • Low GI: • Porridge oats, All Bran, Sultana Bran • Granary and multigrain breads, wholegrain rye breads • Basmati rice, pasta, noodles, sweet potato • Fresh fruit (apples, pears, peaches, oranges, grapefruit) • Beans and lentils (incl. baked beans + other tinned beans) • High GI: • White / brown bread, rice cakes, Cornflakes, Rice Crispies, mashed / ground starchy food e.g. mashed potato, fu-fu, gari, pounded yam, ground rice

15. Glycaemic Index • Foods are ranked on a scale of 0-100 (glucose = 100) Slow release of glucose + more filling • Eating a low GI food at the same time as a high GI food will give a combined glycaemic effect • Beware: Many low GI foods are also high in fat

16. Dietary Considerations when Starting Insulin • Type, dose and timing of insulin • Basal insulin, BD mixed insulin, Multiple daily injection/basal bolus • Carb counting • Overall balance of diet & portions • Regular meals/meal pattern, spread of CHO • Glycaemic control • Targets, minimise hypo risk • Weight/BMI • Minimise weight gain

17. Regular Meals Even distribution of carbohydrates Blood Sugar Meal Time Blood Sugar Meal Meal Meal 3

18. What is the average amount of weight gain following insulin initiation? • UKPDS (prospective multicentre RCT): • Insulin = 4 kg vs. sulphonylureas = 1.7 kg • This stabilised after 3 months • Makimattila et al. (1999) • Weight gain 2 kg for every 1% decrease in HbA1c • Causes: • No glycosuria • Anabolic effects of insulin – enhanced lipogenesis • Decreased BG may increase appetite in short term • Unnecessary eating / snacking – fear of hypos • Hypos – frequent treatment

19. Is weight gain inevitable? • Minimising weight gain is more effective than reversing weight gain • Dietary advice / education is important at this time • Weight gain is a result of long term positive energy balance • Certain insulin + oral medication regimes are associated with less weight gain

20. Safe and Achievable Weight loss • Long term: 5-10 % weight loss as target • Short term= 0.5-1.0 kg (1-2lbs)per week • To achieve the above: deficit of 600 kcal/day • How to achieve the above?

21. Top Tips for Losing Weight Eat 3 regular meals Reduce fats and sugars Control portion sizes Eat more fruit and vegetables Choose healthy snacks and carry them with you Keep treats to just 1 or 2 per week Choose sugar free drinks Plan your meals and shop ahead Increase physical activity

22. Getting the right balance Weight gain is a result of long term positive energy balance How many kcal in 1 choc biscuit? = 100 kcal 1 biscuit each day for a month? = 3000 kcal Weight gain in 1 month = 0.5kg (1 lb) body fat It only takes 1 biscuit a day to gain 12lbs a year! Energy Expended Energy Consumed

23. Dietary Approaches for Weight Loss • Low-carbohydrate diets • Moderate CHO: 130-225g/d • Low-CHO: <130g/d • Very low-CHO: <30g/d (ketogenic) • Intermittent energy restriction • 5:2 diet, Prolon • LCDs & VLCDs • Daily calorie deficit

24. Alcohol: the rules • Department of Health (DOH) recommendations: 14 units per week • Never drink on an empty stomach • Do not substitute the carbohydrates in alcohol for meals (increases risk of hypoglycaemia) • Always have a carbohydrate snack before bed if significant amounts of alcohol have been drunk • Heavy drinking – possibly reduce night time insulin • Wear diabetes identification • Hypoglycaemia may not occur until some hours after drinking alcohol and can last up to 24 hours.

25. Physical Activity At least 150 minutes of moderate intensity physical activity per week: Promotes good health Improves diabetes outcomes: Improves insulin sensitivity Regular exercise reduces HbA1c Reduces cardiovascular risk factors (BP + HDL) Contributes to weight management

26. Effect of physical activity on insulin • Insulin is absorbed more rapidly by muscles that are exercising • Activity increases insulin sensitivity • Activity increases glucose uptake to the muscles • Insulin requirements may be lower during or after physical activity Peirce NS. Br J Sports Med 1999;33:161–72 Royal College of Nursing. http://www.rcn.org.uk/publications/pdf/ Starting%20insulin%20in%20adults%20with%20type%202%20diabetes.pdf, 2005

27. Any Questions?