medical nutrition therapy for diabetes mellitus -...
TRANSCRIPT
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Medical Nutrition Therapy
for Diabetes Mellitus
Raziyeh Shenavar
MSc. of Nutrition
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Diabetes Mellitus
A group of diseases characterized by high blood
glucose concentrations resulting from defects in
insulin secretion, insulin action, or both.
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Types of Diabetes
Type 1 (IDDM)
Type 2 (NIDDM)
Gestational diabetes mellitus (GDM)
Prediabetes (impaired glucose homeostasis)
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Diagnostic Criteria
Diagnosis Criteria
Diabetes
FBS >126 mg/dl
CPG >200 mg/dl
2hPG >200 mg/dl
Pre-diabetes
Impaired fasting glucose FBS 100-125 mg/dl
Impaired glucose tolerance 2hPG 140-199 mg/dl
Normal FBS <100 mg/dl
2hPG <140 mg/dl
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Prediabetes
(Impaired Glucose Homeostasis)
• Two forms; may have either or both
– Impaired fasting glucose (IFG): fasting plasma
glucose(FPG) above normal
– Impaired glucose tolerance (IGT): plasma glucose
elevated after 75 g glucose load
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Type 1 Diabetes
• Two forms
– Immune mediated: beta cells destroyed by
autoimmune process
– Idiopathic: cause of beta cell function loss
unknown
• Symptoms: hyperglycemia, polyuria, polydipsia,
weight loss, dehydration, electrolyte disturbance, and
ketoacidosis
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Type 2 Diabetes
• Most common form of diabetes accounting for 90% to 95% of
diagnosed cases
• Combination of insulin resistance and beta cell failure (insulin
deficiency)
• Progressive disease: hyperglycemia develops gradually and may
not cause the classic symptoms of type 1 diabetes
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Gestational Diabetes Mellitus (GDM)
• Glucose intolerance with onset or first recognition
during pregnancy
• Occurs in about 7% of pregnancies
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• BMI >25
• Physical inactivity
• High-risk ethnic groups
• Previous delivery of baby >9 lbs or GDM
• Hypertension
• HDL <35 mg/dl or triglycerides >250 mg/dl
• IGT or IFG
• History of vascular disease
Risk Factors for Type 2 Diabetes
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Complications of Diabetes
• Macrovascular
– coronary artery disease (MI)
– cerebrovascular disease (Stroke)
– peripheral vascular disease
• Microvascular
– retinopathy
– nephropathy
– neuropathy
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Lifestyle change
– Increase physical activity
– Moderate weight loss
– Education
– Reduced fat and energy intake
– Regular participant follow-up
– Whole grains and dietary fiber
Management of Pre-Diabetes
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Carbohydrate • Low-carbohydrate diets are not recommended
• Sugars do not increase glycemia more than isocaloric amounts of starch
• Factors influencing glycemic response to foods: glycemic index (GI) and glycemic load (GL)
• Carbohydrate counting; portions of food containing 15 g carbohydrate
• Exchange lists
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What is the Glycemic Index?
• All carbs (except fiber) convert to blood glucose eventually
• GI Reflects the magnitude of blood glucose rise in the first 2 hours
• Ranks foods by how much they raise blood glucose levels compared to
glucose or white bread.
• In general, the lower the rating, the better the quality of carbohydrate.
o Usually low in calories and fat, while also being high in fiber,
nutrients and antioxidants.
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What Is Glycemic Load?
• Glycemic load = glycemic index x actual amount of
available carbohydrates consumed
• Reminder that serving size is still important!
• Low G.I. but a very large serving = high glycemic
load
• Total carb intake is a primary factor in glycemic
response of a meal
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Glycemic Index ranking of selected starchy foods
Lower (GI<70) Intermediate (GI: 70-90) Higher (GI>90)
All bran cereals Oat bran Most dry cereals
Oatmeal, muesli,
pumpernickel bread
Whole-wheat bread Most breads
Most pasta Most muffins Most crackers
Barley Long-grain rice White rice, boiled
Most cookies Most cakes
Yams New potatoes Most potatoes
Most dry beans and lentils Sweet corn Pancakes and waffles
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Fiber
• Recommend same as general public:
variety of fiber-containing foods such as
legumes, fiber-rich cereals (>5
g/serving), fruits, vegetables, and whole
grains
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Sweeteners
Sucrose in food plan should be substituted for other carbohydrate
sources or covered with insulin or glucose-lowering medications
• Sugar alcohols (sorbitol, mannitol, xylitol) cause less rise in blood glucose
• >10g/day may cause GI upset
Non-nutritive Sweeteners
• Aspartame
• Sucralose
• Acesulfame Potassium
• Saccharin (Sweet’n Low, Sugar Twin)
• Cylamates
– Both of these not recommended during pregnancy
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Protein
• Does not affect blood glucose levels in well-controlled
diabetes
• 12-20% of daily calories
• From both animal and vegetable sources
• Vegetable source less nephrotoxic than animal protein
• 3-5oz (100-150g) of meat, fish or poultry daily
• Patient with nephropathy should limit to less than 12%
daily
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Dietary Fat
Saturated Fat: <7% of total calories
Cholesterol: <200 mg/day in people with diabetes
Minimize intake of trans-fatty acids
Two or more servings of fish per week providing n-3
polyunsaturated fatty acids are recommended
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Micronutrients
• Vitamins+Minerals: Routine supplementation is not
necessary
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Exercise
• Improves insulin sensitivity
• Lowers Blood Glucose
• Uses Glycogen Stores
– muscle
– liver
• Increases release of FFA from adipose
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Insulin
• Insulin formulations classified according to their duration of action as well as time of onset & peak activity.
Types of Insulin Preparations:
– Long acting insulin – best used as background (basal) insulin
• NPH, Lente, Ultralente – Short acting insulin
• Regular, Toronto – quickly absorbed and best used at mealtime
– Rapid acting insulin
• Novorapid, lispro (Humalog)– rapidly absorbed and best used at mealtime
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Insulin Type Onset Peak Effect Duration
Rapid-acting
10-15 min
60-90 min
3-5 hrs
Short-acting
30-min
2-3 hrs
6.5 hrs
Intermediate & Long-acting
NPH
Lente
Ultralente
1-3 hrs 1-2 hrs 4-8 hrs
5-8 hrs 6-12 hrs 2-12 hrs
10-18 hrs 10-18 hrs 18-24 hrs
Action Times of Human Insulin Preparations
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• Lose weight if you are overweight
– Lose weight slowly and safely, 1-2 pounds weekly
– Enjoy foods from all food groups. Avoid fad diets that eliminate
any specific foods or groups of foods.
– Eat smaller portions and exercise more
• Exercise to promote or maintain weight loss (consult with your doctor before beginning)
– 30 minutes most days of the week is recommended
– Include aerobic exercise and resistance training for the best results
– Start slowly and increase the duration and intensity of exercise if you are new to exercise.
Nutrition Therapy for Type 2 Diabetes
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• Obtain carbohydrates mainly from fruits, vegetables, whole grains, legumes,
and low-fat or skim milk.
These foods are the best carbohydrate sources
o They are usually high in fiber and high in nutrients your body needs
• Consume at least 130 grams of carbohydrate each day
Low-carbohydrate diets are not recommended for diabetes management
Carbohydrates contain important nutrients
Choose most of your carbohydrates from fruits, vegetables, and whole
grains
• Use sugar substitutes if desired
Use only sugar substitutes that are approved by the FDA
Sugar substitutes can help you enjoy sweet treats more often
Sugar substitutes don’t appear to cause weight loss or control blood
sugars
Nutrition Therapy for Type 2 Diabetes
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• Limit saturated fats, trans fat, and dietary cholesterol
These types of dietary fats and cholesterol can contribute to
heart disease, which is related to diabetes
When you use fats, use liquid oils instead of solid fats when
possible.
• Trans fat are produced by the food industry by taking liquid oils
and changing them into solid fats.
This process improves the shelf life and stability of flavors
of processed foods
Nutrition Therapy for Type 2 Diabetes
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• GDM occurs in ~3.7 % of all pregnancies (8-18% in aboriginal
populations)
– Justifies screening for all pregnant women
• Increased risk of later diabetes in mother
• Carbohydrate-controlled meal plan, adequate energy, normoglycemia, and absence of ketosis.
– Adequate in energy to promote normal weight gain and prevent ketonuria
• Individualize and adjust meal plan throughout pregnancy
• Use of insulin
• Carbohydrate distribution
• Exercise
Nutrition Therapy for Gestational Diabetes Mellitus
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Calories Fat (grams) Protein
(grams)
Carbohydrate
(grams)
Carbohydrates
80 0-1 0-3 15 Starch: breads, cereals and
grains. Starchy vegetables,
and beans, peas, and lentils
60 - - 15 Fruits
Milk
100 0-3 8 12 Fat-free, low-fat, 1%
120 5 8 12 Reduced fat, 2%
160 8 8 12 Whole
Varies Varies Varies 15 Sweets, desserts, and other
carbohydrates
25 - 2 5 Nonstarchy Vegetables
Food Exchange List in Diabetes
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Calories Fat (grams) Protein
(grams)
Carbohydrate
(grams)
Meat and Meat Substitutes
45 0-3 7 - Lean
75 4-8 7 - Medium-fat
100 8+ 7 - High-fat
Varies Varies 7 Varies Plant-based
proteins
45 5 - - Fats
Food Exchange List in Diabetes-cont’d
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Serving Size Food
Bread
1 slice (30 grams) White
1 slice (30 grams) whole-grain
Beans, Peas, and lentils
½ cup Beans, cooked (black, garbanzo, kidney, lima, navy, pinto,
white)
½ cup Peas, cooked (black-eyed, split)
Starchy Vegetables
½ cup Corn
½ cup Peas, green
½ cup Parsnips
¼ large (3 oz)
½ cup or ½ medium (3 oz)
Potato
Baked with skin
Boiled, all kinds
Fruits
1 small fresh fruit
½ cup canned or fresh fruit or unsweetened fruit juice
1 cup Milk
Food Exchange List in Diabetes-cont’d
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