diabetes mnt strategies

MNT in Diabetes and MNT in Diabetes and Related DisordersRelated Disorders

Expected Outcomes of Expected Outcomes of MNT in DiabetesMNT in Diabetes ↓ ↓ of 1% of A1C in patients with of 1% of A1C in patients with

newly diagnosed Type 1 diabetesnewly diagnosed Type 1 diabetes ↓ ↓ of about 2% of A1C in persons with of about 2% of A1C in persons with

newly diagnosed Type 2 diabetesnewly diagnosed Type 2 diabetes ↓ ↓ of about 1% of A1C in persons with of about 1% of A1C in persons with

Type 2 diabetes of 4-year durationType 2 diabetes of 4-year duration ↓ ↓ LDL-C by 15-25 mg/dL in 3-6 LDL-C by 15-25 mg/dL in 3-6

monthsmonths

Nutrition recommendations and interventions for diabetes. Diabetes Care 2007;30;S48-S65

MNT in Type 1 MNT in Type 1 DiabetesDiabetes Insulin therapy should be integrated Insulin therapy should be integrated

into an individual’s dietary and into an individual’s dietary and physical activity pattern (E)physical activity pattern (E)

Individuals using rapid-acting insulin Individuals using rapid-acting insulin by injection or an insulin pump by injection or an insulin pump should adjust the meal and snack should adjust the meal and snack insulin doses based on the CHO insulin doses based on the CHO content of the meals and snacks (A)content of the meals and snacks (A)

Nutrition recommendations and interventions for diabetes. Diabetes Care 30; S48-65, 2007

MNT in Type 1 MNT in Type 1 DiabetesDiabetes For individuals using fixed daily For individuals using fixed daily

insulin doses, CHO intake on a day-insulin doses, CHO intake on a day-to-day basis should be kept to-day basis should be kept consistent with respect to time and consistent with respect to time and amount (C)amount (C)

For planned exercise, insulin doses For planned exercise, insulin doses can be adjusted. For unplanned can be adjusted. For unplanned exercise, extra CHO may be needed exercise, extra CHO may be needed (E)(E)


MNT Strategies in MNT Strategies in Type 2 DiabetesType 2 Diabetes Implement lifestyle changes that reduce Implement lifestyle changes that reduce

intakes of energy, saturated and trans intakes of energy, saturated and trans fatty acids, cholesterol, and sodium and fatty acids, cholesterol, and sodium and increase physical activity in order to increase physical activity in order to improve glycemia, dyslipidemia, blood improve glycemia, dyslipidemia, blood pressure (E)pressure (E)

Plasma glucose monitoring can be used to Plasma glucose monitoring can be used to determine whether adjustments to foods determine whether adjustments to foods and meals will be sufficient to achieve and meals will be sufficient to achieve blood glucose goals or if medication(s) blood glucose goals or if medication(s) needs to be combined with MNTneeds to be combined with MNT


Carbohydrates in Carbohydrates in DiabetesDiabetes Dietary pattern that includes CHO Dietary pattern that includes CHO

from fruits, vegetables, whole from fruits, vegetables, whole grains, legumes, and low fat milk grains, legumes, and low fat milk is encouraged for good health (B)is encouraged for good health (B)

Monitoring CHO, whether by CHO Monitoring CHO, whether by CHO counting, exchange, or estimation counting, exchange, or estimation remains a key strategy in remains a key strategy in achieving glycemic control (A)achieving glycemic control (A)Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

Carbohydrate and Carbohydrate and DiabetesDiabetes Sucrose-containing foods can be Sucrose-containing foods can be

substituted for other substituted for other carbohydrates in the meal plan carbohydrates in the meal plan or, if added to the meal plan, or, if added to the meal plan, covered with insulin or other covered with insulin or other glucose-lowering medications. glucose-lowering medications. Care should be taken to avoid Care should be taken to avoid excess energy intake. (A)excess energy intake. (A)

Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

Carbohydrate and Carbohydrate and DiabetesDiabetes The use of glycemic index and The use of glycemic index and

load may provide a modest load may provide a modest additional benefit over that additional benefit over that observed when total CHO is observed when total CHO is considered alone (B)considered alone (B)


Glycemic IndexGlycemic Index

The blood glucose response of a The blood glucose response of a given food compared to an equal given food compared to an equal amount of a CHO standard amount of a CHO standard (typically glucose or white bread)(typically glucose or white bread)

Glycemic IndexGlycemic Index

Influenced by various factorsInfluenced by various factors Starch structureStarch structure Fiber contentFiber content Cooking methodsCooking methods Degree of processingDegree of processing Whether it is eaten in the context of a Whether it is eaten in the context of a

mealmeal Presence or absence of fatPresence or absence of fat A given food can elicit highly variable A given food can elicit highly variable

responsesresponses

Glycemic Index and Glycemic Index and Glycemic Load of Glycemic Load of FoodsFoodsFood Glycemic Index Glycemic Load

Carrots 47 3

Potato baked 85 26

Sweet corn 60 11

Apple 38 6

Chocolate cake 38 20

Corn flakes 92 24

Oatmeal 42 9

Pumpkin 75 3

Sucrose 68 7

Krause’s Food & Nutrition Therapy, 12th ed., Appendix 43

Fiber and DiabetesFiber and Diabetes

As for the general population, people with As for the general population, people with diabetes are encouraged to consume a variety diabetes are encouraged to consume a variety of fiber-containing foods. However, evidence is of fiber-containing foods. However, evidence is lacking to recommend a higher fiber intake for lacking to recommend a higher fiber intake for people with diabetes than for the population people with diabetes than for the population as a whole. (B)as a whole. (B)

It requires very large amount of fiber (~50 It requires very large amount of fiber (~50 grams) to have a beneficial effect on grams) to have a beneficial effect on glycemia, insulinemia, lipemiaglycemia, insulinemia, lipemia

Sweeteners and Sweeteners and DiabetesDiabetes Sugar alcohols and nonnutritive Sugar alcohols and nonnutritive

sweeteners are safe when sweeteners are safe when consumed within the daily intake consumed within the daily intake levels established by the Food levels established by the Food and Drug Administration (FDA) (A)and Drug Administration (FDA) (A)


Nutritive Sweeteners: Nutritive Sweeteners: FructoseFructose Delivers 4 kcals/gramDelivers 4 kcals/gram Has lower glycemic index than Has lower glycemic index than

sucrose or starchsucrose or starch Large amounts may negatively Large amounts may negatively

affect lipidsaffect lipids No advantage to substituting it for No advantage to substituting it for

sucrosesucrose Found naturally in foods such as Found naturally in foods such as

fruits and vegetablesfruits and vegetables

Nutritive Sweeteners: Nutritive Sweeteners: Sugar AlcoholsSugar Alcohols Sorbitol, mannitol, xylitol, isomalt, lactitol, Sorbitol, mannitol, xylitol, isomalt, lactitol,

hydrogenated starch hydrolysateshydrogenated starch hydrolysates Lower glycemic response, lower calorie Lower glycemic response, lower calorie

content than sucrosecontent than sucrose Not water-soluble so often combined with Not water-soluble so often combined with

fats in foods; often deliver as many fats in foods; often deliver as many calories as sucrose-sweetened foodscalories as sucrose-sweetened foods

Unlikely to have a beneficial effect on Unlikely to have a beneficial effect on blood sugarsblood sugars

In large quantities, may cause GI distress In large quantities, may cause GI distress and diarrheaand diarrhea

Non-Caloric SweetenersNon-Caloric Sweeteners

Saccharin (Sweet’N LowSaccharin (Sweet’N Low®)®)

Aspartame (NutraSweetAspartame (NutraSweet®®))

Acesulfame potassium, Acesulfame potassium, acesulfame-K (Sweet acesulfame-K (Sweet OneOne®®))

Sucralose (SPLENDASucralose (SPLENDA®®))

Nonnutritive Nonnutritive SweetenersSweetenersNonnutritive Nonnutritive SweetenersSweeteners

Include aspartame, acesulfame K, Include aspartame, acesulfame K, sucralose, and saccharinsucralose, and saccharin

FDA has established an acceptable FDA has established an acceptable daily intake (ADI) for food additivesdaily intake (ADI) for food additives

Average intake of aspartame is 2 to 4 Average intake of aspartame is 2 to 4 mg/kg/day, whereas the ADI is 50 mg/kg/day, whereas the ADI is 50 mg/kg/daymg/kg/day

ADI of acesulfame K is 15 mg/kg, ADI of acesulfame K is 15 mg/kg, which is the equivalent of a 60 kg which is the equivalent of a 60 kg person eating 36 teaspoons of sugar person eating 36 teaspoons of sugar dailydaily

Include aspartame, acesulfame K, Include aspartame, acesulfame K, sucralose, and saccharinsucralose, and saccharin

FDA has established an acceptable FDA has established an acceptable daily intake (ADI) for food additivesdaily intake (ADI) for food additives

Average intake of aspartame is 2 to 4 Average intake of aspartame is 2 to 4 mg/kg/day, whereas the ADI is 50 mg/kg/day, whereas the ADI is 50 mg/kg/daymg/kg/day

ADI of acesulfame K is 15 mg/kg, ADI of acesulfame K is 15 mg/kg, which is the equivalent of a 60 kg which is the equivalent of a 60 kg person eating 36 teaspoons of sugar person eating 36 teaspoons of sugar dailydaily

Noncaloric Noncaloric Sweeteners: Sweeteners:

All FDA-approved non-All FDA-approved non-nutritive sweeteners nutritive sweeteners can be used by can be used by persons with diabetespersons with diabetes

The carbohydrate and The carbohydrate and calorie content of calorie content of sugar blends must be sugar blends must be taken into accounttaken into account

Protein and DiabetesProtein and DiabetesProtein and DiabetesProtein and Diabetes

Insufficient evidence to suggest Insufficient evidence to suggest that usual protein intake (15-20% that usual protein intake (15-20% of energy) should be modified (E) of energy) should be modified (E)

In individuals with Type 2 In individuals with Type 2 diabetes, ingested protein can diabetes, ingested protein can increase insulin response without increase insulin response without increasing plasma glucose increasing plasma glucose concentrations. Therefore, protein concentrations. Therefore, protein should not be used to treat acute should not be used to treat acute or prevent nighttime or prevent nighttime hypoglycemia (A)hypoglycemia (A)

Insufficient evidence to suggest Insufficient evidence to suggest that usual protein intake (15-20% that usual protein intake (15-20% of energy) should be modified (E) of energy) should be modified (E)

In individuals with Type 2 In individuals with Type 2 diabetes, ingested protein can diabetes, ingested protein can increase insulin response without increase insulin response without increasing plasma glucose increasing plasma glucose concentrations. Therefore, protein concentrations. Therefore, protein should not be used to treat acute should not be used to treat acute or prevent nighttime or prevent nighttime hypoglycemia (A)hypoglycemia (A)Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

Protein and DiabetesProtein and Diabetes

High-protein diets are not recommended as a High-protein diets are not recommended as a method for weight loss at this time. The long-method for weight loss at this time. The long-term effects of protein intake >20% of term effects of protein intake >20% of calories on diabetes management and its calories on diabetes management and its complications are unknown. complications are unknown.

Although such diets may produce short-term Although such diets may produce short-term weight loss and improved glycemia, it has weight loss and improved glycemia, it has not been established that these benefits are not been established that these benefits are maintained long term, and long-term effects maintained long term, and long-term effects on kidney function for persons with diabetes on kidney function for persons with diabetes are unknown. (E) are unknown. (E)


Dietary FatDietary Fat

Saturated Fat: <7% of total calories Saturated Fat: <7% of total calories (A)(A)

Cholesterol: <200 mg/day in people Cholesterol: <200 mg/day in people with diabeteswith diabetes

Minimize intake of trans-fatty acids Minimize intake of trans-fatty acids (E)(E)

Two or more servings of fish per Two or more servings of fish per week providing n-3 polyunsaturated week providing n-3 polyunsaturated fatty acids are recommended (B)fatty acids are recommended (B)


MFA vs CHOMFA vs CHO

↑ ↑ CHO diet (>55% ) may ↑ CHO diet (>55% ) may ↑ triglycerides and postprandial triglycerides and postprandial glucose compared with ↑ MFA dietglucose compared with ↑ MFA diet

However, ↑ CHO ↓ fat diet can However, ↑ CHO ↓ fat diet can produce modest weight lossproduce modest weight loss

Metabolic profile and need for Metabolic profile and need for weight loss will determine balance weight loss will determine balance between CHO and MFAbetween CHO and MFA

Optimal Mix of Optimal Mix of MacronutrientsMacronutrients The best mix of protein, CHO and The best mix of protein, CHO and

fat varies depending on individual fat varies depending on individual circumstancescircumstances

The DRIs recommend that healthy The DRIs recommend that healthy adults should consume 45-65% of adults should consume 45-65% of energy from CHO, 20-35% from energy from CHO, 20-35% from fat, and 10-35% from proteinfat, and 10-35% from protein

Total caloric intake must be Total caloric intake must be appropriate for weight appropriate for weight managementmanagementNutrition recommendations and interventions for diabetes.

Diabetes Care 31:S61-S78, 2008

Lipid Goals in DiabetesLipid Goals in Diabetes LDL cholesterolLDL cholesterol <100 mg/dl<100 mg/dl HDL cholesterolHDL cholesterol

MenMen >40 mg/dl>40 mg/dl

WomenWomen >50 mg/dl>50 mg/dl TriglyceridesTriglycerides <150 mg/dl<150 mg/dl

American Diabetes Assoc. Standards of Medical care for Adults with Diabetes. Diabetes Care 30 (supplement 1) 2007. Accessed 2/13/07

Blood Pressure Goals Blood Pressure Goals in Diabetesin Diabetes Patients with diabetes should Patients with diabetes should

be treated to a systolic blood be treated to a systolic blood pressure <130 mmHg (C)pressure <130 mmHg (C)

Patients with diabetes should Patients with diabetes should be treated to a diastolic blood be treated to a diastolic blood pressure of <80 mmHg (B)pressure of <80 mmHg (B)

American Diabetes Assoc. Standards of Medical Care in Diabetes-2007. Diabetes Care 30 (supplement 1) 2007. Accessed 2/14/07

Fiber and Fiber and PhytoesterolsPhytoesterols Soluble fiber: 3 grams of soluble Soluble fiber: 3 grams of soluble

fiber (3 servings of oatmeal) or 3 fiber (3 servings of oatmeal) or 3 apples can lower total cholesterol apples can lower total cholesterol by 5 mg (2%)by 5 mg (2%)

Plant stanols: 2-3 grams can Plant stanols: 2-3 grams can lower total and LDL-C by 9 to 20%lower total and LDL-C by 9 to 20%

Energy Balance, Energy Balance, Overwt and ObesityOverwt and Obesity In overweight and obese insulin-resistant In overweight and obese insulin-resistant

individuals, modest weight loss has been shown individuals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss to improve insulin resistance. Thus, weight loss is recommended for all such individuals who is recommended for all such individuals who have or are at risk for diabetes. (A) have or are at risk for diabetes. (A)

For weight loss, either low-carbohydrate or low-For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in fat calorie-restricted diets may be effective in the short term (up to 1 year). (A) the short term (up to 1 year). (A)

For patients on low-carbohydrate diets, monitor For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust (in those with nephropathy), and adjust hypoglycemic therapy as needed. (E) hypoglycemic therapy as needed. (E)


Energy Balance, Energy Balance, Overwt and ObesityOverwt and Obesity Physical activity and behavior modification are Physical activity and behavior modification are

important components of weight loss programs important components of weight loss programs and are most helpful in maintenance of weight and are most helpful in maintenance of weight loss. (B) loss. (B)

Weight loss medications may be considered in Weight loss medications may be considered in the treatment of overweight and obese the treatment of overweight and obese individuals with type 2 diabetes and can help individuals with type 2 diabetes and can help achieve a 5–10% weight loss when combined achieve a 5–10% weight loss when combined with lifestyle modification. (B) with lifestyle modification. (B)

American Diabetes Association Nutrition Recommendations and interventions for Diabetes, Diabetes Care 31:S61-S78, 2008

Energy Balance, Energy Balance, Overweight, and Overweight, and ObesityObesity Bariatric surgery may be considered Bariatric surgery may be considered

for individuals with type 2 diabetes for individuals with type 2 diabetes and BMI>35 kg/m2 and can result in and BMI>35 kg/m2 and can result in marked improvements in glycemiamarked improvements in glycemia

Long term benefits and risks of Long term benefits and risks of bariatric surgery in individuals with bariatric surgery in individuals with pre-diabetes or diabetes continue to pre-diabetes or diabetes continue to be studied (B)be studied (B)


Energy Balance and Energy Balance and ObesityObesity Improved glycemic control with Improved glycemic control with

intensive insulin therapy sometimes intensive insulin therapy sometimes results in weight gainresults in weight gain

Insulin therapy should be integrated Insulin therapy should be integrated into usual eating and exercise habitsinto usual eating and exercise habits

Overtreatment of hypoglycemia should Overtreatment of hypoglycemia should be avoidedbe avoided

Adjustments of insulin should be made Adjustments of insulin should be made for exercisefor exercise

Obesity and PrognosisObesity and Prognosis

Obesity in diabetic persons is not Obesity in diabetic persons is not associated with mortality or associated with mortality or microvascular, macrovascular microvascular, macrovascular complicationscomplications

Short term weight loss in subjects Short term weight loss in subjects with Type 2 diabetes is associated with Type 2 diabetes is associated with improvement in insulin with improvement in insulin resistance, glycemia, serum resistance, glycemia, serum lipids, and blood pressure lipids, and blood pressure

AlcoholAlcohol

In the fasting state, alcohol may In the fasting state, alcohol may cause hypoglycemia in persons cause hypoglycemia in persons using exogenous insulin or insulin using exogenous insulin or insulin secretagoguessecretagogues

Alcohol is a source of energy, but Alcohol is a source of energy, but not converted to glucose; not converted to glucose; interferes with gluconeogensisinterferes with gluconeogensis

AlcoholAlcohol

Drinks should be limited to 1 drink a day Drinks should be limited to 1 drink a day (women) or 2 (men) (E)(women) or 2 (men) (E)

To reduce risk of nocturnal hypoglycemia To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin in individuals using insulin or insulin secretagogues, alcohol should be secretagogues, alcohol should be consumed with food (E)consumed with food (E)

In individuals with diabetes, moderate In individuals with diabetes, moderate alcohol consumption (when ingested alcohol consumption (when ingested alone) has no acute effect on glucose and alone) has no acute effect on glucose and insulin concentrations, but carbohydrate insulin concentrations, but carbohydrate coingested with alcohol (as in a mixed coingested with alcohol (as in a mixed drink) may raise blood glucose (B)drink) may raise blood glucose (B)Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

AlcoholAlcohol

Occasional use of alcoholic Occasional use of alcoholic beverages should be considered an beverages should be considered an addition to the regular meal plan, addition to the regular meal plan, and no food should be omittedand no food should be omitted

Excessive amounts of alcohol Excessive amounts of alcohol (three or more drinks per day) on a (three or more drinks per day) on a consistent basis, contributes to consistent basis, contributes to hyperglycemiahyperglycemia

AlcoholAlcoholAlcoholAlcohol For individuals with diabetes, light to For individuals with diabetes, light to

moderate alcohol intake (one to two moderate alcohol intake (one to two drinks per day; 15-30 g alcohol) is drinks per day; 15-30 g alcohol) is associated with a decreased risk of associated with a decreased risk of CVDCVD

Does not appear to be due to an Does not appear to be due to an increase in HDL-Cincrease in HDL-C

For individuals with diabetes, light to For individuals with diabetes, light to moderate alcohol intake (one to two moderate alcohol intake (one to two drinks per day; 15-30 g alcohol) is drinks per day; 15-30 g alcohol) is associated with a decreased risk of associated with a decreased risk of CVDCVD

Does not appear to be due to an Does not appear to be due to an increase in HDL-Cincrease in HDL-C

MicronutrientsMicronutrients

There is no clear evidence of benefit from There is no clear evidence of benefit from vitamin or mineral supplementation in people vitamin or mineral supplementation in people with diabetes (compared with the general with diabetes (compared with the general population) who do not have underlying population) who do not have underlying deficiencies (A)deficiencies (A)

Routine supplementation with antioxidants Routine supplementation with antioxidants such as vitamins E and C and carotene is not such as vitamins E and C and carotene is not advised because of lack of evidence of advised because of lack of evidence of efficacy and concern related to long term efficacy and concern related to long term safety (A)safety (A)

Benefit from chromium supplementation in Benefit from chromium supplementation in individuals with diabetes or obesity has not individuals with diabetes or obesity has not been clearly demonstrated and therefore can been clearly demonstrated and therefore can not be recommended (E)not be recommended (E)Nutrition recommendations and interventions for diabetes.

Diabetes Care 31:S61-S78, 2008

““Diabetes” Diabetes” SupplementsSupplements

““Diabetes” Diabetes” SupplementsSupplements Gymnema sylvestre (herb)Gymnema sylvestre (herb) Vitamin E: Antioxidant - maintains a healthy Vitamin E: Antioxidant - maintains a healthy

heart. heart. Chromium Picolinate: Necessary for proper Chromium Picolinate: Necessary for proper

carbohydrate metabolism. carbohydrate metabolism. Selenium: Antioxidant - Helps protect the body Selenium: Antioxidant - Helps protect the body

from free radicals. from free radicals. Lutein: promotes eye health Lutein: promotes eye health Folic Acid: Helps maintain heart health. Folic Acid: Helps maintain heart health. Vitamin C: Antioxidant - Boosts the immune Vitamin C: Antioxidant - Boosts the immune

system. system. Alpha Lipoic Acid: Antioxidant - Stimulates other Alpha Lipoic Acid: Antioxidant - Stimulates other

antioxidantsantioxidants VanadiumVanadium Resveratrol Resveratrol

MicronutrientsMicronutrientsMicronutrientsMicronutrients

Vitamin/mineral needs of people with Vitamin/mineral needs of people with diabetes who are healthy appear to be diabetes who are healthy appear to be adequately met by the RDAs.adequately met by the RDAs.

Those who may need supplementation Those who may need supplementation include those on extreme weight-include those on extreme weight-reducing diets, strict vegetarians, the reducing diets, strict vegetarians, the elderly, pregnant or lactating women, elderly, pregnant or lactating women, clients with malabsorption disorders, clients with malabsorption disorders, congestive heart failure (CHF) or congestive heart failure (CHF) or myocardial infarction (MI)myocardial infarction (MI)

Chromium and magnesium are Chromium and magnesium are beneficial only if the client is deficient.beneficial only if the client is deficient.

Vitamin/mineral needs of people with Vitamin/mineral needs of people with diabetes who are healthy appear to be diabetes who are healthy appear to be adequately met by the RDAs.adequately met by the RDAs.

Those who may need supplementation Those who may need supplementation include those on extreme weight-include those on extreme weight-reducing diets, strict vegetarians, the reducing diets, strict vegetarians, the elderly, pregnant or lactating women, elderly, pregnant or lactating women, clients with malabsorption disorders, clients with malabsorption disorders, congestive heart failure (CHF) or congestive heart failure (CHF) or myocardial infarction (MI)myocardial infarction (MI)

Chromium and magnesium are Chromium and magnesium are beneficial only if the client is deficient.beneficial only if the client is deficient.Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

SodiumSodiumSodiumSodium

Association between hypertension Association between hypertension (HTN) and both types of diabetes (HTN) and both types of diabetes mellitus (DM)mellitus (DM)

Same intake as general population is Same intake as general population is recommended for otherwise healthy recommended for otherwise healthy people with DM—less than 3000 mg/daypeople with DM—less than 3000 mg/day

For people with mild HTN and diabetesFor people with mild HTN and diabetes—should have less than 2400 mg/day—should have less than 2400 mg/day

For people with more serious HTN or For people with more serious HTN or edematous clients with nephropathy edematous clients with nephropathy recommend 2000 mg/day or less recommend 2000 mg/day or less

Association between hypertension Association between hypertension (HTN) and both types of diabetes (HTN) and both types of diabetes mellitus (DM)mellitus (DM)

Same intake as general population is Same intake as general population is recommended for otherwise healthy recommended for otherwise healthy people with DM—less than 3000 mg/daypeople with DM—less than 3000 mg/day

For people with mild HTN and diabetesFor people with mild HTN and diabetes—should have less than 2400 mg/day—should have less than 2400 mg/day

For people with more serious HTN or For people with more serious HTN or edematous clients with nephropathy edematous clients with nephropathy recommend 2000 mg/day or less recommend 2000 mg/day or less

Goals of MNT for Goals of MNT for Diabetes in ChildrenDiabetes in Children Maintain normal growth and developmentMaintain normal growth and development

– Evaluate using growth charts every 3-6 Evaluate using growth charts every 3-6 monthsmonths

Base nutrition prescription on the Base nutrition prescription on the nutrition assessmentnutrition assessment– Re-evaluate every 3-6 monthsRe-evaluate every 3-6 months

Meal planning approach can be based on Meal planning approach can be based on CHO counting for increased flexibility or CHO counting for increased flexibility or other systemsother systems

Review blood glucose records and revise Review blood glucose records and revise medication regimen as necessarymedication regimen as necessary

Estimating Minimum Estimating Minimum Energy Requirements for Energy Requirements for YouthYouthAgeAge Energy RequirementsEnergy Requirements

1 yr1 yr 1000 kcals for first year1000 kcals for first year

2-11 yr2-11 yr Add 100 kcals/yr to 1000 kcals up to Add 100 kcals/yr to 1000 kcals up to 2000 kcals at age 102000 kcals at age 10

Girls 12-Girls 12-1515

>15 years>15 years

2000 kcals + 50-100 kcals/yr after 2000 kcals + 50-100 kcals/yr after age 10age 10

Calculate as for an adultCalculate as for an adult

Boys 12-Boys 12-1515

>15 yr>15 yr

2000 kcals plus 200 kcal/yr after age 2000 kcals plus 200 kcal/yr after age 1010

Sedentary 16 kcals/lb (30-35 Sedentary 16 kcals/lb (30-35 kcals/kg)kcals/kg)

Moderate activity 18 kcals/lb (40 Moderate activity 18 kcals/lb (40 kcals/kg)kcals/kg)

Very physically active: 23 kcals/lb (50 Very physically active: 23 kcals/lb (50 kcals/kg)kcals/kg)

MNT for Type 2 MNT for Type 2 Diabetes in YouthDiabetes in Youth Cessation of excessive weight gainCessation of excessive weight gain Promotion of normal growth and Promotion of normal growth and

development development Encourage healthy eating habits and Encourage healthy eating habits and

increased activity for the whole familyincreased activity for the whole family Address other health risk factorsAddress other health risk factors Add Metformin if lifestyle changes are Add Metformin if lifestyle changes are

insufficient to achieve goalsinsufficient to achieve goals

Estimating Energy Estimating Energy Requirements for Requirements for AdultsAdultsObese and very Obese and very inactive persons and inactive persons and chronic dieterschronic dieters

10-12 kcals/lb or 20 10-12 kcals/lb or 20 kcals/kgkcals/kg

Persons >55 yr, active Persons >55 yr, active women, sedentary women, sedentary menmen

13 kcals/lb, 25 kcals/kg13 kcals/lb, 25 kcals/kg

Active men, very Active men, very active womenactive women

15 kcals/lb, 30 kcals/kg15 kcals/lb, 30 kcals/kg

Thin or very active Thin or very active menmen

20 kcals/lb or 40 20 kcals/lb or 40 kcals/kgkcals/kg

Source: Franz MJ, Reader D, Monk A. Implementing group and individual medical nutrition therapy for diabetes. Alexandria, VA, 2002, American Diabetes Association

Basic MNT Self-Basic MNT Self-Management Skills for Management Skills for Persons with DMPersons with DM Basic food and meal planning guidelinesBasic food and meal planning guidelines Physical activity guidelinesPhysical activity guidelines Self-monitoring of blood glucose levelsSelf-monitoring of blood glucose levels For insulin or insulin secretagogue users, For insulin or insulin secretagogue users,

signs, symptoms, treatment, and signs, symptoms, treatment, and prevention of hypoglycemiaprevention of hypoglycemia

For insulin or insulin secretagogue users For insulin or insulin secretagogue users guidelines for managing short-term illnessguidelines for managing short-term illness

Plans for follow-up and ongoing educationPlans for follow-up and ongoing education

MNT Essential Self-MNT Essential Self-Management SkillsManagement Skills Sources of CHO, Sources of CHO,

pro, fatpro, fat Understanding Understanding

nutrition labelsnutrition labels Modification of fat Modification of fat

intakeintake Alcohol guidelinesAlcohol guidelines Use of BG Use of BG

monitoring data monitoring data for problem for problem solvingsolving

Recipes, menu Recipes, menu ideas, cookbooksideas, cookbooks

Vitamin, mineral, Vitamin, mineral, botanical botanical supplementssupplements

Behavior Behavior modification modification techniquestechniques

MNT Essential Self-MNT Essential Self-Management SkillsManagement Skills Adjustments of CHO Adjustments of CHO

or insulin for or insulin for exerciseexercise

Grocery shopping Grocery shopping guidelinesguidelines

Guidelines for Guidelines for eating outeating out

Snack choicesSnack choices Mealtime Mealtime

adjustmentsadjustments

Use of sugar-Use of sugar-containing foods containing foods and non-nutritive and non-nutritive sweetenerssweeteners

Problem solving tips Problem solving tips for special occasionsfor special occasions

Travel schedule Travel schedule changeschanges

Work shifts if Work shifts if applicableapplicable

Nutrition Self Nutrition Self Management for Management for DiabetesDiabetes

Goals of MNT for Goals of MNT for Prevention and Prevention and Treatment of DiabetesTreatment of Diabetes

Achieve and maintain Achieve and maintain Blood glucose levels in the normal Blood glucose levels in the normal

range, or as close to normal as is range, or as close to normal as is safely possiblesafely possible

A lipid and lipoprotein profile that A lipid and lipoprotein profile that reduces the risk for vascular diseasereduces the risk for vascular disease

Blood pressure levels in the normal Blood pressure levels in the normal range or as close to normal as is range or as close to normal as is safely possiblesafely possibleNutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008.

Goals of MNT for Goals of MNT for Prevention and Prevention and Treatment of DiabetesTreatment of Diabetes To prevent or at least slow the rate of To prevent or at least slow the rate of

development of the chronic development of the chronic complications of diabetes by modifying complications of diabetes by modifying nutrient intake and lifestylenutrient intake and lifestyle

To address individual nutrition needs, To address individual nutrition needs, taking into account personal and cultural taking into account personal and cultural preferences and willingness to changepreferences and willingness to change

To maintain the pleasure of eating by To maintain the pleasure of eating by only limiting food choices when only limiting food choices when indicated by scientific evidenceindicated by scientific evidence

Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008.

Goals of MNT that Goals of MNT that Apply to Specific Apply to Specific SituationsSituations For youth with type 1 diabetes, youth For youth with type 1 diabetes, youth

with type 2 diabetes, pregnant and with type 2 diabetes, pregnant and lactating women, and older adults with lactating women, and older adults with diabetes, to meet the nutritional needs diabetes, to meet the nutritional needs of these unique times in the life cycleof these unique times in the life cycle

For individuals treated with insulin or For individuals treated with insulin or insulin secretagogues, to provide self-insulin secretagogues, to provide self-management training for safe conduct management training for safe conduct of exercise, including the prevention of exercise, including the prevention and treatment of hypoglycemia and and treatment of hypoglycemia and diabetes treatment during acute illnessdiabetes treatment during acute illness


Effectiveness of MNT Effectiveness of MNT RecommendationsRecommendations Individuals who have pre-diabetes or Individuals who have pre-diabetes or

diabetes should receive individualized diabetes should receive individualized MNT; such therapy is best provided by a MNT; such therapy is best provided by a registered dietitian familiar with the registered dietitian familiar with the components of diabetes MNT (B)components of diabetes MNT (B)

Nutrition counseling should be sensitive Nutrition counseling should be sensitive to the personal needs, willingness to to the personal needs, willingness to change, and ability to make changes of change, and ability to make changes of the individual with pre-diabetes or the individual with pre-diabetes or diabetes (E)diabetes (E)Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

Diabetes Assessment: Diabetes Assessment: Referral DataReferral Data AgeAge Diagnosis of Diagnosis of

diabetes and other diabetes and other pertinent medical pertinent medical historyhistory

Medications, Medications, including diabetes including diabetes and other and other pertinent medspertinent meds

Laboratory data Laboratory data (A1C, cholesterol/ (A1C, cholesterol/ lipid profile, lipid profile, albumin to albumin to creatinine ratio) creatinine ratio)

Blood pressureBlood pressure Clearance for Clearance for

exerciseexercise

Diabetes Assessment Diabetes Assessment DataData Diabetes history: previous diabetes Diabetes history: previous diabetes

education, use of blood glucose education, use of blood glucose monitoring, diabetes problems/ monitoring, diabetes problems/ concernsconcerns

Food/nutrient history: current eating Food/nutrient history: current eating habits with beginning modificationshabits with beginning modifications

Social history: occupation, hours Social history: occupation, hours worked/away from home, living worked/away from home, living situation, financial issuessituation, financial issues

Medications/supplements: medications Medications/supplements: medications taken, vitamin/mineral/supplement taken, vitamin/mineral/supplement use, herbal supplementsuse, herbal supplements

Diabetes Assessment Diabetes Assessment Data: Diet HistoryData: Diet History Usual caloric intakeUsual caloric intake Quality of the usual dietQuality of the usual diet Times, sizes, and contents of meals Times, sizes, and contents of meals

and snacksand snacks Food idiosyncrasiesFood idiosyncrasies Restaurant eatingRestaurant eating Who usually prepares mealsWho usually prepares meals Eating problems/intolerancesEating problems/intolerances Alcoholic beverage intakeAlcoholic beverage intake Supplements usedSupplements used

Diabetes Assessment Diabetes Assessment Data: Daily ScheduleData: Daily Schedule Time of wakingTime of waking Usual meal and eating timesUsual meal and eating times Work schedule or school hoursWork schedule or school hours Type, amount, and timing of Type, amount, and timing of

exerciseexercise Usual sleep habitsUsual sleep habits

Basic Strategies for Basic Strategies for Type 1 DiabetesType 1 Diabetes For individuals with type 1 diabetes, insulin therapy For individuals with type 1 diabetes, insulin therapy

should be integrated into an individual’s dietary and should be integrated into an individual’s dietary and physical activity pattern. (E) physical activity pattern. (E)

Individuals using rapid-acting insulin by injection or an Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin insulin pump should adjust the meal and snack insulin doses based on the carbohydrate content of the meals doses based on the carbohydrate content of the meals and snacks. (A) and snacks. (A)

For individuals using fixed daily insulin doses, For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount. (C) consistent with respect to time and amount. (C)

For planned exercise, insulin doses can be adjusted. For For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed. unplanned exercise, extra carbohydrate may be needed. (E) (E)


Basic Strategies for Basic Strategies for Type 2 DiabetesType 2 Diabetes

Encourage weight loss.Encourage weight loss. Moderate calorie restriction (250–500 Moderate calorie restriction (250–500

kcal/day less) is associated with kcal/day less) is associated with improved control independent of weight improved control independent of weight loss.loss.

Spread nutrient intake, especially Spread nutrient intake, especially carbohydrate (CHO) throughout the day.carbohydrate (CHO) throughout the day.

Encourage physical activity.Encourage physical activity. Decrease fat intake.Decrease fat intake. Monitor BG, and add medications if Monitor BG, and add medications if

needed.needed.

Food Guide PyramidFood Guide Pyramid

Use basic Use basic guideguide

Use diabetes-Use diabetes-specific guidespecific guide

National Diabetes Education Program. http://www.ndep.nih.gov/diabetes/MealPlanner/images/mypyramid.jpg

Recommendations for Recommendations for Weight ManagementWeight Management

Make Make permanentpermanent changes in eating changes in eating behavior.behavior.

Eat regularly.Eat regularly. Slow, gradual weight loss is best.Slow, gradual weight loss is best. Choose lower-fat foods.Choose lower-fat foods. Incorporate regular physical activity.Incorporate regular physical activity.

The Diabetes Meal The Diabetes Meal PlanPlan The meal plan should be based onThe meal plan should be based on

– the patient’s current eating habitsthe patient’s current eating habits– diabetes medications, if any diabetes medications, if any – current weight statuscurrent weight status– collaborative goals (e.g., does the collaborative goals (e.g., does the

patient desire to lose weight?)patient desire to lose weight?)

Macronutrients Based Macronutrients Based OnOn Patient’s current Patient’s current

eating habits (CHO, eating habits (CHO, fat, protein)fat, protein)

Lipid levels and Lipid levels and glycemic controlglycemic control

Patient goalsPatient goals

Meal PlanMeal Plan

Estimate current energy, carbohydrate, Estimate current energy, carbohydrate, protein, and fat intakeprotein, and fat intake

Evaluate current meal pattern and Evaluate current meal pattern and scheduleschedule

Adjust meal plan to promote treatment Adjust meal plan to promote treatment goals (energy, fat, carbohydrate goals (energy, fat, carbohydrate distribution)distribution)

Evaluate based on standard meal planning Evaluate based on standard meal planning standards (e.g. Food Guide Pyramid)standards (e.g. Food Guide Pyramid)

Meal Plan: Patient on Meal Plan: Patient on MNT OnlyMNT Only Often start with 3-4 CHO servings per Often start with 3-4 CHO servings per

meal (includes fruits, starches, milk, meal (includes fruits, starches, milk, sweets) for women and 4-5 for men sweets) for women and 4-5 for men plus 1-2 for snack if desiredplus 1-2 for snack if desired

Evaluate feasibility of meal plan with Evaluate feasibility of meal plan with patientpatient

Trial meal plan and evaluate blood Trial meal plan and evaluate blood glucose recordsglucose records

Adjust plan as necessaryAdjust plan as necessary

Examples of CHO Examples of CHO Servings Mix and Servings Mix and MatchMatch Apple, 1 smallApple, 1 small Fruit cocktail, ½ cFruit cocktail, ½ c Nonfat milk, 1 cNonfat milk, 1 c Orange juice, ½ cOrange juice, ½ c Bread, 1 sliceBread, 1 slice Oatmeal, ½ cOatmeal, ½ c Pasta, 1/3 cPasta, 1/3 c Potatoes, ½ cPotatoes, ½ c

Brownie, 1 smallBrownie, 1 small Yogurt, frozen, ½ cYogurt, frozen, ½ c Cake, frosted, 2 Cake, frosted, 2

inch square, (2 inch square, (2 CHO)CHO)

Corn, ½ cCorn, ½ c Baked beans 1/3 cBaked beans 1/3 c Hummus 1/3 cHummus 1/3 c

Meal Plan: Oral Meal Plan: Oral MedicationsMedications May do well with smaller, more May do well with smaller, more

frequent meals and snacks, frequent meals and snacks, especially if taking an insulin especially if taking an insulin secretagoguesecretagogue

Snack servings should be taken Snack servings should be taken from the meal planfrom the meal plan

Meal Plan: InsulinMeal Plan: Insulin

Can start with the meal plan and Can start with the meal plan and devise an insulin regimen to fitdevise an insulin regimen to fit

Many patients require a bedtime snack Many patients require a bedtime snack to prevent night-time hypoglycemiato prevent night-time hypoglycemia

Patients who use morning Patients who use morning intermediate-acting insulin (NPH) may intermediate-acting insulin (NPH) may require afternoon snackrequire afternoon snack

Patients on rapid-acting insulin do not Patients on rapid-acting insulin do not need a snackneed a snack

Meal Planning: Meal Planning: Carbohydrate CountingCarbohydrate Counting Focuses on CHO as major driver of post-Focuses on CHO as major driver of post-

prandial blood glucoseprandial blood glucose Can be used for intensive management Can be used for intensive management

or for basic meal planningor for basic meal planning May be most appropriate for Type 1 May be most appropriate for Type 1

patients at desirable weightpatients at desirable weight Must still address energy needs and Must still address energy needs and

composition of overall dietcomposition of overall diet Allows increased flexibilityAllows increased flexibility 1 carbohydrate serving = 15 grams1 carbohydrate serving = 15 grams

Managing Acute Managing Acute ComplicationsComplications

HypoglycemiaHypoglycemia

Low blood glucoseLow blood glucose Common side effect of insulin Common side effect of insulin

therapytherapy Sometimes affects patients taking Sometimes affects patients taking

insulin secretagoguesinsulin secretagogues Can be life-threateningCan be life-threatening

Hypoglycemia Hypoglycemia SymptomsSymptoms ShakinessShakiness SweatingSweating PalpitationsPalpitations HungerHunger Slurred speechSlurred speech Mental confusion, disorientationMental confusion, disorientation Extreme fatigue, lethargyExtreme fatigue, lethargy Seizures and unconsciousnessSeizures and unconsciousness

Hypoglycemia Hypoglycemia TreatmentTreatment Glucose of 70 mg/dL or lower should Glucose of 70 mg/dL or lower should

be treated immediatelybe treated immediately A level of 60 to 80 mg/dL may require A level of 60 to 80 mg/dL may require

carbohydrate ingestion, deferral of carbohydrate ingestion, deferral of exercise, change in insulin dosageexercise, change in insulin dosage

Treatment involves ingestion of Treatment involves ingestion of glucose or carbohydrate-containing glucose or carbohydrate-containing food (glucose preferred)food (glucose preferred)

Protein does not help with treatment Protein does not help with treatment or prevent recurrence of hypoglycemiaor prevent recurrence of hypoglycemia

Hypoglycemia Hypoglycemia TreatmentTreatment Ingestion of 15-20 grams of glucose (3 Ingestion of 15-20 grams of glucose (3

glucose tablets, ½ cup fruit juice or glucose tablets, ½ cup fruit juice or regular soft drink, 6 saltine crackers, 1 regular soft drink, 6 saltine crackers, 1 tbsp honey or sugar)tbsp honey or sugar)

Wait 15 minutes and retest; if BG<70 Wait 15 minutes and retest; if BG<70 mg/dL, take another 15 g CHOmg/dL, take another 15 g CHO

Repeat until BG is WNLRepeat until BG is WNL If next meal is >1 hour away, take If next meal is >1 hour away, take

additional 15 g glucoseadditional 15 g glucose Glucagon injection may be prescribed Glucagon injection may be prescribed

for pts at risk for severe hypoglycemiafor pts at risk for severe hypoglycemiaNutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

Hypoglycemia Hypoglycemia TreatmentTreatment Individuals with hypoglycemia Individuals with hypoglycemia

unawareness or one or more episodes unawareness or one or more episodes of severe hypoglycemia should be of severe hypoglycemia should be advised to raise their glycemic targets advised to raise their glycemic targets to strictly avoid further hypoglycemia to strictly avoid further hypoglycemia for at least several weeks in order to for at least several weeks in order to partially reverse hypoglycemia partially reverse hypoglycemia unawareness and reduce risk of future unawareness and reduce risk of future episodes. (B) episodes. (B)

Standards of Medical Care for Diabetes Diabetes Care 31:S3-S4, 2008

Causes of Causes of HypoglycemiaHypoglycemia Medication errorsMedication errors Excessive insulin or oral medicationsExcessive insulin or oral medications Improper timing of insulin in relation Improper timing of insulin in relation

to food intaketo food intake Intensive insulin therapyIntensive insulin therapy Inadequate food intakeInadequate food intake Omitted or inadequate meals or Omitted or inadequate meals or

snackssnacks

Causes of Causes of HypoglycemiaHypoglycemia Delayed meals or snacksDelayed meals or snacks Increased exercise or activityIncreased exercise or activity Unplanned activitiesUnplanned activities Prolonged duration or increased Prolonged duration or increased

intensity of exerciseintensity of exercise Alcohol intake without foodAlcohol intake without food

Diabetic Ketoacidosis Diabetic Ketoacidosis (DKA)(DKA) Caused by hyperglycemiaCaused by hyperglycemia Life-threatening but reversibleLife-threatening but reversible Severe disturbances in carbohydrate, Severe disturbances in carbohydrate,

protein, and fat metabolismprotein, and fat metabolism Caused by inadequate insulin for Caused by inadequate insulin for

glucose utilizationglucose utilization Body uses fat for energy, forming Body uses fat for energy, forming

ketonesketones Acidosis results from Acidosis results from ↑ ↑ production and ↓ production and ↓

utilization of fatty acid metabolitesutilization of fatty acid metabolites

Diabetic KetoacidosisDiabetic Ketoacidosis

Elevated blood glucose levels (≥250 Elevated blood glucose levels (≥250 mg/dL but usually <600 mg/dL)mg/dL but usually <600 mg/dL)

Presence of ketones in blood and urinePresence of ketones in blood and urine Polyuria, polydipsia, hyperventilation, Polyuria, polydipsia, hyperventilation,

dehydration, fruity odor, fatiguedehydration, fruity odor, fatigue Can lead to coma and deathCan lead to coma and death Often occurs during acute illness (flu, Often occurs during acute illness (flu,

colds, vomiting and diarrhea)colds, vomiting and diarrhea)

DKA Prevented byDKA Prevented by

SMBGSMBG Testing for ketonesTesting for ketones Medical interventionMedical intervention Appropriate sick day guidelinesAppropriate sick day guidelines

DKA TreatmentDKA Treatment

Supplemental insulinSupplemental insulin Fluid and electrolyte replacementFluid and electrolyte replacement Medical monitoringMedical monitoring

Sick Day Guidelines Sick Day Guidelines

Take usual doses of insulinTake usual doses of insulin– Need for insulin continues or may increase Need for insulin continues or may increase

during illness due to stress hormonesduring illness due to stress hormones– During acute illnesses, testing of plasma During acute illnesses, testing of plasma

glucose and ketones, drinking adequate glucose and ketones, drinking adequate amounts of fluids, and ingesting amounts of fluids, and ingesting carbohydrate are all important. (B) carbohydrate are all important. (B)

– Monitor BG and urine or blood ketones at Monitor BG and urine or blood ketones at least 4x dailyleast 4x daily

– Levels exceeding 240 mg/dL and ketones Levels exceeding 240 mg/dL and ketones are signals that additional insulin is neededare signals that additional insulin is needed


Sick Day GuidelinesSick Day Guidelines

If regular foods are not tolerated, If regular foods are not tolerated, liquid or soft CHO-containing foods liquid or soft CHO-containing foods (regular soft drinks, soup, juices, ice (regular soft drinks, soup, juices, ice cream)cream)– At least 50 grams (3-4 CHO choices) At least 50 grams (3-4 CHO choices)

should be consumed every 3-4 hoursshould be consumed every 3-4 hours Ample amounts of liquid should be Ample amounts of liquid should be

consumed every hourconsumed every hour– If nausea/vomiting, small sips every 15-30 If nausea/vomiting, small sips every 15-30

minutes. If vomiting continues, health care minutes. If vomiting continues, health care team should be notifiedteam should be notified

Sick Day GuidelinesSick Day Guidelines

The health care team should be called The health care team should be called if illness continues for more than 1 if illness continues for more than 1 dayday

Causes of Fasting Causes of Fasting HyperglycemiaHyperglycemia Waning insulin actionWaning insulin action ““Dawn” phenomenonDawn” phenomenon Somogyi Effect (“rebound” Somogyi Effect (“rebound”

hyperglycemia)hyperglycemia)

Waning Insulin ActionWaning Insulin Action

Inadequate insulin dose overnightInadequate insulin dose overnight Requires adjustment of insulin Requires adjustment of insulin

dosesdoses

Dawn PhenomenonDawn Phenomenon

Insulin needs are lower in predawn Insulin needs are lower in predawn period (1-3 a.m.) than at dawn (4-8 period (1-3 a.m.) than at dawn (4-8 a.m.)a.m.)

Excessive hepatic glucose output Excessive hepatic glucose output overnight (type 2)overnight (type 2)

Blood glucose will drop from 1-3 a.m. Blood glucose will drop from 1-3 a.m. and then increaseand then increase

Treat with metformin (type 2) or taking Treat with metformin (type 2) or taking an intermediate insulin at bedtime or an intermediate insulin at bedtime or using a peakless insulin (glargine)using a peakless insulin (glargine)

Somogyi EffectSomogyi Effect

Hypoglycemia followed by “rebound” Hypoglycemia followed by “rebound” hyperglycemia as counter-regulatory hyperglycemia as counter-regulatory hormones are secretedhormones are secreted

Hepatic glucose production is Hepatic glucose production is stimulatedstimulated

Usually caused by excessive Usually caused by excessive exogenous insulinexogenous insulin

Decrease bedtime insulin doses, take Decrease bedtime insulin doses, take intermediate insulin at bedtime, or intermediate insulin at bedtime, or switch to a long-acting insulinswitch to a long-acting insulin

Hyperosmolar Hyperosmolar Hyperglycemic StateHyperglycemic State Extremely high blood glucose level (600-Extremely high blood glucose level (600-

2000 mg/dL) 2000 mg/dL) Absence of or small amounts of ketonesAbsence of or small amounts of ketones Profound dehydrationProfound dehydration Pts have sufficient insulin to prevent Pts have sufficient insulin to prevent

lipolysis and ketosislipolysis and ketosis Occurs in older patients with type 2 Occurs in older patients with type 2

diabetesdiabetes Treatment: hydration and small doses of Treatment: hydration and small doses of

insulin to correct the hyperglycemiainsulin to correct the hyperglycemia

Long Term Long Term ComplicationsComplications

Macrovascular DiseaseMacrovascular Disease

Disease of large blood vessels, Disease of large blood vessels, including cardiovascular diseasesincluding cardiovascular diseases

Begins with insulin resistance, Begins with insulin resistance, which predates diabetes by which predates diabetes by several yearsseveral years

Produces metabolic changes Produces metabolic changes called metabolic syndromecalled metabolic syndrome

Macrovascular DiseaseMacrovascular Disease

Includes coronary heart disease, Includes coronary heart disease, peripheral vascular disease, and peripheral vascular disease, and cerebrovascular diseasecerebrovascular disease

More common, occurs at an More common, occurs at an earlier age, more extensive and earlier age, more extensive and severe in people with diabetessevere in people with diabetes

Women in particular are at riskWomen in particular are at risk

Treatment and Mgt of Treatment and Mgt of CVD riskCVD risk Target A1C as close to normal as Target A1C as close to normal as

possible without significant possible without significant hypoglycemia (B)hypoglycemia (B)

Diets high in fruits, vegetables, Diets high in fruits, vegetables, and whole grains may reduce risk and whole grains may reduce risk (C)(C)

For pts with heart failure, dietary For pts with heart failure, dietary sodium intake of <2000 mg/day sodium intake of <2000 mg/day may reduce symptomsmay reduce symptomsNutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

Treatment and Mgt of Treatment and Mgt of CVD RiskCVD Risk In normotensive and hypertensive In normotensive and hypertensive

individuals, reduced sodium intake individuals, reduced sodium intake (e.g. 2300 mg/day) with diet high in (e.g. 2300 mg/day) with diet high in fruits, vegetables, and low-fat dairy fruits, vegetables, and low-fat dairy products lowers blood pressure (A)products lowers blood pressure (A)

In most individuals, modest weight In most individuals, modest weight loss beneficially affects blood loss beneficially affects blood pressure.(C)pressure.(C)


DyslipidemiaDyslipidemia

11-44% of adults with diabetes11-44% of adults with diabetes Type 2: hypercholesterolemia Type 2: hypercholesterolemia

prevalence is 28-34%; 5-14% have prevalence is 28-34%; 5-14% have high TG; low HDL-C is commonhigh TG; low HDL-C is common

Patients with Type 2 diabetes have Patients with Type 2 diabetes have smaller, denser LDL particles, smaller, denser LDL particles, increasing atherogenicityincreasing atherogenicity

DyslipidemiaDyslipidemia

Primary therapy (lifestyle interventions) Primary therapy (lifestyle interventions) directed at lowering LDL-C to ≤ 100 directed at lowering LDL-C to ≤ 100 mg/dLmg/dL

Pharmacologic therapy at LDL-C>130 Pharmacologic therapy at LDL-C>130 mg/dLmg/dL

If HDL-C is <40 mg/dL, fibric acid If HDL-C is <40 mg/dL, fibric acid treatmenttreatment

Aspirin therapy in adult pts with diabetes Aspirin therapy in adult pts with diabetes and macrovascular disease or for primary and macrovascular disease or for primary prevention in patients >40 years with prevention in patients >40 years with diabetes and CVD risk factors diabetes and CVD risk factors

Dyslipidemia MNTDyslipidemia MNT

Saturated fat should Saturated fat should be limited to 7%be limited to 7%

Substitute CHO or Substitute CHO or MFAMFA

NephropathyNephropathy

In the US diabetic nephropathy In the US diabetic nephropathy occurs in 20-40% of persons with occurs in 20-40% of persons with diabetes and is the single leading diabetes and is the single leading cause of end stage renal disease. cause of end stage renal disease.

American Diabetes Association Standards of medical care in diabetes. Diabetes Care 30:S4-S36, 2007

NephropathyNephropathy

First symptom is First symptom is microalbuminuria (>30 mg daily microalbuminuria (>30 mg daily or 20 mcg/minute)or 20 mcg/minute)

Progresses to clinical albuminuria Progresses to clinical albuminuria (≥300 mg/day), hypertension, (≥300 mg/day), hypertension, ↓ ↓ in in glomerular filtration rateglomerular filtration rate

Albuminuria is a marker for Albuminuria is a marker for increased CVD risk alsoincreased CVD risk also

Nephropathy Nephropathy ScreeningScreening Perform an annual test for Perform an annual test for

microalbuminuria in type 1 diabetic microalbuminuria in type 1 diabetic patients with diabetes duration >5 patients with diabetes duration >5 years and in all type 2 diabetes pts years and in all type 2 diabetes pts (E)(E)

Serum creatinine should be measured Serum creatinine should be measured annually to determine GFR in all annually to determine GFR in all adults with diabetes to stage the level adults with diabetes to stage the level of chronic kidney disease (E)of chronic kidney disease (E)

Nephropathy Nephropathy TreatmentTreatment Glucose and blood pressure Glucose and blood pressure

control should be optimizedcontrol should be optimized MNT: optimize BG control and BP; MNT: optimize BG control and BP;

limit protein to .8-1.0 g/kg in limit protein to .8-1.0 g/kg in individuals in early stage of CKD individuals in early stage of CKD and to .8 g/kg in later stages is and to .8 g/kg in later stages is recommended (B)recommended (B)


RetinopathyRetinopathy

Most frequent cause of new cases of Most frequent cause of new cases of blindness among adults 20-74 years blindness among adults 20-74 years

After 20 years of DM, nearly all pts After 20 years of DM, nearly all pts with Type 1 and >60% of Type 2 with Type 1 and >60% of Type 2 have some retinopathyhave some retinopathy

Laser photocoagulation surgery can Laser photocoagulation surgery can reduce risk of further vision loss but reduce risk of further vision loss but not correct previous lossesnot correct previous losses

NeuropathyNeuropathy

Nerve damage; affects 60-70% of Nerve damage; affects 60-70% of patients with Type 1 and Type 2 patients with Type 1 and Type 2 diabetesdiabetes

Peripheral: affects nerves that control Peripheral: affects nerves that control sensation in the feet and handssensation in the feet and hands

Autonomic: affects various organ Autonomic: affects various organ systems including GI tract, systems including GI tract, cardiovascular systemcardiovascular system

Sexual dysfunction: erectile dysfunction Sexual dysfunction: erectile dysfunction in 35-75% of men with diabetesin 35-75% of men with diabetes

GastroparesisGastroparesis

Delayed or irregular contractions Delayed or irregular contractions of the stomachof the stomach

Symptoms include feelings of Symptoms include feelings of fullness, bloating, nausea, fullness, bloating, nausea, vomiting, diarrhea, constipationvomiting, diarrhea, constipation

Can affect blood glucose controlCan affect blood glucose control

Gastroparesis Gastroparesis TreatmentTreatment Small, frequent mealsSmall, frequent meals Low in fiber and fatLow in fiber and fat Liquid meals if necessaryLiquid meals if necessary Adjustments in insulin Adjustments in insulin

administrationadministration May need to take insulin after the May need to take insulin after the

mealmeal Frequent blood glucose monitoringFrequent blood glucose monitoring

Nutrition Intervention Nutrition Intervention ResourcesResourcesNutrition Intervention Nutrition Intervention ResourcesResources

Dietary Guidelines Dietary Guidelines for Americansfor Americans

Guide to good eatingGuide to good eating Food Guide PyramidFood Guide Pyramid The first step in The first step in

diabetes meal diabetes meal planningplanning

Healthy food choicesHealthy food choices Healthy eatingHealthy eating

Dietary Guidelines Dietary Guidelines for Americansfor Americans

Guide to good eatingGuide to good eating Food Guide PyramidFood Guide Pyramid The first step in The first step in

diabetes meal diabetes meal planningplanning

Healthy food choicesHealthy food choices Healthy eatingHealthy eating

Single-topic Single-topic diabetes diabetes resourcesresources

Individualized Individualized menusmenus

Month of mealsMonth of meals Exchange lists for Exchange lists for

meal planningmeal planning CHO countingCHO counting Calorie countingCalorie counting Fat countingFat counting

Single-topic Single-topic diabetes diabetes resourcesresources

Individualized Individualized menusmenus

Month of mealsMonth of meals Exchange lists for Exchange lists for

meal planningmeal planning CHO countingCHO counting Calorie countingCalorie counting Fat countingFat counting

Metabolic Syndrome Metabolic Syndrome and Diabetes and Diabetes PreventionPrevention

Metabolic SyndromeMetabolic Syndrome

Intra-abdominal obesity (waist Intra-abdominal obesity (waist circumference>40 inches in men circumference>40 inches in men and >35 inches in women)and >35 inches in women)

DyslipidemiaDyslipidemia HypertensionHypertension Glucose intoleranceGlucose intolerance Compensatory hyperinsulinemia ↑ ↑ macrovascular complicationsmacrovascular complications

Metabolic Syndrome Metabolic Syndrome MNTMNT Modest weight lossModest weight loss Improved glycemic controlImproved glycemic control Restricted saturated fatsRestricted saturated fats Increased physical activityIncreased physical activity If weight is not an issue, add MFAIf weight is not an issue, add MFA For For ↑↑ triglycerides triglycerides

– high dose statins or fibric acidhigh dose statins or fibric acid– Fat restriction, fish oil Fat restriction, fish oil

supplementationsupplementation

Finnish Diabetes Finnish Diabetes Prevention StudyPrevention Study 522 middle-aged, overweight 522 middle-aged, overweight

persons with IGTpersons with IGT Randomized to brief diet and Randomized to brief diet and

exercise counseling or intensive exercise counseling or intensive individualized instruction: goal 5% individualized instruction: goal 5% wt reduction, sfa<10% energy, fat wt reduction, sfa<10% energy, fat <30% energy, fiber >15 grams/1000 <30% energy, fiber >15 grams/1000 kcals; physical activity (>150 kcals; physical activity (>150 minutes weekly)minutes weekly)

Tuomilehto J et al: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344;1390:2001.

Finnish Diabetes Finnish Diabetes Prevention StudyPrevention Study

Finnish Diabetes Finnish Diabetes Prevention Study Prevention Study ResultsResults

Tuomilehto J et al: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344;1390:2001.

Diabetes Prevention Diabetes Prevention Program (DPP)Program (DPP) Randomized 3234 persons (45% Randomized 3234 persons (45%

minority) with IGT to placebo, minority) with IGT to placebo, metformin, or lifestyle interventionmetformin, or lifestyle intervention

Subjects in metformin and placebo Subjects in metformin and placebo groups received standard lifestyle groups received standard lifestyle recommendations including recommendations including written information and an annual written information and an annual 20-30 minute individual session20-30 minute individual session

Orchard TJ et al. Ann Int Med 142;611-619, 2005

Diabetes Prevention Diabetes Prevention ProgramProgram Subjects in lifestyle arm expected to Subjects in lifestyle arm expected to

achieve weight loss of at least 7% and achieve weight loss of at least 7% and to perform 150 minutes of physical to perform 150 minutes of physical activity/weekactivity/week

Subjects seen weekly for first 24 Subjects seen weekly for first 24 weeks, then monthlyweeks, then monthly

After 2.8 years, 58% reduction in After 2.8 years, 58% reduction in diabetes progression in lifestyle group diabetes progression in lifestyle group vs 31% in metformin groupvs 31% in metformin group

Prevention/Delay of Prevention/Delay of Type 2 DiabetesType 2 Diabetes Among individuals at high risk for developing Among individuals at high risk for developing

type 2 diabetes, structured programs that type 2 diabetes, structured programs that emphasize lifestyle changes that include emphasize lifestyle changes that include moderate weight loss (7% body weight) and moderate weight loss (7% body weight) and regular physical activity (150 min/week), with regular physical activity (150 min/week), with dietary strategies including reduced calories dietary strategies including reduced calories and reduced intake of dietary fat, can reduce and reduced intake of dietary fat, can reduce the risk for developing diabetes and are the risk for developing diabetes and are therefore recommended. (A) therefore recommended. (A)


Prevention/Delay of Prevention/Delay of Type 2 DiabetesType 2 Diabetes Individuals at high risk for type 2 diabetes Individuals at high risk for type 2 diabetes

should be encouraged to achieve the U.S. should be encouraged to achieve the U.S. Department of Agriculture (USDA) Department of Agriculture (USDA) recommendation for dietary fiber (14 g recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B) grains (one-half of grain intake). (B)

There is not sufficient, consistent information There is not sufficient, consistent information to conclude that low–glycemic load diets to conclude that low–glycemic load diets reduce the risk for diabetes. Nevertheless, reduce the risk for diabetes. Nevertheless, low–glycemic index foods that are rich in fiber low–glycemic index foods that are rich in fiber and other important nutrients are to be and other important nutrients are to be encouraged. (E) encouraged. (E)


Prevention/Delay of Prevention/Delay of Type 2 DiabetesType 2 Diabetes In addition to lifestyle counseling, In addition to lifestyle counseling,

metformin may be considered in those metformin may be considered in those who are at very high risk (combined IFG who are at very high risk (combined IFG and IGT plus other risk factors) and who and IGT plus other risk factors) and who are obese and under 60 years of age. (E) are obese and under 60 years of age. (E)

Monitoring for the development of Monitoring for the development of diabetes in those with pre-diabetes diabetes in those with pre-diabetes should be performed every year. (E) should be performed every year. (E)

Standards of Medical Care for Diabetes. Diabetes Care 31:S12-S54, 2008

MNT in Non-Diabetic MNT in Non-Diabetic HypoglycemiaHypoglycemia

Types of HypoglycemiaTypes of Hypoglycemia Postprandial hypoglycemiaPostprandial hypoglycemia Alimentary hyperinsulinemiaAlimentary hyperinsulinemia Idiopathic reactive hypoglycemiaIdiopathic reactive hypoglycemia Fasting hypoglycemiaFasting hypoglycemia Factitious hypoglycemiaFactitious hypoglycemia

Postprandial Postprandial (Reactive) (Reactive) HypoglycemiaHypoglycemia Blood glucose levels fall below Blood glucose levels fall below

normal 2-5 hours after eatingnormal 2-5 hours after eating Caused by exaggerated insulin Caused by exaggerated insulin

response due to insulin response due to insulin resistance, elevated glucagon-resistance, elevated glucagon-like-peptide-1 (GLP-1) renal like-peptide-1 (GLP-1) renal glycosuria, defects in glucagon glycosuria, defects in glucagon response, high insulin sensitivityresponse, high insulin sensitivity

Alimentary Alimentary Hyperinsulinism Hyperinsulinism (dumping syndrome)(dumping syndrome) Most common type of Most common type of

documented postprandial documented postprandial hypoglycemiahypoglycemia

Seen after gastric surgery; due to Seen after gastric surgery; due to rapid delivery of food to the small rapid delivery of food to the small intestine intestine → → rapid absorption of rapid absorption of glucose glucose → → exaggerated insulin exaggerated insulin responseresponse

Idiopathic Reactive Idiopathic Reactive HypoglycemiaHypoglycemia Normal insulin secretion but Normal insulin secretion but

increased insulin sensitivityincreased insulin sensitivity Reduced response of glucagon to Reduced response of glucagon to

acute hypoglycemiaacute hypoglycemia Rare, but often inappropriately Rare, but often inappropriately

overdiagnosedoverdiagnosed

Fasting HypoglycemiaFasting Hypoglycemia

Usually the result of a serious Usually the result of a serious underlying medical conditionunderlying medical condition

Causes include hormone Causes include hormone deficiency states, certain drugs, deficiency states, certain drugs, insulinoma and other insulinoma and other nonpancreatic tumorsnonpancreatic tumors

Diagnostic criteria: BG<50 mg/dL, Diagnostic criteria: BG<50 mg/dL, especially during symptomatic especially during symptomatic episodesepisodes

Treatment of Treatment of Hypoglycemic Hypoglycemic SymptomsSymptoms Eat small meals and snacks (5-6 Eat small meals and snacks (5-6

small meals)small meals) Spread the intake of CHO through Spread the intake of CHO through

the day (2-4 CHO servings at a the day (2-4 CHO servings at a meal, 1-2 at a snack)meal, 1-2 at a snack)

Avoid foods that contain large Avoid foods that contain large amounts of CHO (regular soda, amounts of CHO (regular soda, syrups, candy, regular yogurt, syrups, candy, regular yogurt, pies, cakes)pies, cakes)

Treatment of Treatment of Hypoglycemic Hypoglycemic SymptomsSymptoms Avoid beverages and foods Avoid beverages and foods

containing caffeinecontaining caffeine Limit or avoid alcoholic Limit or avoid alcoholic

beverages; interferes with the beverages; interferes with the liver’s ability to release stored liver’s ability to release stored glucose; take ETOH with foodglucose; take ETOH with food

Decrease fat intake (fat may Decrease fat intake (fat may increase insulin resistance) increase insulin resistance)

diabetes mnt strategies

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