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Medical Nutrition Therapy for Diabetes
 

Medical Nutrition Therapy for Diabetes

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The presentation has three parts: UNITE for Diabetes Philippines CPG recommendations on medical nutrition therapy (MNT), improving adherence to MNT and use of SMS.

The presentation has three parts: UNITE for Diabetes Philippines CPG recommendations on medical nutrition therapy (MNT), improving adherence to MNT and use of SMS.

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    Medical Nutrition Therapy for Diabetes Medical Nutrition Therapy for Diabetes Presentation Transcript

    • 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