ty lecture 4d 3 february 2014 type 2 diabetes pathology nutritional intervention-pre- and post-onset
TRANSCRIPT
Ty
Lecture 4d
3 February 2014 Type 2 Diabetes
•Pathology•Nutritional Intervention-pre- and post-onset
Ty
Type 2 diabetes-causes
-genetics including genetically driven diabetes-obesity-caused by poor diet (high fat, high simple sugars or glycaemic index foods), lack of exercise and/or genetics-obesity leads to metabolic syndrome and pre-diabetes (still time to recover before becomingtype 2 diabetic)-obesity leads to insulin resistance which ultimately leads to reduced pancreatic insulin production-metabolic syndrome and pre-diabetes can leadto type 2 diabetes (type 2 diabetes is permanent)
Metabolic syndrome
Prevent and in part manage by Canada’s food guide and exercise (150 minutes per week ofmoderate to vigourous exercise)exercise)
-Type 2 diabetes
Post onset management in part by diet and exercise and if need be oral medications and/or insulin
Canadian Diabetes Association Clinical Practice Guidelines
Nutrition Therapy Chapter 11
Paula D. Dworatzek, Kathryn Arcudi, Réjeanne Gougeon, Nadira Husein,
John L. Sievenpiper, Sandi Williams
Nutrition ChecklistREFER 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
Clinical assessment
Lifestyle 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 Disadvantages
Hi-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 Patterns
Dietary 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 21. 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]
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
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
Recommendations 7 and 87. 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
Recommendations 11 and 1211. 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
Type 2 diabetes
Post-onset management in part exercise
Canadian Diabetes Association Clinical Practice Guidelines
Physical Activity and DiabetesChapter 10
Ronald J Sigal, Marni J Armstrong, Pam Colby,
Glen P Kenny, Ronald C Plotnikoff, Sonja M Reichert, Michael C Riddell
Physical Activity Checklist
DO a minimum of 150 minutes of moderate-to vigorous-
intensity aerobic exercise per week
INCLUDE resistance exercise ≥ 2 times a week
SET physical activity goals and INVOLVE a multi-
disciplinary team
ASSESS patient’s health before prescribing an exercise
regimen
2013
Physical Activity: Bridging the Gap
Problems Solutions
Lack of knowledge of resources
Increase awareness among health care professionals of community resources
Time constraints during physician-patient encounter
Involve a multi-disciplinary team of Physical Therapists, Diabetes Educators and Case Workers who can help motivate patients
Pre-existing or suspected heart disease
If patient wishes to take on activity more vigorous than walking, evaluate with a history and physical, resting ECG and possibly exercise ECG stress test.
Know your Community Resources and Advertise Them
Speak to your patients about community
resources:
Community pools, gyms, safe walking
trails, weight loss smart phone apps etc.
Pre-exercise Assessment
• Assess for conditions that can predispose to injury before prescribing an exercise regimen:– Neuropathy (autonomic and peripheral)
– Retinopathy
– Coronary artery disease – resting ECG +/- exercise stress test (see CPG Chapter 23)
– Peripheral arterial disease
www.guidelines.diabetes.ca
Recommendation 1
1. People with diabetes should accumulate a
minimum of 150 minutes of moderate to vigorous
intensity aerobic exercise each week, spread over
at least 3 days of the week, with no more than 2
consecutive days without exercise [Grade B,
Level 2, for T2DM; Grade C, Level 3 for T1DM]
Recommendation 2
2. People with diabetes (including elderly people)
should perform resistance exercise at least
twice a week, and preferably 3 times per week
[Grade B, Level 2] in addition to aerobic
exercise [Grade B, Level 2]. Initial instruction
and periodic supervision by an exercise
specialist are recommended [Grade C, level 3]
Recommendations 3 and 4
3. People with diabetes should set specific physical activity goals,
anticipate likely barriers to physical activity (e.g. weather, competing
commitments), develop strategies to overcome these barriers [Grade B,
Level 2], and keep records of their physical activity [Grade B, Level 2]
4. Structured exercise programs supervised by qualified trainers should
be implemented when feasible for people with type 2 diabetes to
improve glycemic control, CVD risk factors, and physical fitness
[Grade B, Level 2]
2013
2013
Recommendation 55. People with diabetes with possible cardiovascular disease or
microvascular complications of diabetes, who wish to
undertake exercise that is substantially more vigorous than
brisk walking, should have medical evaluation for conditions
that might increase exercise-associated risk. The evaluation
would include history, physical examination (including
fundoscopic exam, foot exam, and neuropathy screening),
resting ECG, and, possibly, exercise ECG stress testing [Grade
D, consensus]
2013
Diet and exercise type 1 and type 2 diabetes
Along with relevant medications including insulin as appropriate,
diet and exercise are meant to protect the vasculature, damage to
which is the major cause of disability (heart attack and stroke) and
death (heart attack and stroke) in all diabetics
See -Donohoe et al (2007) JAMA 298:765-end of article
-Booth et al (2006) Lancet 368:29-end of article
-Lloyd-Jones et al (2006) 113:791-end of article
CDA Vascular Protection ChecklistA A1C – optimal glycemic control (usually ≤ 7%)
B BP – optimal blood pressure control (< 130/80 mmHg)
CCholesterol – LDL-C ≤ 2.0 mmol/L if decision made to treat(http://guidelines.diabetes.ca/VascularRisks/RiskAssessment/)
D
Drugs to protect the heart (even if the baseline blood pressure or LDL-C is already at target) (http://guidelines.diabetes.ca/VascularRisks/RiskAssessment/)
EExercise / Eating – Regular physical activity, healthy eating, achievement and maintenance of healthy body weight
s Smoking cessation
CDA Vascular Protection Checklist
glycaemic control is best for microvascular disease-gives
decreased nephropathy and decrease retinopathy(both are
microvascular) but gives mixed results for macrovascular
disease
Note book “Heart Health for Canadians’-by Dr. Beth
Abramson-talks in part about health eating.
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients