Diet & Diabetes – current practice and new evidence Nutrition Management of Hypoglycemia

1. HYPOGLYCEMIA MANAGEMENT WORKSHOP 2013 Diet & Diabetes – current practice and new evidenceNutrition Management of Hypoglycemia NOORLAILINA MOHA BT MOHTAR B. Hons Health Sc (Dietetics)(USM), MBA (UKM) Pegawai Dietetik Jabatan Dietetik & Sajian Hospital Sultanah Bahiyah

2. Learning Outcomes Able to explain: • Ways to prevent hypoglycemia • Ways to overcome hypoglycemia

3. Nutrition Matters in Diabetes! American Diabetes Association, Diabetes Care, 2008;31:S61-S78

4. Nutrition Therapy is EFFECTIVE!

5. Lifestyle impact

6. Evidence on Effectiveness of MNT  HBA1C Newly diagnosed type 2 diabetes 2% Type 2 diabetes with an average duration of 4 years1% Pastors et al, Diabetes Care 2002; 25:608-613; Morris et al. J Clin Diabetes 2010; 28:12-18

7. Effective Therapeutic lifestyle Intervention from clinical studies • Weight loss – target 5-7% within 1 year • Calories – restrict ( 1200 -1800 kcal) • Low fat intake ( less than 30% energy), low saturated fat intake • Minimum 15% energy from proteins • Carbohydrate (45-65%) – by counting, exchange lists, insulin-to-carbohydrate ratios • Portion control - simplified meal plans, plate model • Liquid meal replacements / structured meal plans • Healthy balanced food choices

9. Common causes of Hypoglycemia • WHAT PATIENT THINKS • To avoid rice, RICE is DANGEROUS. • Avoid intake of vegetables – “angin”, “sejuk”. • Big meals at times, avoid snacking.

10. Meal Adjustment for Exercise 4-5 mmol/L 4-10 mmol/L 4-5 mmol/L 10-16 mmol/L >16 mmol/L 4-10 mmol/L 4-5 mmol/L 10-16 mmol/L >16 mmol/L Nelson JK et al, Mayo Clinic Diet Manual

11. Treatment of Hypoglycemia

12. Treatment of Hypoglycemia • Treatment of Hypoglycemia requires ingestion of glucose or carbohydrate-containing food. Although any CHO will raise glucose level, glucose is the preferred treatment. • Commercially available glucose have the advantage of being pre-meassured to help overtreatment. Ref : Marion J Franz, Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

13. The form of CHO – liquid/solid  does not matter. • Changes in insulin injections, eating, exercise schedules, and travel routine warrant increased frequency of monitoring (Cryer et al, 2013). • Some patients experience hypoglycemia unawareness. Patients need to be reminded of the need to treat hypoglycemia, even in the absence of symptoms. Ref : Marion J Franz, Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

14. Sugar-based carbohydrates digest and enter your bloodstream quickly, which can raise blood glucose levels back to normal. CHO foods that have significant amounts of sugar, but also large amounts of fat or protein—such as chocolate, cookies, ice cream, and more—are digested much more slowly and will not correct low blood sugar as efficiently. • A plate of rice also will not help in hypoglycemia!

15. Most commonly, hypoglycemia symptoms will go away after this simple at-home treatment. • Once the blood sugar has returned to normal, it is important to eat usual meals and snacks as planned to prevent a recurrence later that day. • If patient does not have a meal or snack planned within 1 hour of the episode of low blood sugar, it is best to add an additional small snack that contains carbohydrates along with protein or fat immediately following treatment.

16. What is 15g of sugar? Honey Jam Kaya Sugar Syrup Cocoa/ Malt-based Powder Condensed Milk Candy = 1 teaspoon= 5g = 1 tablespoon = 10 g

17. Milo any one? 51g? = 1 tablespoon = 10 g = Milo is claimed as low GI foods, therefore it is less in sugar

18. 1 paket = 20g CHO over treatment?

19. Good choices with 15 grams of carbohydrates are: 6 sugar cubes 1 Tablespoon syrup 3- 4 glucose tablets ½ (80 gram) glucose bottle ½ (31 gram) instant glucose tube • ½ cup apple juice • ½ cup orange juice • 2 pieces of hard candy • 1 cup low-fat milk/skim milk • 1 Tablespoon honey • 2 Tablespoons raisins • ½ cup regular gelatin

20. Preventing Hypoglycemia • Eating three balanced meals a day with two or three planned snacks. It is important that patient doesn’t skip meals and snacks. Try not to go any longer than 3-4 hours between eating. • Eating the right amount of carbohydrates during each meal and snack. • Eating foods high in complex carbohydrates and fiber such as whole grains, fruits, vegetables, and beans. High-fiber foods digest more slowly and help keep glucose from "dumping" into your blood stream too quickly. • Eating a high protein food at each meal and snack. Protein-rich foods include fish, chicken, turkey, lean beef and pork, tofu, cottage cheese, cheese, yogurt, milk, eggs, peanut butter, nuts and seeds. Protein can help to maintain blood sugar levels between meals by delaying how quickly the carbohydrate is digested.

21. Achieving and maintaining a healthy body weight. • Limiting alcohol consumption. Always include a snack when drinking an alcoholic beverage. If patient drink alcohol, limit their daily intake—no more than two drinks for men and one drink for women. • Avoiding large meals.

22. CHO exchanges (15g of CHO, 75kCal) 1 ex 1 ex 1 ex 1 ex 3 ex 1 ex 1 ex 3 ex 2 ex 3 ex

23. Cereal : 15g of CHO : 75kCal

24. 3 main meals3 snacks

25. Time Exchanges Carbohidrates Vegetables Fruits breakfast teatime lunch teatime dinner supper

26. Timely interval

27. Time Exchanges Carbohidrates Vegetables Fruits breakfast teatime lunch teatime dinner supper

28. Right amount of Carbohydrates

29. Cereals = 15g CHO 75 kcal

30. CHO exchanges (15g of CHO, 75kCal) 1 ex 1 ex 1 ex 1 ex 3 ex 1 ex 1 ex 3 ex 2 ex 3 ex

31. Time Exchanges Carbohidrates Vegetables Fruits breakfast teatime lunch teatime dinner supper

32. Increase fiber intake during taking CHOPrefer for Whole Meal Foods

33. Time Exchanges Carbohidrates Vegetables Fruits breakfast teatime lunch teatime dinner supper

34. Incorporate fruits into meal

35. Time Exchanges Carbohidrates Vegetables Fruits breakfast teatime lunch teatime dinner supper

36. Is protein allowed freely? Small Serving Small Serving Medium serving Medium serving Large serving Large serving Portions Photos of Popular Food - Hess, ADA & Center for Nutrition Education, University of Wisconsin, Stout

38. Activities by Dietitians

39. 3 monthly follow up

40. Support groups Cooking Classes H. Jitra H. K. Nerang

41. Self-Monitoring Weight Food records Physical activity records Pedometers SMBG

42. Conclusion • Diabetes meal plans need to be individualized : control goals, needs, and preferences, and should include changes that the patient is willing and able to make and maintain. • Integrating evidence-based nutrition principles and recommendations will help exposed misconceptions and myths about the diet and lead to better care of patients! • Patients should be explained about hypoglycemia, consequences and ways to handle the situation.

43. Marion J Franz, Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

44. SUCCESS is difficult… Thank you!