Diabetes Asia (3)

1
Nutrition Therapy In Gestational DiabetesPart 1
AssessmentPart 2 RecommendationsPart 3
Education
2
Objectives

• Discuss factors that should be considered when
  doing a nutritional assessment
• Discuss appropriate balance of meals/snacks
  through the day
• Discuss appropriate weight gain based on
  preconception weight
• Discuss the value of a late night snack to
  prevent early morning ketosis
• Evaluate the importance of folic acid
  supplementation before and during pregnancy
• Discuss the value of multivitamin supplementation
  during pregnancy

3
Goals for MNT in GDM

• Optimal nutrition and weight gain for fetus and
  mother
• Maternal euglycemia
• Reduce the risk of diabetes related complications
  for the mother and child
• Minimize the maternal and infant morbidity and
  mortality rates
• Integrate diet, activity and pharmalogic therapy
• Introducing healthy habits that can prevent or
  delay onset of type 2 DM

4
Assessing from an Interview

• Age
• Obstetric history
• Weight History
• Significant medical history (co-morbidities)
• Food preferences and eating habits
• Food Allergies
• Individual psychological, social and physical
  status
• Lifestyle, culture, and socio-economic status
• Oral health
• Readiness to change

5
Assessing from Clinical Information

• Laboratory tests to determine clinical status
• OGTT, fasting glucose, HbA1c level
• SMBG
• Urine ketones and proteins
• lipid profile (cholesterol HDL, LDL)
• Haemoglobin, creatinine, thyroid function
• Blood pressure
• Anthropometric Data
• Height , Weight and BMI
• Current medications and nutrition supplements

6
Body Mass Index (BMI)

• Use pre pregnancy weight for calculations
• Weight and height measurements to calculate BMI
• BMI weight in kg/(height in m)2
• Standard BMI normograms

Asian ADA norms
Underweight lt18.5 kg/m2
Normal BMI 18.0-22.9 kg/m2 18.5-24.9 kg/m2
Overweight 23.0-24.9 kg/m2 25.0-29.9 kg/m2
Obesity gt25 kg/m2 gt 30 kg/m2
7
Weight Gain Chart

• Plot weight on a prenatal weight gain grid to
  obtain an accurate assessment of total pregnancy
  weight gain and rate of weight gain.
• Determine if weight gain is above, at or below
  the recommended range.
• If weight gain has already exceeded the
  recommended range, slow weight gain in order to
  prevent further excess gain.

8
Nutrition Assessment

• Nutrition history
• usual food intake recorded through interview
• Dietary recall
• food and drink consumed in previous 24 hours
  (24-hour recall)

9

• Activity
• Think of things to check for when doing a
  dietary history.

10
Issues with Dietary Recalls

• Based on memory
• Based on willingness to disclose the truth to a
  healthcare provider
• Nutrient intake and long-term habits are not
  represented
• Accurate estimations of food quantities/ingredient
  s are difficult

11
Nutrition Therapy In Gestational DiabetesPart
1 AssessmentPart 2 RecommendationsPart 3
Education
12
Composition of Food and Drinks

• Macro-nutrients
• protein
• carbohydrates
• fats
• Micro-nutrients
• vitamins
• minerals

13
Recommendations for Weight Gain Singleton
pregnancy

• Where possible a dietitian should develop a meal
  plan.
• At about the 4th month of the pregnancy about 350
  calories should be added daily. This should mean
  the woman is eating about 1900-2000 calories a
  day.
• Overweight women (BMI 23 and over before
  pregnancy) should increase less.
• Underweight women (BMI less than 18 before
  pregnancy) could add more.

Institute of Medicine 2009
14
Dietary Recommendations for GDM

• Macronutrient composition

Nutrient of daily calorie intake
Carbohydrates 45-65
Fats 20-35
Protein 10-35
Dietary fibre 28g/day
Institute Of Medicine 2002
15
Fluids

• Essential for all body functions
• 40-60 of body weight is water
• Important to drink adequate amounts of fluid
• Restrictions may be required in case of pedal
  edema

16
Proteins

• Provide amino acids
• Help to build muscle mass
• Animal sources
• Plant sources
• 1 g of protein gives 4 kcal energy

17
Protein Recommendations

• 1.1 g protein per kg bodyweight per day
• 10-35 of total energy per day
• Animal protein often high in fat, especially
  saturated.
• Attention must be paid to meeting the protein
  requirements of women who are vegetarians or
  vegans

18
Carbohydrates

• Provide main source of energy for the body
  (45-65) individualized
• Nutrient that most influences blood glucose
  levels
• Source of simple sugars glucose, fructose
• 1 g of carbohydrate provides 4 kcal

19
Activity

• Name some of the common carbohydrates and staple
  foods in your region.

20
Carbohydrates And Meal Planning

• Amount and source of carbohydrates is considered
  when planning meals
• Recommended source of carbohydrates is mainly
  from
• whole grains wheat, rice, pasta, bread, rice,
  wheat, barley, oats, maize and corn
• legumes, beans, pulses (bengal gram, black gram,
  rajma)
• fruit and vegetables
• milk

21
Carbohydrate (CHO) content of common foods
Food Amount Serving CHO (g)
Bread, whole wheat 28 g 1 slice 11
Rice (cooked) 75 g 0.3 cup 13
Pasta 125 mL 0.5 cup 16
Chappati 44 g 1 small 19
Corn meal 45 mL 3 tbsps 16
Potato 84 g 1 small 15
Couscous, cooked 125 mL 0.5 cup 17
Lentils 250 mL 1 cup 15
Banana 101 g 1 small 20
(Canadian Diabetes Association, 2006)
22
Benefits of Fibre

• A high-fibre diet is healthy
• Mixture of soluble and insoluble fibre
• slows absorption of glucose
• reduces absorption of dietary fats
• retains water to soften stool
• may reduce the risk of colon cancer
• may reduce the risk of heart disease

23
Fibre Recommendations

• Recommended amounts of total fibre 28 g per day
• Sources of insoluble fibre include wheat bran,
  whole grains, seeds, fruits and vegetables
• Sources of soluble fibre legumes (beans), oat
  bran, barley, apples, citrus fruits

CDA, 2013
24
Glycaemic Index (GI)

• Ranks carbohydrate-rich foods according to the
  increase in blood glucose levels they cause in
  comparison with a standard food (white
  bread/glucose).

25
Glycaemic Response of Glucose and Lentils
Blood glucose level
Glucose
Lentils
Reprinted with permission from CDA, 2004
26
Factors Affecting the Glycaemic Index

• Type of sugar
• glucose, fructose, galactose
• Nature of starch
• amylose, amylopectin
• Starch-nutrient interactions
• resistant starch
• Cooking/food processing

27
Factors Affecting The Glycaemic Index

• Processing/form of the food
• gelatinization
• particle size
• cellular structure
• Presence of other food components
• fat and protein
• dietary fibre

Kalergis, De Grandpre, Andersons, 2005
28
Glycaemic Index of Foods
Low glycaemic index foods Intermediate glycaemic index High glycaemic index
Oats Multigrain bread White Bread
Lentils/dhal Some rice (long grain) White Rice
Yogurt Pasta Processed breakfast cereal
Milk Bananas Glucose
Most Fruits and vegetables Grapes Mashed and baked potatoes
CDA , 2006
29
Low GI - Advantages

• Promotes healthy eating
• Increases fibre intake
• Helps control
• appetite
• blood glucose levels
• blood lipid levels

30
Fats

• The most concentrated source of energy
• Foods may contain fat naturally or have it added
  during cooking
• 1 g fat provides 9 kcal

31
Fat Recommendations

• Low in polyunsaturated fats (up to 10 of total
  daily energy)
• High in monounsaturated fats (gt10)
• Low in saturated fats (lt10)
• Trans or hydrogenated fat should be avoided

IoM 2002
32
Fats

• Common sources of different fats
• Polyunsaturated safflower oil, sunflower oil,
  corn oil
• Monounsaturated olive oil, canola oil, rape
  seed oil, groundnut oil, mustard oil, sesame oil
• Saturated red meats, butter, cheese, margarine,
  ghee (clarified butter), whole milk, cream, lard
• Trans fats baked products, biscuits, cakes

33
Activity

• Identify major sources of fats in foods in your
  region.

34
Vitamins

• Organic substances present in very small amounts
  in food
• Essential to good health
• A balanced meal automatically provides all
  necessary vitamins
• Either fat-soluble or water-soluble
• In some countries foods are fortified with
  vitamins and minerals

35
Vitamin Recommendations

• Daily multivitamin supplement should be added as
  they are often not met by diet alone.
• Multivitamin content varies depending on the
  product used.
• Women at higher risk for dietary deficiencies
  include multiple gestation, heavy smokers,
  adolescents, complete vegetarians, substance
  abusers, and women with lactase deficiency.

36
Minerals

• Substance present in bones, teeth, soft tissue,
  muscle, blood and nerve cells
• Help maintain physiological processes, strengthen
  skeletal structures, preserve heart and brain
  function and muscle and nerve systems
• Act as a catalyst to essential enzymatic
  reactions
• Low levels of minerals puts stress on essential
  life functions

37
Minerals And Trace Elements

• A balanced diet supplies minerals and trace
  elements
• Supplements are important as requirements are
  higher during pregnancy
• Calcium supplementation
• Iron supplementation
• Folic acid supplementation 0.4mg (should be
  started three months prior to conception)

CDA , 2013
38
Sodium Recommendations

• Most people consume too much salt
• Sodium restriction may be advised in case of
  uncontrolled hypertension and edema
• Targets for daily sodium intake

Age Adequate Intake (mg/day) Upper limit (mg/day)
14-50 1500 2300
51-70 1300 2300
over 70 1200 2300
Health Canada, 2005
39
Lowering Salt Intake

• Sodium content is often high in restaurant foods
• Encourage meal plans with
• more fresh foods fruits and vegetable
• less processed, fast, convenience or canned foods
• herbs and spices used when cooking instead of
  salt.
• Teach people to read food labels.
• Choose salt free, reduced or low in sodium foods

40
Substance Use

• The following substances should be avoided
  completely once the woman plans a pregnancy
• Tobacco in any form
• Alcohol
• Drugs (street, illegal)

41
Sweeteners

• Sweeteners that increase blood glucose
• Sugar, honey
• Polydextrose Sugar alcohols maltitol,
  sorbitol, Xylitol
• Sweeteners that do not increase blood glucose
• Acesulfame potassium
• Aspartame
• Cyclamate
• Saccharin
• Sucralose

Must be avoided during pregnancy
To check with Health care team prior to starting
use of sweeteners
CDA, 2006
42
Food Labels

• Nutrition facts
• Serving size (if available)
• Nutrient content
• Ingredients
• Nutrition information

43
Food labels
Nutrition Facts Per 1 cup (250g) Nutrition Facts Per 1 cup (250g) Nutrition Facts Per 1 cup (250g) Nutrition Facts Per 1 cup (250g) Nutrition Facts Per 1 cup (250g) Nutrition Facts Per 1 cup (250g)
Amount Amount Amount Amount Daily Value Daily Value
Calories 100 Calories 100 Calories 100 Calories 100
Fat 0g Fat 0g Fat 0g Fat 0g 0 0
Saturated 0 g Trans 0 g Saturated 0 g Trans 0 g Saturated 0 g Trans 0 g Saturated 0 g Trans 0 g 0 0
Cholesterol 0 mg Cholesterol 0 mg Cholesterol 0 mg Cholesterol 0 mg
Sodium 3 mg Sodium 3 mg Sodium 3 mg Sodium 3 mg 0 0
Carbohydrate 26 g Carbohydrate 26 g Carbohydrate 26 g Carbohydrate 26 g 8 8
Fibre 1 g Fibre 1 g Fibre 1 g 4 4
Sugars 23 g Sugars 23 g Sugars 23 g
Protein 2 g Protein 2 g Protein 2 g Protein 2 g
Vitamin A Vitamin A 20 Vitamin C 170
Calcium Calcium 2 Iron 2
Food labels may look different in different
countries, but the same information is usually
available
44
Activity

• Practice reading a food label
• Calculate the following
• Serving size
• Number of calories in one serving
• Number of carbohydrates in one serving
• Amount of fat in one serving

45
Summary of Dietary Recommendations

• Carbohydrates 45-65
• Dietary fibre 28 g / day
• Fats 20-35
• Protein 10-35 (1.1 g/kg/day)
• Sodium 1500 - 2300 mg/day

46
Nutrition Therapy in Gestational Diabetes
Part 1 AssessmentPart 2 RecommendationsPar
t 3 Education
47
Approach To Meal Planning

• A uniform approach to meal planning does not work
  for everyone
• A flexible plan or a variety of approaches is
  necessary to address different needs

48
Meal Planning

• Before deciding on the content of meal plans,
  consider
• Food preferences and eating habits
• Previous experience, knowledge and skills
• Current clinical, psychological and dietary
  status
• Appropriate clinical and nutrition goals
• Lifestyle factors

49
What to teach and when?

• Basic
• Basic information about nutrition
• Nutrient requirements
• Healthy eating guidelines
• Making healthy food choices
• Self-management training and use of educational
  tools

50
Nutrition Education Tools

• Awareness of the basics of healthy eating/balance
  of good health
• Food Pyramid
• The plate model

51
Food Guides

• Australian Food Guide

52
Healthy eating
Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day Recommended Number of Food Guide Servings per Day
Children Children Children Children Teens Teens Adults Adults Adults Adults
Age In Years 2-3 2-3 4-8 9-13 14-18 14-18 19-50 19-50 51 51
Sex Girls and Boys Girls and Boys Girls and Boys Girls and Boys Females Males Females Males Females Males
Vegetables and fruits 4 4 5 6 7 8 7-8 8-10 7 7
Grain Products 3 3 4 6 6 7 6-7 8 6 7
Milk and Alternatives 2 2 2 3-4 3-4 3-4 2 2 3 3
Meat and Alternatives 1 1 1 1-2 2 3 2 3 2 3
The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality. The chart above shows how many Food Guide Servings you need from each of the four food groups every day. Having the amount and tyoe of food recommended and following the tips in Canadas Food Guide will help Meet your needs for vitamins, minerals and other nutrients. Reduce your risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis. Contribute to your overall health and vitality.

• Eating Well with Canadas Food Guide

53
Food pyramid India


Diabetes India, 2005
54
Balance of good health - UK eat well plate
Bread, cerealsand potatoes
Fruits and vegetables
Milk and dairy products
Meat, fish and protein alternatives
Foods rich in sugars and fat
(Reproduced with kind permission of the Food
Standards Agency)
55
These graphics will change to be the same as the
new ones going in the booklets
Example of Healthy food plate with South-Asian
foods
Healthy food plate (Source Diabetes Education
Modules 2011)
56
Activity

• Draw on a paper plate either
• The recommended proportions of foods from your
  region
• The proportions of what you ate last night

57
Practical Advice/ 1

• Make healthy food choices
• Avoid fatty foods
• Use low-fat cooking methods
• Substitute high fat foods with low fat options
  e.g use low fat milk
• Minimize consumption of sugar and salt
• Use fresh foods instead of preserved or canned
  foods

58
Practical Advice/ 2

• At least five servings of fruit and vegetables
  per day
• Choose colourful fruits and vegetables
• Choose whole fruits over juices
• Replace high calorie beverages with water
• Eat small frequent meals that are well spaced
• Do not skip meals
• Calories should be restricted especially if
  overweight
• Eat free foods as desired, include in between
  major meals

59
Practical Advice/ 3

• One low GI food at each meal
• Mix high and low GI food intermediate GI meal
• Substitute high GI cereals/breads/rice with low
  GI cereals/bread/rice
• Eat low GI snacks instead of high GI snacks
  (remember to choose lower fat snacks)

60
References

• American Diabetes Association. (2013). Clinical
  Practice Recommendations. Diabetes Care, 36,
  (supple 1).
• Canadian Diabetes Association Clinical Practice
  Guidelines Expert Committee. (2013). Canadian
  Diabetes Association 2013. Clinical Practice
  Guidelines for the Prevention and Management of
  Diabetes in Canada. Canadian Journal of Diabetes,
  37(suppl 1).
• Canadian Diabetes Association. (2006). Beyond the
  Basics. Toronto ON Canadian Diabetes Association
• Diabetes India. (2005). Diet Charts. Retreived
  September 13, 2010. http//www.diabetesindia.com/d
  iabetes/diet_chart.htm
• Franz MJ, Evert AB (Eds.) American Diabetes
  Association Guide to Nutrition Therapy for
  Diabetes. 2nd Ed. 1012
• Health Canada. Food and Nutrition. Sodium. Its
  Your Health. Available from http//www.hc-sc.gc.c
  a/hl-vs/iyh-vsv/food-aliment/sodium-eng.php
• Health Canada. (2005). Food and Nutrition. The
  Issue of sodium. (Retrieved September 13, 2010)
  http//www.hc-sc.gc.ca/fn-an/nutrition/reference/t
  able/ref_elements_tbl-eng.php
• Institute of Medicine 2002 http//www.iom.edu/Glob
  al/News20Announcements//media/C5CD2DD7840544979A
  549EC47E56A02B.ashx
• Institute Of Medicine 2009 http//www.ncbi.nlm.nih
  .gov/books/NBK32799/table/summary.t1/?reportobjec
  tonly
• Kalergis, M., De Grandpre, E., Andersons, C.
  (2005). The Role of Glycemic Index in the
  Prevention and Management of Diabetes A Review
  and Discussion. Can J of Diab, 29(1), 27-38.
• Misra A, Chowbey P, Makkar PM, Vikram NK, Wasir
  JS, Chadha D, et al. Consensus Statement for
  Diagnosis of Obesity, Abdominal Obesity and the
  Metabolic Syndrome for Asian Indians and
  Recommendations for Physical Activity, Medical
  and Surgical Management. JAPI 200957.