Nutritional

Management of

DiabetesDiabetes

Diabetes Specialist Dietitians

MCN for Diabetes

Overview

1. Diet and lifestyle factors:1. Current recommendations

2. Benefits to glycaemic control, weight management and long-term health risks

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and long-term health risks

2. NHS Dietetic Services:1. Primary and Secondary care

2. Level 1, 2 & 3 education provision

3. Value of patient education

4. Goal setting

Diabetes Mellitus

� Changes in diet and lifestyle can help to manage the following health parameters in Diabetes:

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Diabetes:

- Glycaemic Control (HbA1c)

- Hyper/Hypo glycaemia

- Blood pressure

- Lipid profile

- Weight

Dietary Recommendations

Which of these food groups do you think has the largest impact on blood glucose levels

and why?and why?

Carbohydrate (CHO)

Protein

Fat

Carbohydrate Sources

Carbohydrate

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Sugars

Fructose e.g. fruit & fruit juice

Lactose e.g milk, yogurt, custard

Sucrose e.g. table sugar, cakes, sweets &

full sugar drinks

Starches

e.g potatoes, rice, pasta, noodles, bread,

cereals, couscous, lentils, beans & flour

products

An example of a normal response to food intake:

BLO

OD

GLU

CO

SE

LE

VE

L

CHO CHOCHO

BLO

OD

GLU

CO

SE

LE

VE

L

INSULIN INSULININSULIN

Non-carbohydrate foods

� Fluids

� Water, sugar free, diet, zero, etc.

� Fats

� Butter, margarine, oils, cheese, etc.

� Protein

� Eggs, meat, fish, chicken, cheese, etc.

� Vegetables

� Salad and non-starchy vegetables

Carbohydrates – Glycaemic Index

(GI)

� The GI is the speed which a carbohydrate affects the blood glucose level…

� low GI – gradual

� medium – intermediate

� high – rapid

� National guidance to not advise for the choice of low GI foods or to limit CHO intake for type 1 diabetes patients

CarbohydratesGlycaemic Index (GI)

GI Food ExamplesLow

�Lentils

Medium

�Breads

High GI

�Dextrose/glucose �Lentils

�Beans & pulses

�Sweetcorn, squash & parsnips

�Tomatoes, cherries, lemons & limes

�Nuts

�Quorn, tofu & soya

�Breads

�Rice

�Pasta

�Flour

�Potatoes

�Milk & yoghurts

�Chocolate

�Dextrose/glucose tablets

�Jelly/chewy sweets

�Lucozade

�Full sugar drinks

Diabetes UK, Carbs Count (2012)

Level 1 Education - Acute

� One-to-one or joint consultations:

� Newly diagnosed type 1

� long-term patients type 1

� complex type 2 patients� complex type 2 patients

� pregnancy

Level 2 Education – Acute

� Group education sessions

� Gestational diabetes group sessions� Targets the same as for those with diabetes pre-pregnancy� Gestational diabetes diagnosed with OGTT results of fasting

level ≥5.1mmol/L and/or 2 hour post level of ≥8.5mmol/Llevel ≥5.1mmol/L and/or 2 hour post level of ≥8.5mmol/L� Pre meal targets of <5.5 and 2 hour post meal of <7.0mmol/L� CHO awareness/CHO portion size education essential to

prevent inappropriate glycaemic rises� Limit of between-meal snacks to 10g carbohydrate

� Refresher/update patient education sessions� Injection techniques, hypoglycaemia, alcohol, sick-day rules

� CHO counting sessions

Level 3 Education - Acute

� All adults with Type 1 Diabetes should be offered a structured education

programme within first 6-12 months of diagnosis (SIGN 116, 2013; DUK,

2018)

� NHS GGC offers DAFNE (Dose Adjustment for Normal Eating)

� Week-long structured education course

� Pre-assessment data collection

� Involves DSN, Dietitian & Consultant

� Covers insulins, injection technique, carbohydrate counting and GI

awareness, hypoglycaemia management, alcohol, exercise, eating out…

� To promote self-management

� 6-week & 1 year follow up

The main things that would be improved if people did not have diabetes

700 people

-4.00

-3.50

-3.00

-2.50

Mean

Im

pact

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-2.00

-1.50

-1.00

-0.50

0.00

Life Domains

Mean

Im

pact

Education & management – further

considerations

�Does their insulin regime meet their social

needs re eating pattern? e.g.

� Fasting for religion� Fasting for religion

� Work shift pattern

� Availability of carers to attend for meal provision

� Capacity of ward staff for meal

assistance/medication provision

Education & management – further

considerations� Reduced dietary intake/ appetite

� Enteral feeding- Considerations- Is the patient NBM?

- Can they be artificially fed e.g. NG/PEG feeding?

- Is pump or bolus feeding most appropriate?

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Blood glucose elevations should be treated medically to meet

targets – feed should not be withheld remember additional

hyperglycaemic factors e.g. steroid medication; sepsis

� Hypoglycaemia-Risk with insulin therapy if feed being withheld/delayed

- Use of feeding tube for hypoglycaemia treatment, if appropriate

- If tube dislodged/patient unconscious/not appropriate consider IV treatment

- see algorithms for hypoglycaemia treatments in ward hypo boxes

Referrals to Acute Dietetics

Diabetes Service

� Patient must currently be under the care of a hospital consultant

� Paper & email referrals from consultants/acute/community dietitians

� Appointed via opt-in response, telephone contact or from clinic attendance with MDT colleague

� Dietetic notes on Portal & entry on SCI Diabetes

� Who? Newly diagnosed Type 1, complex type 2, gestational diabetes

� No input at ward level; point of liaison

Type 2 Diabetes - Overview

� Insulin resistance +/- Insulin deficiency

� Often secondary to poor diet and lifestyle

� Rise in early onset of Type 2 Diabetes

� Treatment of Type 2 diabetes includes:

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� Treatment of Type 2 diabetes includes:- Diet - OHA’s- Injectable therapies- Insulin - Weight management - Bariatric Surgery

Treatment may be combination of the above.

Diabetes UK Recommendations

2018

� Offer ongoing nutritional advice guided by a

dieititan to all people with diabetes

� Person centred approach and a variety of

learning styles learning styles

� No one size fits all approach

� Food choices must be acceptable and enjoyable

as well as achieving treatment goals

Type 2 Diabetes -Education

� Practice based with nurse +/- dietitian

� Referral to dietitian if required

� All adults with Type 2 diabetes should have access to Structured education

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access to Structured education

(SIGN 116 2013; DUK 2018)

� Conversation Maps is used in GG&C (Currently under review)

� Weight Management ServicesSelf-referral scheme now in place

Self Referral Criteria

BMI+ one or more of the following co-morbidity

>25 (22.5)* Type 2 diabetes

>30 (27.5)*

Diabetes (Type 1 and Type 2)

Heart disease

Stroke

Health Professional Referral Criteria

BMI+ one or more of the following co-morbidity

>25 (22.5)*Impaired fasting glucose/ Impaired glucose tolerance/High risk of T2DM

T2DM

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T2DM

>30 (27.5)*

T1DM

T2DM

Existing CVD

Mobility issues

Weight loss required pre surgery

Being seen in secondary care for:

>30 (27.5)*

Sleep Apnoea

NAFLD

Psoraisis

Renal CKD4+

Hypertension

>40 No co-morbidity required

>180kg No co-morbidity required

* Patients with South Asian/Chinese/middle Eastern Ethnicity have a lower BMI threshold

10 % weight

Fasting Glucose

Total Cholesterol

Blood Pressure

Why is weight loss beneficial?

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weight loss

LDL Cholesterol

Triglycerides

HDL Cholesterol

1993

82

2009

87

Adult waist circumferenceHealth Survey for England

2009

Mean waist circumference (cm)

% with raised* waist circumference

1993

93cm

2009

96cm

Adult waist circumferenceHealth Survey for England

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82cm

27%

87cm

44%

Adults aged 16+ years

* Raised waist circumference is taken to be greater than 102cm in men and greater than 88cm in women

% with raised waist circumference is a three year average for 1993-95 and 2007-09

93cm

21%

96cm

33%

© NOO 2011

Preventing Type 2 Diabetes(IFG,IGT)

� Weight loss is dominant factor, aim for 5%

� 5-7% loss ↓ relative risk by 50%

� Every kg lost ↓ relative risk by 16%� Every kg lost ↓ relative risk by 16%

� E.g.. 100kg patient (5-7kg is achievable)

Remission of Type 2 Diabetes

� DiRECT trial (results due 2018)

� Aim for weight loss of 15kg as soon as possible after diagnosispossible after diagnosis

� Diabetes UK Position Statement 2018

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Fruit & Vegetables

� at least 5 (80g) portions a day.

�Provide antioxidants and soluble fibre

� Increase satiety

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� Increase satiety

�Low calories

�Fruit - consider portion sizes/ timings

�Smoothies??

Fruit & Vegetables – portions (80g)

� Fresh fruit and veg-

tennis ball/ handful

� Dried fruit - golf ball

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� Dried fruit - golf ball

� Veg- half a plate

� Juices- 100ml

Starchy Carbohydrate

� Requirements can vary for individuals but should be included in each main meal (min 130g/day)

Includes bread, rice, pasta, potatoes,

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� Includes bread, rice, pasta, potatoes, cereals.

� Soluble/ insoluble fibre

� Glycaemic index

� Aim to spread regular portions throughout the day.

Starchy Carbohydrate- Portions

29Carbs & Cals; Chettette & Balolia, 2016

Low Carbohydrate Diets

� Some controversy

� Overall evidence is safe and effective in short term for weight lossshort term for weight loss

� Long term evidence unknown

� Degree of adherence to a ‘diet’ that predicts outcomes rather than the type of diet (low carb, low fat, high protein, HE)

Fats - Dietary Recommendations

� Reduce intake of (SFA’s) saturated fatse.g. butter, hard cheese, fatty meats, biscuits, pastries�these increase TC levels

� Replace with unsaturated fats(PUFA’s) polyunsaturated e.g. sunflower oil/corn oil(MUFA’s) monounsaturated e.g. olive oil, rapeseed oil, nuts

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(MUFA’s) monounsaturated e.g. olive oil, rapeseed oil, nuts�these decrease TC levels

� Remember that fat is still fat! 1g fat = 9 calories (regardless of type and effect on cholesterol) so a (small) matchbox size of butter (weighing about 15g) has just as much calories as a tablespoon (about 15ml) of rapeseed oil � 135 calories!!!

� omega 3 oils

Protein – Dietary

Recommendations

� Aim for 2 portions fish weekly (1 of which oily)� Be mindful of high fat/kcal content � Lean meats and poultry� Beans/eggs/lentils/peas/chickpeas (also high fibre)

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� Beans/eggs/lentils/peas/chickpeas (also high fibre)� Meat alt (soya/quorn/tofu)� Cooking methods� Limit Processed meats (sausage/hot dogs)

Ref: SIGN 116, NICE CG 181

Palm-sized portion meat

Extras…. Refined Carbohydrates

and high fat snacks

�� These foods and drinks are absorbed These foods and drinks are absorbed quickly by the body and will cause blood quickly by the body and will cause blood glucose level to rise rapidly (high GI)glucose level to rise rapidly (high GI)

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glucose level to rise rapidly (high GI)glucose level to rise rapidly (high GI)

�� High in calories, very little nutritional valueHigh in calories, very little nutritional value

�� Keep as treatsKeep as treats

�� Not excludedNot excluded

Diabetic/Sugar-free Foods

Avoid!

�Higher fat content/ calorie content

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�Higher fat content/ calorie content

�Laxative effect

�Expensive

�Taste

Artificial Sweeteners

� Nutritive sweeteners/sugar substitutes

� E.g. sorbitol, fructose, xylitol

� Contain calories

� Can have a laxative effect

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� No evidence for any effect on glycaemia

� Non-nutritive sweeteners/Artificial sweeteners

� E.g. aspartame, saccharine, sucralose, stevia

� No calories

� No effect on blood glucose

� Deemed safe

Salt - Dietary Recommendations

� Recommended maximum of 6g per day (WHO 5g/day max)� equates to 1 teaspoon� minimise risk of hypertension� advised reduction in added salt.

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� A switch from regular salt to salt-substitutes e.g. ‘Lo-Salt’, ‘Pansalt’ is not recommended � albeit a lower sodium content, there will be comparably elevated

potassium level; and therefore should not be taken in those with CKD (SIGN 103)

Alcohol � no more than 14U per week for men and women.

� Hypo risk

� Empty calories (7kcal/g) (weight mgt)

� Sugar free mixers

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Food labelling

� Traffic light system for

fat and sugar

� Ingredients list to

highlight quantity

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highlight quantity

� Beware of food claims

as foods may not be

as they seem.

The Impact of inactivity?

� It is estimated that in Scotland low activity contributes to around 2,500 deaths per year and costs the NHS £94 million annually

� Being inactive shortens lifespan by 3-5 years (Lancet, 2012)

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(Lancet, 2012)

Scotland's Strategy 2022 target is:

1. 50% of adults will be achieving 5x 30mins (moderate activity) weekly

2. 80% of children will be achieving 1 hour per day

(At least moderate activity)

Simple strategies to increase

opportunistic activities

� Piano musical stairs added to an underground station in Sweden

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Referrals to Community Dietetics� Electronic Via GP/DSN/PN through SCi Gateway

� Paper referrals from consultants/acute dietitians

� Sent opt in letter and if accepted appointment will be booked

� 12 weeks max waiting time for both local clinic and dom visits� 12 weeks max waiting time for both local clinic and dom visits

� Progress and discharge letters can be viewed in clinical portal

� Who? Newly diagnosed T2, deteriorating glycaemic control, insulin or new treatment started, multiple medical conditions requiring in depth advice

� Excessive weight gain consider Weight Management Service

Community Dietetic Dept Contact

Numbers

� Springburn HC 0141 232 9101

� Drumchapel HC 0141 232 9184� Drumchapel HC 0141 232 9184

� Pollock HC 0141 531 6821

� Castlemilk HC 0141 531 8562

� Shettleston HC 0141 531 6272

Case Studies…

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Case Study 1

� Case Study 1� Ethel is an 87-year-old lady admitted to a nursing home following a stroke.

She has been in hospital for 3 months. She was diagnosed as having Type 2 Diabetes after her stroke. She is being treated with diet alone. She has reported some swallowing difficulties. She has lost a lot of weight recently and is now underweight. Unfortunately the stroke has meant she is left with limited use of her arm so she needs assistance at meal times. Her family

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limited use of her arm so she needs assistance at meal times. Her family take her out in the afternoon most days.

� Her last Hba1c was 55mmol/mol. She does not report symptoms of polydipsia, polyuria or tiredness.

� Is there any other information you would want to know about your patient?

� What do you consider the priorities to be in relation to the provision of dietary advice?

� Are there any other considerations that require to be tackled in relation to your patient?

BREAKFAST Porridge ½ bowl½ slice toast with margarineTea with milk & 2 sugars100ml fresh fruit juice

MID MORNING Rich tea biscuitTea with milk and 2 sugars

LUNCH Pork casserole ½ portionBoiled potato x1

Case Study 1 - Diet History

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Boiled potato x1Carrot 1 tablespoonDiluting juice

MID AFTERNOON Coffee

EVENING MEAL Cheese sandwichJelly & Ice creamDiluting juice

SUPPER Tea with milk and 2 sugars

Case Study 2

� Dave is a 50-year-old taxi driver who has type 1 diabetes. He has been living with the condition for the past 15 years but has presented at clinic following a recent hospital discharge with a severe hypoglycaemic episode; with a complaint of impaired hypoglycaemic awareness. On review of his blood glucose diary, he has not been testing regularly; however the data he has been

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has not been testing regularly; however the data he has been collecting shows fluctuations pre meals and bed varying from 2.6-17.9mmol/L over the past 7 day period.

� His current treatment is Humulin M3 24 units in the morning and 24 units in the evening.

� What questions would you want to ask about Dave’s dietary intake or understanding?

� What would be your main safety considerations?� What would be your recommendations?

Case Study 2 – Diet history

BREAKFAST Bacon & Eggs

Or 2 x toast

MID MORNING Tea with milk

LUNCH Nil

Or Sandwich, crisps, & biscuit

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Or Sandwich, crisps, & biscuit

Or Crisps

MID AFTERNOON Tea with milk +/- scone

EVENING MEAL Sugar free fizzy juice

Lasagne with garlic bread

Or Omelette

SUPPER Tea with milk 1-3 slices toast

Or takeaway chips