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Plate,
Pyramid or
Perseverance?
Medical Nutrition
Therapy for Diabetes
Iris Thiele Isip Tan MD, MSc
Associate Professor, UP College of Medicine
Chief, UP Medical Informatics Unit
July 2014
Melons by kisa12
http://www.freeimages.com/photo/863924
Monday, July 14, 14
Improving Adherence
to Medical Nutrition
Therapy
SMS & MNT
in Diabetes
Medical Nutrition
Therapy
UNITE CPG
Light meal by elvinstar
http://www.freeimages.com/photo/318333
Women holding delicious grapefruit in her hand by african_fi
http://www.freeimages.com/photo/1386617
icon_sms_hires by Hans Dorsch
https://flic.kr/p/5mXKNj
Monday, July 14, 14
UNITE CPG
Part 2: Management
Section 9. Therapeutic Lifestyle Change:
Medical Nutrition Therapy, Alcohol & Smoking
Monday, July 14, 14
UNITE CPG
9.1.1 Who should
receive MNT?
All individuals
at risk for diabetes,
those with prediabetes
or diabetes and overweight
individuals with metabolic
syndrome should be advised
regarding MNT to help attain
treatment targets (Level 1, Grade A).
Morbidly obese belly by FBellon
https://flic.kr/p/iczMwD
Monday, July 14, 14
Goals of MNT in those at risk of
diabetes or those with prediabetes
ADA Position Statement: Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2008.
Promote healthy food
choices and physical
activity ➞ weight loss
Monday, July 14, 14
Goals of MNT in those with diabetes
Normal or as near
normal as possible
glucose, lipids and
blood pressure
Prevent or slow
down the rate of
development of
chronic
complications
Address individual
nutrition needs
(personal/cultural
preferences and
willingness to change)
Maintain pleasure
of eating by only
limiting food choices
when indicated by
scientific evidence
ADA Position Statement: Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2008.
Monday, July 14, 14
MNT decreases A1c
by 1-2% and reduces
LDL by 15-25 mg/dL
Monday, July 14, 14
UNITE CPG
9.1.2 How should
counseling for MNT
be carried out?
MNT should preferably be provided
by a registered dietitian/
nutritionist or other healthcare
professional trained in the principles
of nutrition (Level 1, Grade A).
The scope and manner of delivery of
MNT will depend on the setting.
Eating salad for health by typexnick
http://www.freeimages.com/photo/1432591
Monday, July 14, 14
Individual MNT counseling or
in small groups
Canadian Diabetes Association
Counseling upon or shortly
after diagnosis, with an initial
consultation and 2-3 follow-up
sessions.
International Diabetes Federation
Chair rainbow meeting by deafstar
http://www.freeimages.com/photo/1379341
Tube flip calendar & clock by Rendy
http://www.freeimages.com/photo/772984
Monday, July 14, 14
UNITE CPG
9.1.3 In the barangay health station, the following
simple nutrition messages are to be emphasized:
a. Food choices
b. Idaho plate method
diet 1 by ppreacher
http://www.freeimages.com/photo/203247
Monday, July 14, 14
EAT MOST
Use one or more of these foods as the
basis of every meal
Vegetables, legumes, lentils, noodles, rice, bread,
grains, barley, wholegrain cereals, fresh fruit (non-
sweet)
EAT MODERATELY
Have small servings of protein-rich foods
fish, seafood, eggs, lean meat, skinless chicken, low-
fat cheese, low-fat yoghurt, low-fat milk, nuts
EAT LEAST
Minimise fats, sugars, salt and alcohol
butter, oil, ghee, cream, coconut milk and cream,
processed meat, fried foods, preserved or processed
foods, pastries, sweets, biscuits, soft drink
Fresh vegetables 6 by MeiTeng
http://www.freeimages.com/photo/1441972
Bits-n-bites Truffle by Subhadipin
http://www.freeimages.com/photo/1437365
Japanese sushi by chokingxi
http://www.freeimages.com/photo/1443887
Asia Pacific Type 2 Diabetes Policy Group
Monday, July 14, 14
From MyPyramid to MyPlate myplate.gov
http://www.straitstimes.com/news/singapore/health/story/my-
healthy-plate-replace-food-pyramid-singapore-textbooks-20140711
Monday, July 14, 14
Idaho Plate Method Provides 1,200-1,500 cal
Monday, July 14, 14
Idaho Plate Method Provides 1,200-1,500 cal
Monday, July 14, 14
Plate method works
well for the following:
Eat 3 meals a
day (move
side items to
snack time)
Low literacy
level or have
cognitive
difficulties
Works well when
eating outside
the home
Does not require
math skills or
high reading level
✓elderly
✓need to lose
weight
✓hospitalized
needing
“survival”
information
Challenging for those whom rice is a staple and
those who enjoy only a limited variety of vegetables
Brown et al Diabetes Spectrum 2001
Monday, July 14, 14
Tight fist = 1/2 cup Handful = 1 cup
Palm = 3 oz
Thumb =
2 tbsp
or 1 oz
Thumb tip
= 1 tsp
Hand guides
for portion
control
Monday, July 14, 14
UNITE CPG
9.1.4 Hospital-based
nutrition advice
a. Calculation of caloric requirement
& macronutrient distribution
b. Exchanges or CHO counting
c. How to read food labels
d. Glycemic index
e. Meal replacement
Weighing my food by Judy Baxter
https://flic.kr/p/7Jod31
Monday, July 14, 14
Fat
Not >30%
Saturated fat
<10%
Olive oil by TanjaS
http://www.freeimages.com/photo/259035
Carbohydrate
50-55%
Sucrose <10%
Protein
15-20%
Asia Pacific Type 2 Diabetes
Policy Group
Bowl of Basmati Rice by manjides
http://www.freeimages.com/photo/800204
Pink salmon by lockstockb
http://www.freeimages.com/photo/977608
Monday, July 14, 14
Reduce salt intake to
<6 g/day for those with
hypertension
Asia Pacific Type 2 Diabetes Policy Group
Higher dietary fiber intake
(25-50 g/day) for persons
with diabetes
Canadian Diabetes Association
Salt in red by socyo
http://www.freeimages.com/photo/913569
bread by lockstockb
http://www.freeimages.com/photo/1097404
Monday, July 14, 14
Diabetic Exchanges
Starch Meat/meat
substitutes
Non-starchy
vegetables
FatsFruit Milk
Daily meal plan based on a set amount of servings from each category
Monday, July 14, 14
Diabetic Exchanges
Starch Meat/meat
substitutes
Non-starchy
vegetables
FatsFruit Milk
• Allows a person to measure rather than weigh food
• Any food may be substituted for another within the same
food category
• Free food contains <20 cal (can be eaten in any amount
spread throughout the day) i.e. catsup, soy sauce, spices
Monday, July 14, 14
GLYCEMIC INDEX
(GI)
Increase in blood glucose
(over fasting level) in 2 h following
ingestion of 50 g CHO
Low GI
0-55
Intermediate
56-69
High GI
>70
Llona A. Nutr Hosp 2006;21:53-59
Monday, July 14, 14
Issues with GI
Only accounts for CHO type (not
total amount)
Measures response to individual
food consumed in isolation
GI for any particular food item
highly variable
Inaccurate predictor of
postprandial response in diabetes
Dietary CHO (Amount & Type) in the Prevention & Management of Diabetes:
American Diabetes Association Position Statement (2004)
Monday, July 14, 14
UNITE CPG
9.2 Are sucrose & sucrose-containing foods allowed?
Individuals with diabetes need not avoid sucrose or table
sugar as small amounts do not adversely affect glycemic
control (Level 3, Grade B). Table sugar when consumed,
should however replace other carbohydrate in the meal plan.
sugar cube by Zeppelin5
http://www.freeimages.com/photo/670527
Monday, July 14, 14
UNITE CPG
9.3 Are sugar alcohols and
nonnutritive sweeteners safe?
Xylitol, sorbitol, saccharin,
aspartame, cyclamate and sucralose
in the quantities usually consumed
are allowed in the diet of individuals
with diabetes as these have
negligible effects on postprandial
glucose (Level 3, Grade B).
sugar cubes on white by humusak2
http://www.freeimages.com/photo/1426045
Monday, July 14, 14
UNITE CPG
9.4 Is vitamin
supplementation needed?
Routine supplementation with
vitamin E and C or carotene as
antioxidants or chromium is not
advised (Level 1, Grade A).
Vitaminas by Capgros
http://www.freeimages.com/photo/872788
Monday, July 14, 14
UNITE CPG
9.5 Is alcohol intake allowed?
Avoid alcohol intake. Advise
caution as alcohol may cause
hypoglycemia in those taking
sulfonylureas or insulin, especially
when taken without food.
Cold beer glass isolated on white by engindeniz
http://www.freeimages.com/photo/1209276
Monday, July 14, 14
Improving Adherence
to Medical Nutrition
Therapy
Medical Nutrition
Therapy
UNITE CPG
Light meal by elvinstar
http://www.freeimages.com/photo/318333
Women holding delicious grapefruit in her hand by african_fi
http://www.freeimages.com/photo/1386617
icon_sms_hires by Hans Dorsch
https://flic.kr/p/5mXKNj
SMS & MNT
in Diabetes
Monday, July 14, 14
Eating salad for health by typexmick,
http://www.freeimages.com/photo/1432591
“Adherence
WHO definition (2003)
the extent to which a
person’s behavior - taking
medication, following a diet,
and/or executing lifestyle
changes, corresponds with
agreed recommendations
from a healthcare provider
Monday, July 14, 14
In developed countries, adherence to
long-term therapies in the general
population is around 50% and is
much lower in developing countries.
WHO report (2003)
“
Take your medicine! by Morgan,
https://flic.kr/p/6jfAxH
Monday, July 14, 14
The Five Dimensions of Adherence
WHO (2003)
Adherence to Long-term Therapies: Evidence for Action
Monday, July 14, 14
Set nutrition goals
with the patient
Monday, July 14, 14
Goal Setting in Diabetes
Behavioral goals
Assist in changing a person’s lifestyle
Diabetes
Management
Clinical parameters:
HbA1c, lipids, BP, BMI
Education
Self-management
training
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Monday, July 14, 14
Behavioral Goal Setting
• Less clinically focused
but individualized
• Purpose: establish
realistic target behaviors
→ evaluate patient
success in making
lifestyle changes
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Monday, July 14, 14
•Be sensitive to
need for
flexibility and
structure
•Guide, but
encourage
independent
self-care
Behavioral Goal Setting
• Goals are established by
mutual agreement
- Patient will “own” the goals
and become committed
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Monday, July 14, 14
What To Ask
• What behaviors would you like to
change?
• What changes do you want to make
to your current lifestyle?
• What are you willing to do right now?
• What obstacles do you see to making
these changes?
• What benefits do you see as a result
of making these changes?
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Monday, July 14, 14
Goal setting is a continuous process ...
• Each goal should be specific
and measurable
• Set up the patient for success
- Start with 1 to 3 achievable
goals
• Use a form to track daily
progress
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Monday, July 14, 14
GOALS
Things I will do to improve my eating behavior
Check off each day you meet your goal.
M T W T F S S M T W T F S S
M T W T F S S M T W T F S S
Goal 1. Eat breakfast, lunch and dinner everyday.
Notes:______________________________________________________
____________________________________________________________
M T W T F S S M T W T F S S
M T W T F S S M T W T F S S
Goal 2. Eat five servings of fruits and vegetables everyday.
Notes:______________________________________________________
____________________________________________________________
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Monday, July 14, 14
Learn what the patient thinks about
food and diabetes (including
preconceptions or misconceptions)
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Di puwede ang kanin!
Okay lang ang tinapay.
Bawal softdrinks!
Di ba juice puwede
basta unsweetened?
Bawal ang karne!
Skyflakes at oatmeal na
lang kinakain ko, Dok.
Monday, July 14, 14
Assess interest and willingness to
change eating habits; ask what they
would like to know about nutrition
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Dok, ano ba talaga ang
bawal at puwedeng kainin?
Di na ba talaga
puwede ang kanin?
Diet coke, ok lang?
Eh, Milo?
Di naman nakakapili ng
pagkain sa barko, Dok!
Monday, July 14, 14
Find out what the patient typically
eats and drinks for meals and
snacks each day
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
Sa hapon merienda ko
kanin, minsan noodles.
Kape lang ako sa
almusal, bawi na
lang sa tanghalian.
Hindi ako nagme-
merienda sa umaga.
Malakas talaga ako sa
kanin, Dok!
Monday, July 14, 14
• Set individualized goals for
eating behavior change
- As opposed to providing a
calculated calorie prescription
and giving a structured meal
plan
Start with what the patient is currently eating
Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003.
•Eat something
in the first 2 h
of the day
•Eat 25% less
CHO at dinner
•Walk for 10
minutes after
eating a meal
Monday, July 14, 14
Interventions to enhance adherence to
dietary advice for preventing and
managing chronic diseases in adults
Cochrane Review
Monday, July 14, 14
38 studies
n=9445
Desroches S et al. Cochrane Database of Systematic Reviews 2013,
Issue 2. Art. No.:CD008722
Cardiovascular
disease
Diabetes
Hypertension Renal
disease
Mobile phone in hand by sqback
http://www.freeimages.com/photo/1307593
Shaking hands by lockstockb
http://www.freeimages.com/photo/1097209
Monitor by mrceviz
http://www.freeimages.com/photo/1326722
Papers #1 by deSpool
http://www.freeimages.com/photo/259450
Monday, July 14, 14
38 studies
n=9445
Desroches S et al. Cochrane Database of Systematic Reviews 2013,
Issue 2. Art. No.:CD008722
Education
n=9
Restriction
n=1
Persuasion
n=2
Incentivization
n=1
Training
n=3
Modeling
n=7
Enablement
n=3
Multiple
n=18
Mobile phone in hand by sqback
http://www.freeimages.com/photo/1307593
Shaking hands by lockstockb
http://www.freeimages.com/photo/1097209
Monitor by mrceviz
http://www.freeimages.com/photo/1326722
Papers #1 by deSpool
http://www.freeimages.com/photo/259450
Monday, July 14, 14
Primary Outcome:
Client adherence to dietary advice
Desroches S et al. Cochrane Database of Systematic Reviews 2013,
Issue 2. Art. No.:CD008722
Process
measures
Mobile phone in hand by sqback
http://www.freeimages.com/photo/1307593
Shaking hands by lockstockb
http://www.freeimages.com/photo/1097209
Monitor by mrceviz
http://www.freeimages.com/photo/1326722
Papers #1 by deSpool
http://www.freeimages.com/photo/259450
Client-based
health or
behaviour
outcomes
Organisational
outcomes
Harms or
secondary
outcomes
Monday, July 14, 14
Potentially beneficial
interventions
Telephone follow-up
Video
Contract
Feedback
Nutritional tools
Desroches S et al. Cochrane Database of
Systematic Reviews 2013, Issue 2. Art. No.:CD008722
Mobile phone in hand by sqback
http://www.freeimages.com/photo/1307593
Monitor by mrceviz
http://www.freeimages.com/photo/1326722
Monday, July 14, 14
Improving Adherence
to Medical Nutrition
Therapy
Medical Nutrition
Therapy
UNITE CPG
Light meal by elvinstar
http://www.freeimages.com/photo/318333
Women holding delicious grapefruit in her hand by african_fi
http://www.freeimages.com/photo/1386617
icon_sms_hires by Hans Dorsch
https://flic.kr/p/5mXKNj
SMS & MNT
in Diabetes
Monday, July 14, 14
Objective
To determine if 3x a week SMS will improve
adherence to diet and exercise
Secondary Objective
To determine the mean change in body weight, BMI & HbA1c
JAFES 2013;28(2):143-9
Monday, July 14, 14
I
M
O
P
Use of SMS for the Management of Type 2 Diabetes
Mellitus: A Randomized Controlled Trial
Tamban C, Isip Tan IT & Jimeno C JAFES 2013;28(2):143-9
104 patients with T2DM, personal owner of a cellphone
and attended at least 1 lecture by the DM educator
Control group (n=36) vs SMS group (n=46) for 6 months
SMS 3x a week
Primary: Adherence to diet & exercise at 3 and 6 months
(interview by DM educator and patient diary)
Secondary: Mean change in body weight, BMI & HbA1c at
3 and 6 months
Randomized controlled trial
Monday, July 14, 14
Adherence to diet:
2-3 main meals >4 days/week
Non-adherence to diet:
1 main meal <3 days/week
SMS schedule
Monday: Diet
Wednesday: Exercise
Friday: Consequences of non-
adherence to DM management
Pyramid on a plate by Steve Garfield
https://flic.kr/p/HA2Qf
The Nelson by Pamela Graham
https://flic.kr/p/ebWV1w
Tamban C, Isip Tan IT & Jimeno C
JAFES 2013;28(2):143-9
Monday, July 14, 14
Sample SMS
translated to Filipino
Month 1
Week 1: Eat vegetables and fruits
everyday. Follow the dietary advice
given by the doctor and dietitian.
Week 2: Avoid soft drinks and
chocolates. Follow the dietary advice
given by the doctor and dietitian.
Week 3: Avoid fried and salty foods.
Follow the dietary advice given by the
doctor and dietitian.
Week 4: Avoid fatty and cholesterol-
rich foods. Follow the dietary advice
given by the doctor and dietitian.
Mobile phone in hand by sqback
http://www.freeimages.com/photo/1307593
Pyramid on a plate by Steve Garfield
https://flic.kr/p/HA2Qf
Monday, July 14, 14
6
6.5
7
7.5
8
3 mos 6 mos
Control SMSHbA1c
60
65
70
75
3 mos 6 mos
25
26
27
28
29
30
3 mos 6 mos
Bodyweight
BMI
p=0.04
p=0.84
p=0.195
Primary Outcomes
Diet adherence
Days/week: NS
Meals/day:
Control 2.29 + 0.72 p=0.018
SMS 7.13 + 0.99
Tamban C, Isip Tan IT & Jimeno C
JAFES 2013;28(2):143-9
Monday, July 14, 14
Improving Adherence
to Medical Nutrition
Therapy
Medical Nutrition
Therapy
UNITE CPG
Light meal by elvinstar
http://www.freeimages.com/photo/318333
Women holding delicious grapefruit in her hand by african_fi
http://www.freeimages.com/photo/1386617
icon_sms_hires by Hans Dorsch
https://flic.kr/p/5mXKNj
SMS & MNT
in Diabetes
Monday, July 14, 14
Questions?
www.endocrine-witch.net
One, Two ... Count my food.
Three, Four ... Exercise more.
Five, Six ... Small meals I fix.
Seven, Eight ... Now how’s my weight?
Nine, Ten ... Start again.
Brown et al Diabetes Spectrum 2001
@endocrine_witch
Monday, July 14, 14

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Medical Nutrition Therapy for Diabetes

  • 1. Plate, Pyramid or Perseverance? Medical Nutrition Therapy for Diabetes Iris Thiele Isip Tan MD, MSc Associate Professor, UP College of Medicine Chief, UP Medical Informatics Unit July 2014 Melons by kisa12 http://www.freeimages.com/photo/863924 Monday, July 14, 14
  • 2. Improving Adherence to Medical Nutrition Therapy SMS & MNT in Diabetes Medical Nutrition Therapy UNITE CPG Light meal by elvinstar http://www.freeimages.com/photo/318333 Women holding delicious grapefruit in her hand by african_fi http://www.freeimages.com/photo/1386617 icon_sms_hires by Hans Dorsch https://flic.kr/p/5mXKNj Monday, July 14, 14
  • 3. UNITE CPG Part 2: Management Section 9. Therapeutic Lifestyle Change: Medical Nutrition Therapy, Alcohol & Smoking Monday, July 14, 14
  • 4. UNITE CPG 9.1.1 Who should receive MNT? All individuals at risk for diabetes, those with prediabetes or diabetes and overweight individuals with metabolic syndrome should be advised regarding MNT to help attain treatment targets (Level 1, Grade A). Morbidly obese belly by FBellon https://flic.kr/p/iczMwD Monday, July 14, 14
  • 5. Goals of MNT in those at risk of diabetes or those with prediabetes ADA Position Statement: Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2008. Promote healthy food choices and physical activity ➞ weight loss Monday, July 14, 14
  • 6. Goals of MNT in those with diabetes Normal or as near normal as possible glucose, lipids and blood pressure Prevent or slow down the rate of development of chronic complications Address individual nutrition needs (personal/cultural preferences and willingness to change) Maintain pleasure of eating by only limiting food choices when indicated by scientific evidence ADA Position Statement: Nutrition Recommendations and Interventions for Diabetes. Diabetes Care 2008. Monday, July 14, 14
  • 7. MNT decreases A1c by 1-2% and reduces LDL by 15-25 mg/dL Monday, July 14, 14
  • 8. UNITE CPG 9.1.2 How should counseling for MNT be carried out? MNT should preferably be provided by a registered dietitian/ nutritionist or other healthcare professional trained in the principles of nutrition (Level 1, Grade A). The scope and manner of delivery of MNT will depend on the setting. Eating salad for health by typexnick http://www.freeimages.com/photo/1432591 Monday, July 14, 14
  • 9. Individual MNT counseling or in small groups Canadian Diabetes Association Counseling upon or shortly after diagnosis, with an initial consultation and 2-3 follow-up sessions. International Diabetes Federation Chair rainbow meeting by deafstar http://www.freeimages.com/photo/1379341 Tube flip calendar & clock by Rendy http://www.freeimages.com/photo/772984 Monday, July 14, 14
  • 10. UNITE CPG 9.1.3 In the barangay health station, the following simple nutrition messages are to be emphasized: a. Food choices b. Idaho plate method diet 1 by ppreacher http://www.freeimages.com/photo/203247 Monday, July 14, 14
  • 11. EAT MOST Use one or more of these foods as the basis of every meal Vegetables, legumes, lentils, noodles, rice, bread, grains, barley, wholegrain cereals, fresh fruit (non- sweet) EAT MODERATELY Have small servings of protein-rich foods fish, seafood, eggs, lean meat, skinless chicken, low- fat cheese, low-fat yoghurt, low-fat milk, nuts EAT LEAST Minimise fats, sugars, salt and alcohol butter, oil, ghee, cream, coconut milk and cream, processed meat, fried foods, preserved or processed foods, pastries, sweets, biscuits, soft drink Fresh vegetables 6 by MeiTeng http://www.freeimages.com/photo/1441972 Bits-n-bites Truffle by Subhadipin http://www.freeimages.com/photo/1437365 Japanese sushi by chokingxi http://www.freeimages.com/photo/1443887 Asia Pacific Type 2 Diabetes Policy Group Monday, July 14, 14
  • 12. From MyPyramid to MyPlate myplate.gov http://www.straitstimes.com/news/singapore/health/story/my- healthy-plate-replace-food-pyramid-singapore-textbooks-20140711 Monday, July 14, 14
  • 13. Idaho Plate Method Provides 1,200-1,500 cal Monday, July 14, 14
  • 14. Idaho Plate Method Provides 1,200-1,500 cal Monday, July 14, 14
  • 15. Plate method works well for the following: Eat 3 meals a day (move side items to snack time) Low literacy level or have cognitive difficulties Works well when eating outside the home Does not require math skills or high reading level ✓elderly ✓need to lose weight ✓hospitalized needing “survival” information Challenging for those whom rice is a staple and those who enjoy only a limited variety of vegetables Brown et al Diabetes Spectrum 2001 Monday, July 14, 14
  • 16. Tight fist = 1/2 cup Handful = 1 cup Palm = 3 oz Thumb = 2 tbsp or 1 oz Thumb tip = 1 tsp Hand guides for portion control Monday, July 14, 14
  • 17. UNITE CPG 9.1.4 Hospital-based nutrition advice a. Calculation of caloric requirement & macronutrient distribution b. Exchanges or CHO counting c. How to read food labels d. Glycemic index e. Meal replacement Weighing my food by Judy Baxter https://flic.kr/p/7Jod31 Monday, July 14, 14
  • 18. Fat Not >30% Saturated fat <10% Olive oil by TanjaS http://www.freeimages.com/photo/259035 Carbohydrate 50-55% Sucrose <10% Protein 15-20% Asia Pacific Type 2 Diabetes Policy Group Bowl of Basmati Rice by manjides http://www.freeimages.com/photo/800204 Pink salmon by lockstockb http://www.freeimages.com/photo/977608 Monday, July 14, 14
  • 19. Reduce salt intake to <6 g/day for those with hypertension Asia Pacific Type 2 Diabetes Policy Group Higher dietary fiber intake (25-50 g/day) for persons with diabetes Canadian Diabetes Association Salt in red by socyo http://www.freeimages.com/photo/913569 bread by lockstockb http://www.freeimages.com/photo/1097404 Monday, July 14, 14
  • 20. Diabetic Exchanges Starch Meat/meat substitutes Non-starchy vegetables FatsFruit Milk Daily meal plan based on a set amount of servings from each category Monday, July 14, 14
  • 21. Diabetic Exchanges Starch Meat/meat substitutes Non-starchy vegetables FatsFruit Milk • Allows a person to measure rather than weigh food • Any food may be substituted for another within the same food category • Free food contains <20 cal (can be eaten in any amount spread throughout the day) i.e. catsup, soy sauce, spices Monday, July 14, 14
  • 22. GLYCEMIC INDEX (GI) Increase in blood glucose (over fasting level) in 2 h following ingestion of 50 g CHO Low GI 0-55 Intermediate 56-69 High GI >70 Llona A. Nutr Hosp 2006;21:53-59 Monday, July 14, 14
  • 23. Issues with GI Only accounts for CHO type (not total amount) Measures response to individual food consumed in isolation GI for any particular food item highly variable Inaccurate predictor of postprandial response in diabetes Dietary CHO (Amount & Type) in the Prevention & Management of Diabetes: American Diabetes Association Position Statement (2004) Monday, July 14, 14
  • 24. UNITE CPG 9.2 Are sucrose & sucrose-containing foods allowed? Individuals with diabetes need not avoid sucrose or table sugar as small amounts do not adversely affect glycemic control (Level 3, Grade B). Table sugar when consumed, should however replace other carbohydrate in the meal plan. sugar cube by Zeppelin5 http://www.freeimages.com/photo/670527 Monday, July 14, 14
  • 25. UNITE CPG 9.3 Are sugar alcohols and nonnutritive sweeteners safe? Xylitol, sorbitol, saccharin, aspartame, cyclamate and sucralose in the quantities usually consumed are allowed in the diet of individuals with diabetes as these have negligible effects on postprandial glucose (Level 3, Grade B). sugar cubes on white by humusak2 http://www.freeimages.com/photo/1426045 Monday, July 14, 14
  • 26. UNITE CPG 9.4 Is vitamin supplementation needed? Routine supplementation with vitamin E and C or carotene as antioxidants or chromium is not advised (Level 1, Grade A). Vitaminas by Capgros http://www.freeimages.com/photo/872788 Monday, July 14, 14
  • 27. UNITE CPG 9.5 Is alcohol intake allowed? Avoid alcohol intake. Advise caution as alcohol may cause hypoglycemia in those taking sulfonylureas or insulin, especially when taken without food. Cold beer glass isolated on white by engindeniz http://www.freeimages.com/photo/1209276 Monday, July 14, 14
  • 28. Improving Adherence to Medical Nutrition Therapy Medical Nutrition Therapy UNITE CPG Light meal by elvinstar http://www.freeimages.com/photo/318333 Women holding delicious grapefruit in her hand by african_fi http://www.freeimages.com/photo/1386617 icon_sms_hires by Hans Dorsch https://flic.kr/p/5mXKNj SMS & MNT in Diabetes Monday, July 14, 14
  • 29. Eating salad for health by typexmick, http://www.freeimages.com/photo/1432591 “Adherence WHO definition (2003) the extent to which a person’s behavior - taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider Monday, July 14, 14
  • 30. In developed countries, adherence to long-term therapies in the general population is around 50% and is much lower in developing countries. WHO report (2003) “ Take your medicine! by Morgan, https://flic.kr/p/6jfAxH Monday, July 14, 14
  • 31. The Five Dimensions of Adherence WHO (2003) Adherence to Long-term Therapies: Evidence for Action Monday, July 14, 14
  • 32. Set nutrition goals with the patient Monday, July 14, 14
  • 33. Goal Setting in Diabetes Behavioral goals Assist in changing a person’s lifestyle Diabetes Management Clinical parameters: HbA1c, lipids, BP, BMI Education Self-management training Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Monday, July 14, 14
  • 34. Behavioral Goal Setting • Less clinically focused but individualized • Purpose: establish realistic target behaviors → evaluate patient success in making lifestyle changes Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Monday, July 14, 14
  • 35. •Be sensitive to need for flexibility and structure •Guide, but encourage independent self-care Behavioral Goal Setting • Goals are established by mutual agreement - Patient will “own” the goals and become committed Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Monday, July 14, 14
  • 36. What To Ask • What behaviors would you like to change? • What changes do you want to make to your current lifestyle? • What are you willing to do right now? • What obstacles do you see to making these changes? • What benefits do you see as a result of making these changes? Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Monday, July 14, 14
  • 37. Goal setting is a continuous process ... • Each goal should be specific and measurable • Set up the patient for success - Start with 1 to 3 achievable goals • Use a form to track daily progress Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Monday, July 14, 14
  • 38. GOALS Things I will do to improve my eating behavior Check off each day you meet your goal. M T W T F S S M T W T F S S M T W T F S S M T W T F S S Goal 1. Eat breakfast, lunch and dinner everyday. Notes:______________________________________________________ ____________________________________________________________ M T W T F S S M T W T F S S M T W T F S S M T W T F S S Goal 2. Eat five servings of fruits and vegetables everyday. Notes:______________________________________________________ ____________________________________________________________ Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Monday, July 14, 14
  • 39. Learn what the patient thinks about food and diabetes (including preconceptions or misconceptions) Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Di puwede ang kanin! Okay lang ang tinapay. Bawal softdrinks! Di ba juice puwede basta unsweetened? Bawal ang karne! Skyflakes at oatmeal na lang kinakain ko, Dok. Monday, July 14, 14
  • 40. Assess interest and willingness to change eating habits; ask what they would like to know about nutrition Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Dok, ano ba talaga ang bawal at puwedeng kainin? Di na ba talaga puwede ang kanin? Diet coke, ok lang? Eh, Milo? Di naman nakakapili ng pagkain sa barko, Dok! Monday, July 14, 14
  • 41. Find out what the patient typically eats and drinks for meals and snacks each day Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. Sa hapon merienda ko kanin, minsan noodles. Kape lang ako sa almusal, bawi na lang sa tanghalian. Hindi ako nagme- merienda sa umaga. Malakas talaga ako sa kanin, Dok! Monday, July 14, 14
  • 42. • Set individualized goals for eating behavior change - As opposed to providing a calculated calorie prescription and giving a structured meal plan Start with what the patient is currently eating Diabetes Nutrition Q & A for Health Professionals. Pastors JG (Ed.) 2003. •Eat something in the first 2 h of the day •Eat 25% less CHO at dinner •Walk for 10 minutes after eating a meal Monday, July 14, 14
  • 43. Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults Cochrane Review Monday, July 14, 14
  • 44. 38 studies n=9445 Desroches S et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.:CD008722 Cardiovascular disease Diabetes Hypertension Renal disease Mobile phone in hand by sqback http://www.freeimages.com/photo/1307593 Shaking hands by lockstockb http://www.freeimages.com/photo/1097209 Monitor by mrceviz http://www.freeimages.com/photo/1326722 Papers #1 by deSpool http://www.freeimages.com/photo/259450 Monday, July 14, 14
  • 45. 38 studies n=9445 Desroches S et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.:CD008722 Education n=9 Restriction n=1 Persuasion n=2 Incentivization n=1 Training n=3 Modeling n=7 Enablement n=3 Multiple n=18 Mobile phone in hand by sqback http://www.freeimages.com/photo/1307593 Shaking hands by lockstockb http://www.freeimages.com/photo/1097209 Monitor by mrceviz http://www.freeimages.com/photo/1326722 Papers #1 by deSpool http://www.freeimages.com/photo/259450 Monday, July 14, 14
  • 46. Primary Outcome: Client adherence to dietary advice Desroches S et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.:CD008722 Process measures Mobile phone in hand by sqback http://www.freeimages.com/photo/1307593 Shaking hands by lockstockb http://www.freeimages.com/photo/1097209 Monitor by mrceviz http://www.freeimages.com/photo/1326722 Papers #1 by deSpool http://www.freeimages.com/photo/259450 Client-based health or behaviour outcomes Organisational outcomes Harms or secondary outcomes Monday, July 14, 14
  • 47. Potentially beneficial interventions Telephone follow-up Video Contract Feedback Nutritional tools Desroches S et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.:CD008722 Mobile phone in hand by sqback http://www.freeimages.com/photo/1307593 Monitor by mrceviz http://www.freeimages.com/photo/1326722 Monday, July 14, 14
  • 48. Improving Adherence to Medical Nutrition Therapy Medical Nutrition Therapy UNITE CPG Light meal by elvinstar http://www.freeimages.com/photo/318333 Women holding delicious grapefruit in her hand by african_fi http://www.freeimages.com/photo/1386617 icon_sms_hires by Hans Dorsch https://flic.kr/p/5mXKNj SMS & MNT in Diabetes Monday, July 14, 14
  • 49. Objective To determine if 3x a week SMS will improve adherence to diet and exercise Secondary Objective To determine the mean change in body weight, BMI & HbA1c JAFES 2013;28(2):143-9 Monday, July 14, 14
  • 50. I M O P Use of SMS for the Management of Type 2 Diabetes Mellitus: A Randomized Controlled Trial Tamban C, Isip Tan IT & Jimeno C JAFES 2013;28(2):143-9 104 patients with T2DM, personal owner of a cellphone and attended at least 1 lecture by the DM educator Control group (n=36) vs SMS group (n=46) for 6 months SMS 3x a week Primary: Adherence to diet & exercise at 3 and 6 months (interview by DM educator and patient diary) Secondary: Mean change in body weight, BMI & HbA1c at 3 and 6 months Randomized controlled trial Monday, July 14, 14
  • 51. Adherence to diet: 2-3 main meals >4 days/week Non-adherence to diet: 1 main meal <3 days/week SMS schedule Monday: Diet Wednesday: Exercise Friday: Consequences of non- adherence to DM management Pyramid on a plate by Steve Garfield https://flic.kr/p/HA2Qf The Nelson by Pamela Graham https://flic.kr/p/ebWV1w Tamban C, Isip Tan IT & Jimeno C JAFES 2013;28(2):143-9 Monday, July 14, 14
  • 52. Sample SMS translated to Filipino Month 1 Week 1: Eat vegetables and fruits everyday. Follow the dietary advice given by the doctor and dietitian. Week 2: Avoid soft drinks and chocolates. Follow the dietary advice given by the doctor and dietitian. Week 3: Avoid fried and salty foods. Follow the dietary advice given by the doctor and dietitian. Week 4: Avoid fatty and cholesterol- rich foods. Follow the dietary advice given by the doctor and dietitian. Mobile phone in hand by sqback http://www.freeimages.com/photo/1307593 Pyramid on a plate by Steve Garfield https://flic.kr/p/HA2Qf Monday, July 14, 14
  • 53. 6 6.5 7 7.5 8 3 mos 6 mos Control SMSHbA1c 60 65 70 75 3 mos 6 mos 25 26 27 28 29 30 3 mos 6 mos Bodyweight BMI p=0.04 p=0.84 p=0.195 Primary Outcomes Diet adherence Days/week: NS Meals/day: Control 2.29 + 0.72 p=0.018 SMS 7.13 + 0.99 Tamban C, Isip Tan IT & Jimeno C JAFES 2013;28(2):143-9 Monday, July 14, 14
  • 54. Improving Adherence to Medical Nutrition Therapy Medical Nutrition Therapy UNITE CPG Light meal by elvinstar http://www.freeimages.com/photo/318333 Women holding delicious grapefruit in her hand by african_fi http://www.freeimages.com/photo/1386617 icon_sms_hires by Hans Dorsch https://flic.kr/p/5mXKNj SMS & MNT in Diabetes Monday, July 14, 14
  • 55. Questions? www.endocrine-witch.net One, Two ... Count my food. Three, Four ... Exercise more. Five, Six ... Small meals I fix. Seven, Eight ... Now how’s my weight? Nine, Ten ... Start again. Brown et al Diabetes Spectrum 2001 @endocrine_witch Monday, July 14, 14