Ministry of Health, Malaysia had published the latest Clinical Practice Guideline for Management of Diabetes Mellitus in November 2015 updating the previous 2009 guideline. This latest guideline will be reviewed in 2019.
For the benefit of the readers, herewith I share some aspect of the management for your reading info.
Below is the excerpt which covers only for the target for control, A1c targets, lifestyle modification that are needed in the management of diabetes. The rest, feel free to visit KKM website.
Targets for Control
*
Glycaemic target should be individualised to minimise risk of hypoglycaemia.
41 (Level I) The committee acknowledges the increased CVD death in the
intensive group of the ACCORD study.41 (Level I) However, the
committee believes it is due to the overall treatment strategies that were
employed to achieve the A1c target rather than the reduction in A1c. This is
also collaborated by the ADVANCE study. 39 (Level I)
++
A1c ≤6.5% is advocated for patients with a
shorter duration of diabetes, no evidence of significant CVD and longer life
expectancy and have minimal risk of hypoglycaemia. There are strong benefits
for reduction of nephropathy
(ADVANCE) and retinopathy (ACCORD/ACCORD Eye Study Group) at or below
this level of A1c.39,44 (Level I) #
In Individuals with overt CVD, LDL cholesterol target is <1.8 mmol/L.
§ th 45
(Level III)
In children and adolescents, blood pressure (BP) should be <95
percentile for age and sex.
Table 10: A1c Targets
*Modified
from Management of Hyperglycaemia in Type 2 Diabetes: A Patient-Centered
Approach A Position
Statement
of the American Diabetes Association and the European Association for the Study
of Diabetes, 2012.46 (Level I)
3.5
Lifestyle Modification
3.5.1 Medical
Nutrition Therapy
Medical nutrition therapy (MNT) is important in preventing diabetes,
managing existing diabetes, and delaying complications. Proper diet is
crucial at any stage of management of diabetes including those on
medication.
The goals of MNT together with medication are to attain and maintain
blood glucose, blood pressure and lipid profile as close to normal as safely as
possible. These goals can be achieved through healthy food choices.
General recommendations:
•
Nutrition care by a dietitian should be provided
under the following conditions: at diagnosis, sub-optimal metabolic and/or
weight control, at initiation of insulin therapy, development of other
co-morbidities such as hyperlipidaemia, hypertension and chronic kidney
disease. 47 (Level I)
•
Diet counseling is effective to help lower A1c
by an average of 1–2%. 48 (Level I) Patients who have
diabetes should receive individualised nutrition care from a dietitian to
achieve treatment goals. 49 (Level I)
•
Dietary counseling should be individualised
according to nutritional needs, severity of disease, cultural preferences and
willingness to change. 47 (Level III)
Specific recommendations
• Prevention
of diabetes:
a)
Weight loss of 5-10% of initial body weight over
a 6-month period is recommended for all overweight or obese patients who have
or at risk for diabetes. 42,43 (Level I) This can
be achieved by:
i)
A reduced calorie diet. Standard weight-loss
diets reduce daily energy by 500–1,000 kcal to achieve an initial weight loss
of ½–1 kg per week. 50 (Level I)
ii) Physical
activity of 150 minutes per week i.e. 30 minutes five days or more per week. 51
(Level
I)
iii)
A combination of reduced calorie diet, physical
activity and behaviour modification can provide greater initial weight loss. 51
(Level I)
iv)
Meal replacements (MRPs) can be used as part of
a comprehensive meal plan for weight loss and weight maintenance. 52
(Level I)
b)
There is no ideal percentage of energy for
carbohydrate, protein and fat for diabetes. A balanced diet consisting of
45–60% energy from carbohydrate, 15–20% energy from protein and 25–35% energy
from fat are encouraged.53 (Level III) These
recommendations must be individualised based on weight, glycaemic and other
metabolic goals, cultural preferences and individual lifestyle.
c)
A high dietary fiber diet is encouraged for the
prevention of diabetes . A high fibre diet (20–30 g fibre/day) consisting of
vegetables, fruits, legumes and whole grain cereals is encouraged. 54
(Level
II-2)
d)
Whole grains should form 50% of the total grains
intake as recommended by the Malaysian Dietary Guidelines, 2010. Higher consumption of whole grains can
contribute to the prevention
of T2DM. 54 (Level II-2)
e)
Limit consumption of sugar-sweetened beverages
(SSB) to less than 2 servings a day or about
10% of
total daily caloric intake for prevention of diabetes and weight gain 55,56
(Level II-2)
• Management
of diabetes
In addition to the above recommendations:
a)
Total carbohydrate (CHO) intake should be
monitored in patients with T2DM. 57 (Level I)
i.
Total CHO intake can be monitored by using
grams, exchange list, household or hand measures as long as it is practical for
patients to comprehend and follow. Please refer to APPENDIX 1 and APPENDIX 2.
ii.
CHO intake must be kept consistent on a
day-to-day basis if patient is on diet therapy alone, oral anti-diabetic agents
(OADs) or fixed insulin regime.
iii.
It is prudent to individualise the distribution
of the total CHO exchanges allowed in a day into meals according to the
patient’s lifestyle.
iv.
If patient is adjusting their meal-time insulin
doses or on insulin pump (i.e. flexible insulin) consistency is not required.
Insulin doses should be adjusted to match CHO intake. Selfmonitoring of blood
glucose is essential to adjust CHO intake and insulin dose.
v.
A minimum of 130 g/day CHO should be provided to
ensure adequate intake of fiber,
vitamins,
and minerals, as well as to prevent ketosis and to provide dietary palatability.
58 (Level
I)
vi.
Sucrose (e.g. table sugar) intake must be
counted as part of the total carbohydrate intake.
59(Level
III) Excess sucrose intake contributes to calories and may cause weight gain.
60 (Level I) vii. Non-nutritive
sweeteners do not impact glycaemic level. 56,60 (Level II-2) Intake
should not exceed Acceptable Daily Intake (ADI) levels.
b)
In patients with normal renal function, usual
protein intake of 15–20% energy has minimal effect on glycaemic control. 61
(Level I) It is recommended to include lean sources of protein such
as lean meat, fish, chicken/poultry without skin and soy protein. In patients
with impaired renal function, protein restriction of 0.8–1.0 g/kg body
weight/day may be recommended. 62 (Level I)
c)
Patients with diabetes should limit total fat
(25–35% energy intake), saturated fats (<7% energy intake), minimal trans
fat (<1% energy intake) and dietary cholesterol (<200 mg/day) for
prevention and treatment of cardiovascular disease. 49,63 (Level I)
i.
Saturated fats are usually found in animal fats
(skin of poultry, fatty meats, full cream dairy products) and coconut milk.
ii.
A healthy diet incorporating oats, nuts and
legumes, green leafy vegetables and soy protein may be beneficial for
cardiovascular health. 63 (Level
I)
d)
In normotensive and hypertensive patients, a
reduced sodium intake (<2,400 mg sodium/day or 6 g of salt a day
or 1 teaspoon) with a diet high in fruits, vegetables, and
low-fat dairy products lowers
blood
pressure. 64 (Level I)
Sodium
restriction can be achieved through avoiding high sodium foods (soya sauce,
ketchup & other sauces, pre-mixed cooking paste, monosodium glutamate, salt
preserved foods and processed foods), reducing the frequency of eating out and
limiting salt in cooking to ¼ to ½ teaspoonful of salt per person per day.
e)
Patients with diabetes have the same vitamin
& mineral requirements as the general population. There is no clear
evidence of benefit from the use of antioxidant vitamins A, C, E, selenium and
herbs and omega-e fatty acids in diabetes management. 65 (Level
I)
f)
Patients with diabetes do not require special
oral nutritional supplement beverages unless malnourished, have not been eating
well for prolonged periods of time or used as meal replacements for weight
loss. 49
(Level III)
