Beyond Carb Counting: o Nutrition goals for people with diabetes The - PDF document

2/19/2018 Objectives o Define glycemic variability Beyond Carb Counting: o Nutrition goals for people with diabetes The Relationship Between Glycemic o Understand differences between type and amount of carbs Variability and Carbohydrates o Define different types and benefits of dietary fiber o Define Glycemic Index (GI) and Glycemic Load (GL) Erin Caroulis, MPH, RD, LDN, CDE Registered Dietitian, Certified Diabetes o Explain how to incorporate GI and GL into diet Educator Managing Blood Glucose- What is Glycemic Variability? Balancing Act! Spikes in glucose levels from pre-meal to post- meal • Post-meal blood glucose checks 3 hours after start of meal Questions to Ask... • How long does the blood glucose stay high? • How high does the blood glucose spike? Both impact A1c-approximately 1% and contribute to diabetes complications What Effects Glycemic Variability? How to Measure Glycemic Variability CGMS Sensitivity to (Continuous Insulin Glucose • Real-time Sensor Monitoring Carbohydrate Insulin Type Counting: System) and Underestimating/ Glycemic Delivery GI Variability • Post meal BG should SMBG be 50 points within the pre-meal BG (Self-monitoring • Test 3 hours after Compliance: Glucose Blood Glucose) starting the meal Monitoring: Forgetting to SMBG/CGM Bolus 1

2/19/2018 Timing of Insulin and Carbohydrates Issues with Post Meal Dosing • After first bite, BG levels increase within Carbohydrate 10-15 minutes • Peak within 60-90 minutes Metabolism • Takes 2-4 hours for BG to return to pre meal level • Pre-meal vs. Post-meal Timing of • Lag Time- Realistic? Insulin • Inject insulin 10 minutes before meal (BG ~100) • Inject insulin 20 minutes before meal (BG ~200) • Inject insulin 30 minutes before meal (BG ~ 300) Effect of Different Nutrients on Blood Glucose Protein • Minimal effect on blood glucose • Eating large portions may require insulin What messages Fat • Delays food digestion are you • May result in delayed hyperglycemia hearing? Carbohydrates • Greatest impact on blood glucose • High fiber, glycemic index and resistant starch may improve blood glucose Goals of Nutrition Therapy for Adults With Amount of Carbs Diabetes 1. To promote and support healthful eating patterns, emphasizing a variety of o Matching grams of carb to nutrient-dense foods in appropriate portion sizes, in order to improve overall health fast-acting insulin and specifically to:  Achieve and maintain body weight goals  Flexible approach to eating  Attain individualized glycemic, blood pressure, and lipid goals  Delay or prevent the complications of diabetes o 45-65% total calories/day 2. To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness  ADA Position Statement at least 130 and ability to make behavioral changes, and barriers to change g carb/day 3. To maintain the pleasure of eating by providing nonjudgmental messages about food choices 4. To provide an individual with diabetes the practical tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods 2

2/19/2018 Accuracy of Carb Counting Effects Can’t Always Measure Carbs? Glycemic Variability o Average adult’s fist = 1 cup o Baseball = 1 cup o Child’s fist = 1/2 cup o Weighing Carbs o Cupped hand = 1/2 cup o Measuring Carbs o Deck of cards = 3 ounces meat o Carbohydrate Factors o Half-pint of milk = 1 cup o Tennis ball= ¾ cup Types of Carbs Not All Carbs Are the Same! Whole Grain Refined/Simple • Milk • 100% whole grain bread, pasta, cereal, • Fruit crackers • Desserts • Brown rice • Sweets • Popcorn • Juice • Quinoa • Enriched Wheat, • Barley/Buckwheat Unbleached Flour • Rye • Pretzels, chips, white • Oatmeal and whole bread/pasta/rice oats Benefits to Eating Fiber Rich Foods How Much Fiber Do We Need? • 1-3 years: 19 g • 4-8 years: 25 g DRI Fiber • Research shows eating 44-50 g • 9-13 years: 26-31 g Recommendations dietary fiber/day improves BG • 14-18 years: 26-38 g compared to less than 24 g/day • 19-50: 25-30 g • 50+: 21-30 g • Not digested and absorbed • 1 medium apple with skin: 3g • Lower calories • 1 medium banana: 3 g • ½ cup cooked broccoli: 2 g Fiber Grams • Improves fullness/weight • 1 whole wheat tortilla: 2-5 g • ¼ cup almonds: 3 g management • ½ cup Fiber One cereal: 14 g 3

2/19/2018 Are All Fibers Alike? Reading Food Labels • Beta glucan (barley and oats) guar gum, Blood Glucose Blood Glucose psyllium, resistant starch, maltodextrin, inulin ( chicory root, Jerusalem artichoke ) Lowering Lowering • Beta glucan (barley and oats), guar Improve Cholesterol Improve Cholesterol gum, pectin (citrus fruits), psyllium and Reduce and Reduce (Metamucil) Inflammation Inflammation • Choose whole-grain products with 3 grams of fiber or more • Beta glucan (barley and oats), inulin Improve GI Health Improve GI Health per serving (chicory root, Jerusalem artichoke), (Prebiotic) (Prebiotic) agave, pectin (fruit fiber), psyllium Compare White Whole Grain vs. White Whole Grain? Whole Wheat • Same nutritional advantages of traditional Nutrition Facts/2 oz dry whole wheat, but with • Total Carbs: 43 g • Dietary Fiber: 6 g lighter color and milder • Ingredients: Semolina (Wheat), Durum Wheat Flour, Whole Durum Wheat Flour , Corn Starch , Niacin, Iron (Ferrous taste Sulfate), Thiamine Mononitrate, Riboflavin, Folic Acid. • Contains WHOLE flour – Nutrition Facts/2 oz dry including the bran, germ • Total Carbs: 41 g and endosperm – made • Dietary Fiber: 6 g • Ingredients: Whole Grain Durum Wheat Flour , Semolina (Wheat), from WHITE wheat Durum Wheat Flour, Oat Fiber What is the Glycemic Index or Ways to Add Fiber Glycemic Load? Homemade trail mix with dried fruit Add fresh fruit to breakfast and dinner Glycemic Index (GI) Glycemic Load (GL) Mix bran or whole grain cereals with your • Introduced in 1981 favorite cereal • The effect of a portion of Eat oatmeal for breakfast food has on blood glucose • Blood glucose response of a 50 g carb portion of a food Mix Kashi into yogurt compared to glucose or • GI x carbohydrate white bread grams/100 Add salad or raw vegetables before dinner Statement from the ADA : “ low-glycemic index diets can Try whole wheat pasta or brown rice produce a modest benefit in controlling postprandial hyperglycemia" 4

2/19/2018 Low vs. High GI What Affects a Food’s GI? Botanical • Different Variety of Foods (Rice/Potatoes) • Instant vs. Steel-Cut Oats Processing of Food • More finely ground grain (Higher GI) Fiber • Oats, barley and legumes (Lower GI) Preparation of Food • Al dente vs Fully Cooked pasta • Prior food intake External Factors • Blood glucose level at the time of meal • Exercise Glycemic Load = GI and GL Ranges (Glycemic Index X grams of How to Calculate GL carbohydrate) ÷ 100 GI • Low GI= ≤ 55 Glycemic • Watermelon GI: 72 • Moderate GI= 56-69 Index Carbohydrate • High GI= 70+ • 1 ¼ cup: 14 g Calculate GL • 14 g carb x 72 (GI) = 1,008 • Low GL= ≤ 10 Glycemic • 1,008÷100= 10 (GL) • Moderate GL=11-19 Take Home Message Load • Watermelon has a HIGH GI but a LOW GL depending • High GL=20+ on portion size Low GI diet in children with T1DM  Improved diet quality  Fiber increased: 24.5 vs. 14.5 g  Decreased fat: 45.7 vs. 76.9 g  Decreased daytime hyperglycemia  Small study-short duration The Effect of a Low-Glycemic Diet vs. a Standard Diet on Blood Glucose Levels and Macronutrient Intake in Children with Type 1 Diabetes (Journal of  Unrealistic foods? American Dietetic Assoc. 2009;109:303-307) 5

2/19/2018 High GI: Low fiber diet Study in Adults with Type 1 DM 20% lower with Low  Fat, Carbs, Fiber GI diet and Calories were Average BS: 173 similar A1C: 7.8% Spikes and  Low GI Diet: 59 Grazing  Legumes, pasta, olive oil, apple, tunafish  High GI Diet: 90  Rice, tunafish, Effects of meals with different glycaemic index on white bread, olive postprandial blood glucose response in patients with oil, banana Type 1 diabetes treated with continuous subcutaneous insulin infusion (Diabetic Medicine. 2001. 28, 227-229) Lower GI Diet: High fiber diet Medium GL… but is it healthy? Average BS: 124 Less Glycemic A1C: 6.3% Variability When should your Pros and Cons of GI patient eat high GI foods? • Minimizes blood glucose • Not accurate when eating a Sports Hypoglycemia mixed meal peak Pros Cons • Increases dietary fiber • Unreliable (variable • To increase BG • Protein and fat with responses among test intake if choosing more levels quickly carbs delays high whole grains subjects) BG • Sports drinks, gels • May improve lipid levels • Limited food choices and carb chews • 100% glucose best if high fiber, low GI foods choice to raise BG are eaten • May increase fat intake quickly • No long term studies in children with TIDM 6