Plate, Pyramid or

Perseverance?Medical Nutrition

Therapy for Diabetes

Iris Thiele Isip Tan MD, MScAssociate Professor, UP College of Medicine

Chief, UP Medical Informatics Unit

July 2014

Melons by kisa12http://www.freeimages.com/photo/863924

Monday, July 14, 14

Improving Adherence to Medical Nutrition

Therapy

SMS & MNTin Diabetes

Medical Nutrition Therapy

UNITE CPG

Light meal by elvinstarhttp://www.freeimages.com/photo/318333

Women holding delicious grapefruit in her hand by african_fihttp://www.freeimages.com/photo/1386617

icon_sms_hires by Hans Dorschhttps://flic.kr/p/5mXKNj

Monday, July 14, 14

UNITE CPGPart 2: Management

Section 9. Therapeutic Lifestyle Change: Medical Nutrition Therapy, Alcohol & Smoking

Monday, July 14, 14

UNITE CPG9.1.1 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 CPG9.1.2 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 deafstarhttp://www.freeimages.com/photo/1379341

Tube flip calendar & clock by Rendyhttp://www.freeimages.com/photo/772984

Monday, July 14, 14

UNITE CPG9.1.3 In the barangay health station, the following simple nutrition messages are to be emphasized:

a. Food choicesb. Idaho plate method

diet 1 by ppreacherhttp://www.freeimages.com/photo/203247

Monday, July 14, 14

EAT MOSTUse one or more of these foods as the basis of every mealVegetables, legumes, lentils, noodles, rice, bread, grains, barley, wholegrain cereals, fresh fruit (non-sweet)

EAT MODERATELYHave small servings of protein-rich foodsfish, seafood, eggs, lean meat, skinless chicken, low-fat cheese, low-fat yoghurt, low-fat milk, nuts

EAT LEASTMinimise fats, sugars, salt and alcoholbutter, oil, ghee, cream, coconut milk and cream, processed meat, fried foods, preserved or processed foods, pastries, sweets, biscuits, soft drink

Fresh vegetables 6 by MeiTenghttp://www.freeimages.com/photo/1441972

Bits-n-bites Truffle by Subhadipinhttp://www.freeimages.com/photo/1437365

Japanese sushi by chokingxihttp://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 2001Monday, July 14, 14

Tight fist = 1/2 cup Handful = 1 cup

Palm = 3 oz

Thumb = 2 tbsp or 1 oz

Thumb tip = 1 tspHand guides

for portion control

Monday, July 14, 14

UNITE CPG9.1.4 Hospital-based nutrition advice

a. Calculation of caloric requirement & macronutrient distributionb. Exchanges or CHO countingc. How to read food labelsd. Glycemic indexe. Meal replacement

Weighing my food by Judy Baxterhttps://flic.kr/p/7Jod31

Monday, July 14, 14

FatNot >30%

Saturated fat <10%

Olive oil by TanjaShttp://www.freeimages.com/photo/259035

Carbohydrate50-55%

Sucrose <10%

Protein15-20%

Asia Pacific Type 2 Diabetes Policy Group

Bowl of Basmati Rice by manjideshttp://www.freeimages.com/photo/800204

Pink salmon by lockstockbhttp://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 socyohttp://www.freeimages.com/photo/913569

bread by lockstockbhttp://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 ExchangesStarch Meat/meat

substitutesNon-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, spicesMonday, July 14, 14

GLYCEMIC INDEX (GI)

Increase in blood glucose (over fasting level) in 2 h following

ingestion of 50 g CHO

Low GI0-55

Intermediate56-69

High GI>70

Llona A. Nutr Hosp 2006;21:53-59

Monday, July 14, 14

Issues with GIOnly accounts for CHO type (not total amount)Measures response to individual food consumed in isolationGI for any particular food item highly variableInaccurate 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 CPG9.2 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 Zeppelin5http://www.freeimages.com/photo/670527

Monday, July 14, 14

UNITE CPG9.3 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 humusak2http://www.freeimages.com/photo/1426045

Monday, July 14, 14

UNITE CPG9.4 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 Capgroshttp://www.freeimages.com/photo/872788

Monday, July 14, 14

UNITE CPG9.5 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 engindenizhttp://www.freeimages.com/photo/1209276

Monday, July 14, 14

Improving Adherence to Medical Nutrition

Therapy

Medical Nutrition Therapy

UNITE CPG

Light meal by elvinstarhttp://www.freeimages.com/photo/318333

Women holding delicious grapefruit in her hand by african_fihttp://www.freeimages.com/photo/1386617

icon_sms_hires by Hans Dorschhttps://flic.kr/p/5mXKNj

SMS & MNTin Diabetes

Monday, July 14, 14

Eating salad for health by typexmick,http://www.freeimages.com/photo/1432591

“ AdherenceWHO 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 AdherenceWHO (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 goalsAssist 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

GOALSThings I will do to improve my eating behaviorCheck 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 adultsCochrane 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

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Monitor by mrcevizhttp://www.freeimages.com/photo/1326722

Papers #1 by deSpoolhttp://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

Educationn=9

Restrictionn=1

Persuasionn=2

Incentivizationn=1

Trainingn=3

Modelingn=7

Enablementn=3

Multiplen=18

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Shaking hands by lockstockbhttp://www.freeimages.com/photo/1097209

Monitor by mrcevizhttp://www.freeimages.com/photo/1326722

Papers #1 by deSpoolhttp://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

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Shaking hands by lockstockbhttp://www.freeimages.com/photo/1097209

Monitor by mrcevizhttp://www.freeimages.com/photo/1326722

Papers #1 by deSpoolhttp://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-upVideoContractFeedbackNutritional tools

Desroches S et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.:CD008722

Mobile phone in hand by sqbackhttp://www.freeimages.com/photo/1307593

Monitor by mrcevizhttp://www.freeimages.com/photo/1326722

Monday, July 14, 14

Improving Adherence to Medical Nutrition

Therapy

Medical Nutrition Therapy

UNITE CPG

Light meal by elvinstarhttp://www.freeimages.com/photo/318333

Women holding delicious grapefruit in her hand by african_fihttp://www.freeimages.com/photo/1386617

icon_sms_hires by Hans Dorschhttps://flic.kr/p/5mXKNj

SMS & MNTin Diabetes

Monday, July 14, 14

Objective To determine if 3x a week SMS will improve

adherence to diet and exerciseSecondary 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 TrialTamban 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 monthsSMS 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 scheduleMonday: DietWednesday: ExerciseFriday: Consequences of non-adherence to DM management

Pyramid on a plate by Steve Garfieldhttps://flic.kr/p/HA2Qf

The Nelson by Pamela Grahamhttps://flic.kr/p/ebWV1w

Tamban C, Isip Tan IT & Jimeno C JAFES 2013;28(2):143-9

Monday, July 14, 14

Sample SMStranslated to FilipinoMonth 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 sqbackhttp://www.freeimages.com/photo/1307593

Pyramid on a plate by Steve Garfieldhttps://flic.kr/p/HA2Qf

Monday, July 14, 14

6

6.5

7

7.5

8

3 mos 6 mos

Control SMS H

bA1c

60

65

70

75

3 mos 6 mos 25

26

27

28

29

30

3 mos 6 mos

Body

wei

ght

BMI

p=0.04

p=0.84 p=0.195

Primary Outcomes

Diet adherenceDays/week: NS

Meals/day:Control 2.29 + 0.72 p=0.018SMS 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 elvinstarhttp://www.freeimages.com/photo/318333

Women holding delicious grapefruit in her hand by african_fihttp://www.freeimages.com/photo/1386617

icon_sms_hires by Hans Dorschhttps://flic.kr/p/5mXKNj

SMS & MNTin 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