Building Competency in Diabetes Education THE ESSENTIALS

5-28 | CHAPTER 5

several possible explanations for the weight gain associated with the initiation of diabetes medication (109,111). First and foremost, improved glycemic control improves energy use, even without increased energy intake, and this may lead to weight gain. There may also be some weight gain with rehydration. People may start to eat more regularly and, thus, possibly increase energy intake. Others may eat more to prevent hypoglycemia, and those who have frequent hypoglycemia consume excess energy to treat (or over-treat) it. Those who learn to adjust their insulin may increase energy intake as they enjoy larger portions and/or frequent sweets or snack-type foods. If weight gain following improved glycemia increases BMI above an acceptable level, then it is ultimately a positive energy balance (excess energy intake and/or inadequate energy output) that is responsible for maintaining the increased weight. This does not necessarily mean excess carbohydrate intake; it may be excess protein, fat, alcohol or a combination of nutrients. This is a very difficult concept for many people with diabetes to accept, as they relate the weight gain to the initiation of medication and, therefore, blame the weight gain on the medication. There are several methods for determining appropriate energy and carbohydrate intake. A simple and practical method is to use Canada’s Food Guide to assess portion sizes and balance of nutrients. An accurate food-intake record is the best method for determining energy requirements. However, accuracy in food records can be difficult to achieve. There are several formulas for calculating energy requirements, but even the most sophisticated formulas have been shown to under-predict energy needs in children and overestimate the energy needs of obese adults. Therefore, a combination of food records and formula calculations is ideal for the calculation of energy requirements. Special considerations for type 2 diabetes The focus of nutrition therapy for patients with type 2 diabetes is on lifestyle strategies to reduce glycemia, dyslipidemia and blood pressure (40). An estimated 80 to 90% of people with type 2 diabetes are overweight or obese (11). Glucose intolerance increases with body weight, so that, in most cases, type 2 diabetes can be delayed and, in some cases, possibly prevented, with effective weight management. Weight management improves all aspects of diabetes control, including BG, blood lipids and hypertension. Weight loss has also been shown to improve glycemia by increasing insulin sensitivity and glucose uptake, and diminishing hepatic glucose output (112,113). Excess body fat increases the risk of death from all causes, CVD and some forms of cancer (114). The optimal rate of weight loss is 2 to 4 kg per month (115). Weight loss of 5 to 10% of initial