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Canadian Diabetes Association Clinical Practice Guidelines
Nutrition Therapy
Chapter 11
Paula D. Dworatzek, Kathryn Arcudi, Réjeanne Gougeon, Nadira Husein,
John L. Sievenpiper, Sandi Williams
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Nutrition Checklist
REFER 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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Choose low glycemic index carbohydrates
www.guidelines.diabetes.ca
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendations 1 and 2
1. 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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendations 7 and 8
7. 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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendations 11 and 12
11. 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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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].
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients