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Non-Pharmacology Intervention

Lecture:

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

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2.5 million years 50 years

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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

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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

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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

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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)

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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

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Guidelines for a healthy diet PERKENI 2011

• Healthy balanced diet composed of:

• 45-65% carbohydrate

• 20-25% fat

• 10–20% protein

Fat

Carbohydrate Protein

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The Indonesian Food Pyramid

http://www.fagnutrition.com

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,

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Proteins

East Less of These Eat More of These

Chicken, Fish, Tofu Sausages, processed meat, Shrimps and shell fish, Red Meat

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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

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How you cook is important

Less Healthy More Healthy

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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

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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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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

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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

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Group Discussion

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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

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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

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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)

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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

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