Non-Pharmacology Intervention Lecture
Main Learning Points
• The relationship between nutrition and blood glucose control
• Understand the eating pattern in the local region that could play a role on the fat or carbohydrate intake
• Determine healthy and unhealthy eating and initiating and assessing dietary intervention in a clinical setting
• Understand the importance of exercise and the relationship between exercise and blood glucose control
• Understand the relationship between smoking and diabetes associated complications
Slide 2
Slide 4
Diet & Exercise in Diabetes
• Important in type 1 and type 2 diabetes
• In type 2 diabetes:
• Obesity and physical inactivity are major risk factors
• Diet and exercise may provide good long-term glycaemic control in some patients
• Improved cardiovascular status
• Cost-effective
Slide 5
Medical Nutrition Therapy in Diabetes
As integral part of :
• Prevention and management of diabetes
• Component of diabetes education
• Prevention of diabetes complication
Source: Diabetes Care, Vol. 31, Suppl. 1, 2008
Slide 6
Targets of Medical Nutrition Therapy in prevention and management of Type 2 Diabetes
Diabetes Care, Vol. 31, Suppl. 1, 2008
Individual with Diabetes Risk-factors or with pre-diabetes
Individual with diagnosed Diabetes
1) To reduce the risk of diabetes and cardiovascular disease by promoting healthy food choices and physical activity leading to moderate weight loss that is maintained.
1) To achieve and maintain:
• Blood Glucose levels in the normal range
• A lipid profile that reduces the risk for vascular diseases
• Blood Pressure levels in the normal range
2) To prevent / delay progressivity of chronic complications
3) To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change
Slide 7
The Fundamentals of food management for diabetes patients
Similar with healthy people:
• Balance food intake according to calories and nutrition needs for each individual
• Weight loss, increased physical activity, and weight management
• Consistency in day-to-day carbohydrate intake at meals and snacks
• Nutritional content
• Timing of meals and snacks
• Carbohydrates are the principal determinant for blood glucose
Emphasis (‘triple Js)’:
• Jadwal (Schedule)
• Jenis (Type)
• Jumlah (Amount)
Slide 8
The relationship between healthy nutrition and blood glucose
Source: Long-term Effects of a Lifestyle Intervention on Weight and Cardiovascular Risk Factors in Individuals with Type 2 Diabetes; Four Yesr Results of the Look AHEAD Trial. The Look AHEAD Reseach Group
DSE: Usual Diabetes Care
ILI: Intensive Lifestyle Intervention
Slide 9
Guidelines for a healthy diet PERKENI 2011
• Healthy balanced diet composed of:
• 45-65% carbohydrate
• 20-25% fat
• 10–20% protein
Fat
Carbohydrate Protein
Carbohydrate
East Less of These Eat More of These
Fruit, Low fat Milk, Beans, Brown rice, Yoghurt, Whole wheat bread
White sugar, Brown sugar, White bread, White rice,
Slide 11
Proteins
East Less of These Eat More of These
Chicken, Fish, Tofu Sausages, processed meat, Shrimps and shell fish, Red Meat
Slide 12
Fat
East Less of These Eat More of These
Avocado, Nuts, Olives, Oils rich in poly and mono unsaturated fats
Coconut, Margarine/butter, Cheese, Oils/fats rich in saturated fat
Slide 13
Slide 15
Understanding portion sizes is important Recommendation to take smaller portion sizes of the less recommended food
Rice boiled – 100 g Calorie – 175 kcal
Carbohydrates – 40gm
Rice boiled – 200 g Calorie – 350 kcal
Carbohydrates – 80gm
Noodles boiled – 200 gm Calorie – 175 Kcal Carbohydrates – 40 gm
Source: Daftar Bahan Makanan Penukar
Slide 17
The relationship between exercise and blood glucose
Diabetology & Metabolic Syndrome, 2009, 1:27
HbA1c values collected 12 weeks prior to the initiation of the exercise program (Baseline), at the start of the exercise program (Pre-Intervention) and at the completion of the 10 weeks program (Post-Intervention). Ten week changes are denoted by * (p < 0.05). A difference between exercise groups is denoted by # (p < 0.008).
Both resistance and aerobic exercise were effective in reducing blood glucose levels and HbA1c levels
Boulé NG, et al. JAMA 2001;286:1218-27.
-0.66% -0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0.0
0.1
0.2
Exercise
Non-exercise control
Change in H
bA
1c
from
baseline t
o p
ost-
inte
rvention
(weig
hte
d m
ean d
iffe
rence)
p<0.001
Effect was weight-
independent
0.08%
Pooled meta-analysis of 14 exercise trials
%
Exercise significantly reduces HbA1c
Source: Boule NG et al. Effects of exercise on glycemic control and body mass in T2 Diabetes: JAMA2001; 286:1218-27
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Slide 20
Diabetes and Smoking Background
‘Before’ diabetes
• Smoking is associated with insulin resistance
• dose-response relationship between smoking and the risk of type 2 diabetes
• Stopping to smoke decreases the risk of type 2 diabetes
‘Additional’ to diabetes
• Smoking increases the risk of developing diabetic complications - nephropathy, neuropathy and retinopathy
• Independent risk factor for CVD and all-cause mortality
• Smokers are also lipid intolerant
• Smoking cessation increases HDL and reduces LDL levels, despite weight gain
Facchini. F. S et al Lancet, (1992) 339 (8802) , pp. 1128-1130 . Al-Delaimy WK, et al. Arch Intern Med. 2002;162(3):273-279. Patja, K., et al Journal of Internal Medicine, 258: 356–362. Chaturvedi N, Diabetes Care 1995; 18: 785–92.Jacobs DR Jr et al Arch Intern Med 1999;159: 733-40. Axelsen M., et al (1995), Journal of Internal Medicine, 237: 449–455.D.P. Mikhailidis, et al (1998) The Journal of the Royal Society for the Promotion of Health 118: 91
Slide 21
Significant reduction in mortality of diabetes patients among non-smokers
591
368323275215
1,984
1,443
1,2191,249
1,012
0
500
1,000
1,500
2,000
Mort
ality
Rate
(per
100.0
00 p
ers
on-y
ears
)
Past 1-14 cig / day Never 15-34 cig / day
35+ cig / day
Non-diabetic woman
Diabetic woman
Source: Wael K. Al-Delaimy et al. Diabetes Care 24: 2043-2048, 2001
cig = cigarette
Slide 23
Practical Initiation of Diet Programs for diabetes patients Food Mapping Systems
Food Mapping System can be used for patient education to increase patient compliance with diet scheme
Beras Merah Kukus
Nasi Putih Nasi Goreng
Ayam Bakar Ayam Goreng Ayam Goreng
Tepung
Ikan Bakar / Kukus
Ikan Goreng Udang Goreng
Sayur Kukus Kukus Dim Sum Dim Sum Goreng
Slide 24
Practical Initiation of Diet Programs for diabetes patients Healthy Plate Models
T-shaped plate model to loose
weight
Y-shaped plate model to
maintain weight
Portion Control Plate was effective in inducing weight loss and decreased use of hypoglycemic medications in obese patients with type 2 diabetes mellitus
Vegetables
Carbo-hydrate /
Starch
Protein
Carbo-hydrate /
Starch Vegetables
Protein
Pedersen DE et al. Arch Intern Med. 2007; 167
Slide 25
Practical Initiation of Exercise Programs for diabetes patients CRIPE Pricnciple
CRIPE: Continuous, Rhytmic, Interval, Progressive, Endurance
Continuous • Exercises should be done continuously without
rest (e.g. 30 minutes of jogging without rest)
Rhythmic • Choose more rhythmical sports where regular
contraction and relaxation are possible (e.g. walking, jogging, running and swimming)
Interval • Exercises with both quick and slower actions
(e.g. running followed by jogging)
Progressive • Increase intensity according to abilities (heart
rate target: 75-85% from maximum heart rate)
Endurance • Exercise for endurance to improve
cardiorespiratory abilities (e.g. walking, jogging, swimming, cycling)
Slide 26
Non-Pharmacology Intervention Cases - Instructions
1. Watch Video Case 1
2. Discuss at your tables
3. Selected Group Presents recommendations
4. Watch Video Case 2
5. Discuss at your tables
6. Selected Group Presents recommendations
7. Wrap-up
5 minutes
10 minutes
5 minutes
5 minutes
10 minutes
5 minutes
5 minutes
Non-Pharmacology Intervention Lecture and Workshop
Main Learning Points
• The relationship between nutrition and blood glucose control
• Understand the eating pattern in the local region that could play a role on the fat or carbohydrate intake
• Determine healthy and unhealthy eating and initiating and assessing dietary intervention in a clinical setting
• Understand the importance of exercise and the relationship between exercise and blood glucose control
• Understand the relationship between smoking and diabetes associated complications
Summary
• It’s importance to educate the patients about diet, exercise and non-smoking recommendations as sufficient evidence is available about the improvement in HbA1c levels through lifestyle intervention
• Simple patient supporting tools like food mapping system or the CRIPE exercise principle are readily available
• It is important to negotiate with the patients on which food choices are the healthiest based upon the patient eating patterns
Slide 27