Diet & Diabetes – current practice and new evidence

Nutrition Management of HypoglycemiaNOORLAILINA MOHA BT MOHTARB. Hons Health Sc (Dietetics)(USM), MBA (UKM)

Pegawai Dietetik

Jabatan Dietetik & Sajian

Hospital Sultanah Bahiyah

HYPOGLYCEMIA MANAGEMENT WORKSHOP 2013

Learning Outcomes

Able to explain: Ways to prevent hypoglycemiaWays to overcome hypoglycemia

Nutrition Matters in Diabetes!Prevention Use of Medical Nutrition Therapy

Primary Individuals with obesity and pre-diabetes

Secondary Metabolic control of diabetes

Tertiary Delay and manage complications of diabetes

American Diabetes Association, Diabetes Care, 2008;31:S61-S78

Nutrition Therapy is

EFFECTIVE!

Lifestyle impact

Pastors et al, Diabetes Care 2002; 25:608-613; Morris et al. J Clin Diabetes 2010; 28:12-18

Newly diagnosed type 2 diabetes 2%

Type 2 diabetes with an average duration of 4 years 1%

HBA1C

Evidence on Effectiveness of MNT

Effective Therapeutic lifestyle Intervention from clinical studies Weight loss – target 5-7% within 1 year Calories – restrict ( 1200 -1800 kcal) Low fat intake ( less than 30% energy), low saturated fat intake Minimum 15% energy from proteins Carbohydrate (45-65%) – by counting, exchange lists, insulin-to-

carbohydrate ratios Portion control - simplified meal plans, plate model Liquid meal replacements / structured meal plans Healthy balanced food choices

Common causes of Hypoglycemia

WHAT PATIENT THINKS

To avoid rice, RICE is DANGEROUS.Avoid intake of vegetables – “angin”, “sejuk”.Big meals at times, avoid snacking.

Meal Adjustment for Exercise

Nelson JK et al, Mayo Clinic Diet Manual

4-5 mmol/L

4-10 mmol/L

10-16 mmol/L

4-5 mmol/L

>16 mmol/L

4-10 mmol/L

10-16 mmol/L

4-5 mmol/L

>16 mmol/L

Treatment of Hypoglycemia

Treatment of Hypoglycemia Treatment of Hypoglycemia requires

ingestion of glucose or carbohydrate-containing food. Although any CHO will raise glucose level, glucose is the preferred treatment.

Commercially available glucose have the advantage of being pre-meassured to help overtreatment.

Ref : Marion J Franz, Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

The form of CHO – liquid/solid does not matter.

Changes in insulin injections, eating, exercise schedules, and travel routine warrant increased frequency of monitoring (Cryer et al, 2013).

Some patients experience hypoglycemia unawareness. Patients need to be reminded of the need to treat hypoglycemia, even in the absence of symptoms.

Ref : Marion J Franz, Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

Sugar-based carbohydrates digest and enter your bloodstream quickly, which can raise blood glucose levels back to normal. CHO foods that have significant amounts of sugar, but also large amounts of fat or protein—such as chocolate, cookies, ice cream, and more—are digested much more slowly and will not correct low blood sugar as efficiently.

A plate of rice also will not help in hypoglycemia!

Most commonly, hypoglycemia symptoms will go away after this simple at-home treatment.

Once the blood sugar has returned to normal, it is important to eat usual meals and snacks as planned to prevent a recurrence later that day.

If patient does not have a meal or snack planned within 1 hour of the episode of low blood sugar, it is best to add an additional small snack that contains carbohydrates along with protein or fat immediately following treatment.

Honey

Sugar

Jam

Cocoa/ Malt-based Powder

Candy

Condensed Milk

Syrup

Kaya

= 1 tablespoon = 10 g= 1 teaspoon= 5g

What is 15g of sugar?

Milo any one?

= 1 tablespoon = 10 g

=Milo is

claimed as low GI foods, therefore it is less in sugar

Good choices with 15 grams of carbohydrates are:

½ cup apple juice ½ cup orange juice 2 pieces of hard candy 1 cup low-fat milk/skim

milk 1 Tablespoon honey 2 Tablespoons raisins ½ cup regular gelatin

6 sugar cubes 1 Tablespoon syrup 3- 4 glucose tablets ½ (80 gram) glucose

bottle ½ (31 gram) instant

glucose tube

Preventing Hypoglycemia Eating three balanced meals a day with two or three planned snacks.

It is important that patient doesn’t skip meals and snacks. Try not to go any longer than 3-4 hours between eating.

Eating the right amount of carbohydrates during each meal and snack.

Eating foods high in complex carbohydrates and fiber such as whole grains, fruits, vegetables, and beans. High-fiber foods digest more slowly and help keep glucose from "dumping" into your blood stream too quickly.

Eating a high protein food at each meal and snack. Protein-rich foods include fish, chicken, turkey, lean beef and pork, tofu, cottage cheese, cheese, yogurt, milk, eggs, peanut butter, nuts and seeds. Protein can help to maintain blood sugar levels between meals by delaying how quickly the carbohydrate is digested.

Achieving and maintaining a healthy body weight.

Limiting alcohol consumption. Always include a snack when drinking an alcoholic beverage. If patient drink alcohol, limit their daily intake—no more than two drinks for men and one drink for women.

Avoiding large meals.

CHO exchanges (15g of CHO, 75kCal)

BREAKFAST LUNCH

MID AFTERNOON SNACK DINNER

1 ex 1 ex

1 ex

3 ex

1 ex

2 ex

3 ex

1 ex

3 ex1 ex

3 main meals3 snacks

Masa

Jumlah Hidangan

Karbohidrat Sayur-sayuran Buah-buahan

Exchanges

TimeCarbohidrates Vegetables Fruits

Timely interval

Masa

Jumlah Hidangan

Karbohidrat Sayur-sayuran Buah-buahan

7.30

10.30

12.30

3.30

6.30

9.30

Exchanges

TimeCarbohidrates Vegetables Fruits

Right amount of Carbohydrates

CHO exchanges (15g of CHO, 75kCal)

BREAKFAST LUNCH

MID AFTERNOON SNACK DINNER

1 ex 1 ex

1 ex

3 ex

1 ex

2 ex

3 ex

1 ex

3 ex1 ex

Masa

Jumlah Hidangan

Karbohidrat Sayur-sayuran Buah-buahan

7.303

10.30 1

12.303

3.30 1

6.303

9.30 1

TOTAL 12

Exchanges

TimeCarbohidrates Vegetables Fruits

Increase fiber intake during taking CHO

Prefer for Whole Meal Foods

Masa

Jumlah Hidangan

Karbohidrat Sayur-sayuran Buah-buahan

7.303 1

10.30 1

12.303 1

3.30 1

6.303 1

9.30 1

TOTAL 12 3

Exchanges

TimeCarbohidrates Vegetables Fruits

Incorporate fruits into meal

Masa

Jumlah Hidangan

Karbohidrat Sayur-sayuran Buah-buahan

7.303 1

10.30 1

12.303 1 1

3.30 1

6.303 1 1

9.30 1

TOTAL 12 3 2

Exchanges

TimeCarbohidrates Vegetables Fruits

Largeserving

Medium serving

Small Serving

Largeserving

Medium serving

Small Serving

Portions Photos of Popular Food - Hess, ADA & Center for Nutrition Education, University of Wisconsin, Stout

Is protein allowed freely?

MEAL TIME

TIME

EXCHANGES

CHO VEGE FRUITS PROTEIN FAT

BREAKFAST 7.303 1 1 2

TEATIME 10.301

LUNCH 12.303 1 1 2 2

TEATIME 3.301

DINNER 6.303 1 1 2 2

SUPPER 9.301

TOTAL 12 3 2

Activities by Dietitians

3 monthly follow up

Support groups

Self-Monitoring

Weight

Food records

Physical activity records

Pedometers

SMBG

Conclusion Diabetes meal plans need to be individualized :

control goals, needs, and preferences, and should include changes that the patient is willing and able to make and maintain.

Integrating evidence-based nutrition principles and recommendations will help exposed misconceptions and myths about the diet and lead to better care of patients!

Patients should be explained about hypoglycemia, consequences and ways to handle the situation.

Marion J Franz, Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin