Medical Nutrition Therapy for Diabetes: Improving Adherence through SMS and Goal Setting

Plate,
Pyramid or
Perseverance?
Medical Nutrition
Therapy for Diabetes
Iris Thiele Isip Tan MD, MSc
Associate Professor, UP College of Medicine
Chief, UP Medical Informatics Unit
July 2014
Melons by kisa12
http://www.freeimages.com/photo/863924
Monday, July 14, 14

Improving Adherence
to Medical Nutrition
Therapy
SMS & MNT
in Diabetes
Medical Nutrition
Therapy
UNITE CPG
Light meal by elvinstar
Women holding delicious grapefruit in her hand by african_ﬁ
icon_sms_hires by Hans Dorsch
https://ﬂic.kr/p/5mXKNj
Monday, July 14, 14

UNITE CPG
Part 2: Management
Section 9. Therapeutic Lifestyle Change:
Medical Nutrition Therapy, Alcohol & Smoking
Monday, July 14, 14

UNITE CPG
9.1.1 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 CPG
9.1.2 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
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 deafstar
Tube ﬂip calendar & clock by Rendy
Monday, July 14, 14

UNITE CPG
9.1.3 In the barangay health station, the following
simple nutrition messages are to be emphasized:
a. Food choices
b. Idaho plate method
diet 1 by ppreacher
Monday, July 14, 14

EAT MOST
Use one or more of these foods as the
basis of every meal
Vegetables, legumes, lentils, noodles, rice, bread,
grains, barley, wholegrain cereals, fresh fruit (non-
sweet)
EAT MODERATELY
Have small servings of protein-rich foods
fish, seafood, eggs, lean meat, skinless chicken, low-
fat cheese, low-fat yoghurt, low-fat milk, nuts
EAT LEAST
Minimise fats, sugars, salt and alcohol
butter, oil, ghee, cream, coconut milk and cream,
processed meat, fried foods, preserved or processed
foods, pastries, sweets, biscuits, soft drink
Fresh vegetables 6 by MeiTeng
Bits-n-bites Truffle by Subhadipin
Japanese sushi by chokingxi
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

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 2001
Monday, July 14, 14

Tight ﬁst = 1/2 cup Handful = 1 cup
Palm = 3 oz
Thumb =
2 tbsp
or 1 oz
Thumb tip
= 1 tsp
Hand guides
for portion
control
Monday, July 14, 14

UNITE CPG
9.1.4 Hospital-based
nutrition advice
a. Calculation of caloric requirement
& macronutrient distribution
b. Exchanges or CHO counting
c. How to read food labels
d. Glycemic index
e. Meal replacement
Weighing my food by Judy Baxter
https://ﬂic.kr/p/7Jod31
Monday, July 14, 14

Fat
Not >30%
Saturated fat
<10%
Olive oil by TanjaS
Carbohydrate
50-55%
Sucrose <10%
Protein
15-20%
Asia Paciﬁc Type 2 Diabetes
Policy Group
Bowl of Basmati Rice by manjides
Pink salmon by lockstockb
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 socyo
bread by lockstockb
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 Exchanges
Starch Meat/meat
substitutes
Non-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, spices
Monday, July 14, 14

GLYCEMIC INDEX
(GI)
Increase in blood glucose
(over fasting level) in 2 h following
ingestion of 50 g CHO
Low GI
0-55
Intermediate
56-69
High GI
>70
Llona A. Nutr Hosp 2006;21:53-59
Monday, July 14, 14

Issues with GI
Only accounts for CHO type (not
total amount)
Measures response to individual
food consumed in isolation
GI for any particular food item
highly variable
Inaccurate 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 CPG
9.2 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 Zeppelin5
Monday, July 14, 14

UNITE CPG
9.3 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 humusak2
Monday, July 14, 14

UNITE CPG
9.4 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 Capgros
Monday, July 14, 14

UNITE CPG
9.5 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 engindeniz
Monday, July 14, 14

Improving Adherence
to Medical Nutrition
Therapy
Medical Nutrition
Therapy
UNITE CPG
Light meal by elvinstar
Women holding delicious grapefruit in her hand by african_ﬁ
icon_sms_hires by Hans Dorsch
https://ﬂic.kr/p/5mXKNj
SMS & MNT
in Diabetes
Monday, July 14, 14

Eating salad for health by typexmick,
“Adherence
WHO 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 Adherence
WHO (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 goals
Assist 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
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
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?
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
Monday, July 14, 14

GOALS
Things I will do to improve my eating behavior
Check off each day you meet your goal.
M T W T F S S M T W T F S S
Goal 1. Eat breakfast, lunch and dinner everyday.
Notes:______________________________________________________
____________________________________________________________
Goal 2. Eat ﬁve servings of fruits and vegetables everyday.
Notes:______________________________________________________
____________________________________________________________
Monday, July 14, 14

Learn what the patient thinks about
food and diabetes (including
preconceptions or misconceptions)
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
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
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
•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 adults
Cochrane 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
Mobile phone in hand by sqback
Shaking hands by lockstockb
Monitor by mrceviz
Papers #1 by deSpool
Monday, July 14, 14

38 studies
n=9445
Education
n=9
Restriction
n=1
Persuasion
n=2
Incentivization
n=1
Training
n=3
Modeling
n=7
Enablement
n=3
Multiple
n=18
Monitor by mrceviz
Monday, July 14, 14

Primary Outcome:
Client adherence to dietary advice
Process
measures
Monitor by mrceviz
Client-based
health or
behaviour
outcomes
Organisational
outcomes
Harms or
secondary
outcomes
Monday, July 14, 14

Potentially beneﬁcial
interventions
Telephone follow-up
Video
Contract
Feedback
Nutritional tools
Desroches S et al. Cochrane Database of
Systematic Reviews 2013, Issue 2. Art. No.:CD008722
Monitor by mrceviz
Monday, July 14, 14

Objective
To determine if 3x a week SMS will improve
adherence to diet and exercise
Secondary 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 Trial
Tamban 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 months
SMS 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 schedule
Monday: Diet
Wednesday: Exercise
Friday: Consequences of non-
adherence to DM management
Pyramid on a plate by Steve Garfield
https://flic.kr/p/HA2Qf
The Nelson by Pamela Graham
https://flic.kr/p/ebWV1w
Tamban C, Isip Tan IT & Jimeno C
JAFES 2013;28(2):143-9
Monday, July 14, 14

Sample SMS
translated to Filipino
Month 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
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
Pyramid on a plate by Steve Garﬁeld
https://ﬂic.kr/p/HA2Qf
Monday, July 14, 14

6
6.5
7
7.5
8
3 mos 6 mos
Control SMSHbA1c
60
65
70
75
3 mos 6 mos
25
26
27
28
29
30
3 mos 6 mos
Bodyweight
BMI
p=0.04
p=0.84
p=0.195
Primary Outcomes
Diet adherence
Days/week: NS
Meals/day:
Control 2.29 + 0.72 p=0.018
SMS 7.13 + 0.99
Tamban C, Isip Tan IT & Jimeno C
JAFES 2013;28(2):143-9
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

Medical Nutrition Therapy for Diabetes: Improving Adherence through SMS and Goal Setting

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Medical Nutrition Therapy for Diabetes: Improving Adherence through SMS and Goal Setting