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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 newly of 1% of A1C in patients with newly

diagnosed Type 1 diabetesdiagnosed 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

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

MNT in Type 1 DiabetesMNT in Type 1 Diabetes

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

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

MNT in Type 1 DiabetesMNT in Type 1 Diabetes

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

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


MNT Strategies in Type 2 MNT Strategies in Type 2 DiabetesDiabetes Implement lifestyle changes that reduce Implement lifestyle changes that reduce

intakes of energy, saturated and trans fatty intakes of energy, saturated and trans fatty acids, cholesterol, and sodium and increase acids, cholesterol, and sodium and increase physical activity in order to improve physical activity in order to improve glycemia, dyslipidemia, blood pressure (E)glycemia, dyslipidemia, blood 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 blood and meals will be sufficient to achieve blood glucose goals or if medication(s) needs to glucose goals or if medication(s) needs to be combined with MNTbe combined with MNT


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

fruits, vegetables, whole grains, fruits, vegetables, whole grains, legumes, and low fat milk is legumes, and low fat milk is encouraged for good health (B)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 achieving remains a key strategy in achieving glycemic control (A)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 carbohydrates in substituted for other carbohydrates in the meal plan or, if added to the meal the meal plan or, if added to the meal plan, covered with insulin or other plan, covered with insulin or other glucose-lowering medications. Care glucose-lowering medications. Care should be taken to avoid excess should be taken to avoid excess energy intake. (A)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 load The use of glycemic index and load

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


Glycemic IndexGlycemic Index

The blood glucose response of a given The blood glucose response of a given food compared to an equal amount of a food compared to an equal amount of a CHO standard (typically glucose or white CHO standard (typically glucose or white bread)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 mealWhether it is eaten in the context of a meal 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 FoodsGlycemic Load of FoodsFood Glycemic Index Glycemic LoadCarrots 47 3Potato baked 85 26Sweet corn 60 11Apple 38 6Chocolate cake 38 20Corn flakes 92 24Oatmeal 42 9Pumpkin 75 3Sucrose 68 7Krause’s Food & Nutrition Therapy, 12th ed., Appendix 43

Fiber and DiabetesFiber and Diabetes

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

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

Sweeteners and DiabetesSweeteners and Diabetes

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


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

or starchor starch Large amounts may negatively affect Large amounts may negatively affect

lipidslipids No advantage to substituting it for No advantage to substituting it for

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

and vegetablesand 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 calories fats in foods; often deliver as many calories as sucrose-sweetened foodsas sucrose-sweetened foods

Unlikely to have a beneficial effect on blood Unlikely to have a beneficial effect on blood sugarssugars

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 Oneacesulfame-K (Sweet One®®))

Sucralose (SPLENDASucralose (SPLENDA®®))

http://www.sweetone.com/box.html

Nonnutritive SweetenersNonnutritive Sweeteners

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

FDA has established an acceptable daily FDA has established an acceptable daily intake (ADI) for food additivesintake (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, which is ADI of acesulfame K is 15 mg/kg, which is the equivalent of a 60 kg person eating 36 the equivalent of a 60 kg person eating 36 teaspoons of sugar dailyteaspoons of sugar daily

Noncaloric Sweeteners: Noncaloric Sweeteners:

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

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

Protein and DiabetesProtein and Diabetes Insufficient evidence to suggest that Insufficient evidence to suggest that

usual protein intake (15-20% of usual protein intake (15-20% of energy) should be modified (E) energy) should be modified (E)

In individuals with Type 2 diabetes, In individuals with Type 2 diabetes, ingested protein can increase insulin ingested protein can increase insulin response without increasing plasma response without increasing plasma glucose concentrations. Therefore, glucose concentrations. Therefore, protein should not be used to treat protein should not be used to treat acute or prevent nighttime acute 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-term method for weight loss at this time. The long-term effects of protein intake >20% of calories on effects of protein intake >20% of calories on diabetes management and its complications are diabetes management and its complications are unknown. unknown.

Although such diets may produce short-term weight Although such diets may produce short-term weight loss and improved glycemia, it has not been loss and improved glycemia, it has not been established that these benefits are maintained long established that these benefits are maintained long term, and long-term effects on kidney function for term, and long-term effects on kidney function for persons with diabetes are unknown. (E) persons with diabetes 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 (E)Minimize intake of trans-fatty acids (E) Two or more servings of fish per week Two or more servings of fish per week

providing n-3 polyunsaturated fatty providing n-3 polyunsaturated fatty acids are recommended (B)acids are recommended (B)


MFA vs CHOMFA vs CHO

↑ ↑ CHO diet (>55% ) may ↑CHO diet (>55% ) may ↑triglycerides and postprandial glucose triglycerides and postprandial glucose compared with MFA diet↑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 weight Metabolic profile and need for weight loss will determine balance between loss will determine balance between CHO and MFACHO and MFA

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

varies depending on individual 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 fat, energy from CHO, 20-35% from fat, and 10-35% from proteinand 10-35% from protein

Total caloric intake must be Total caloric intake must be appropriate for weight managementappropriate for weight management


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/dlWomenWomen >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 in Blood Pressure Goals in DiabetesDiabetes Patients with diabetes should be Patients with diabetes should be

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

Patients with diabetes should be Patients with diabetes should be treated to a diastolic blood 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 PhytoesterolsFiber and Phytoesterols

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

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

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

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

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

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


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

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

Weight loss medications may be considered in the Weight loss medications may be considered in the treatment of overweight and obese individuals with treatment of overweight and obese individuals with type 2 diabetes and can help achieve a 5–10% weight type 2 diabetes and can help achieve a 5–10% weight loss when combined with lifestyle modification. (B) loss when combined 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 ObesityOverweight, and Obesity 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)Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

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

insulin therapy sometimes results in weight insulin therapy sometimes results in weight gaingain

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

Overtreatment of hypoglycemia should be Overtreatment of hypoglycemia should be avoidedavoided

Adjustments of insulin should be made for Adjustments of insulin should be made for exerciseexercise

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

AlcoholAlcohol

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

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

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 in To reduce risk of nocturnal hypoglycemia in

individuals using insulin or insulin individuals using insulin or insulin secretagogues, alcohol should be consumed secretagogues, alcohol should be consumed with food (E)with food (E)

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

AlcoholAlcohol

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

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

AlcoholAlcohol 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 CVDassociated with a decreased risk of CVD

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

MicronutrientsMicronutrients

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

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

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


““Diabetes” SupplementsDiabetes” Supplements

““Diabetes” SupplementsDiabetes” Supplements

Gymnema sylvestre (herb)Gymnema sylvestre (herb) Vitamin E: Antioxidant - maintains a healthy heart. Vitamin E: Antioxidant - maintains a healthy 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

MicronutrientsMicronutrients

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

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


SodiumSodium

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

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

For people with mild HTN and diabetes—For people with mild HTN and diabetes—should have less than 2400 mg/dayshould 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 Diabetes Goals of MNT for Diabetes in Childrenin Children Maintain normal growth and developmentMaintain normal growth and development

– Evaluate using growth charts every 3-6 monthsEvaluate using growth charts every 3-6 months Base nutrition prescription on the nutrition Base nutrition prescription on the nutrition

assessmentassessment– 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 Energy Estimating Minimum Energy Requirements for YouthRequirements for YouthAgeAge 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 2000 Add 100 kcals/yr to 1000 kcals up to 2000 kcals at age 10kcals at age 10

Girls 12-15Girls 12-15>15 years>15 years

2000 kcals + 50-100 kcals/yr after age 102000 kcals + 50-100 kcals/yr after age 10Calculate as for an adultCalculate as for an adult

Boys 12-15Boys 12-15>15 yr>15 yr

2000 kcals plus 200 kcal/yr after age 102000 kcals plus 200 kcal/yr after age 10Sedentary 16 kcals/lb (30-35 kcals/kg)Sedentary 16 kcals/lb (30-35 kcals/kg)Moderate activity 18 kcals/lb (40 kcals/kg)Moderate activity 18 kcals/lb (40 kcals/kg)Very physically active: 23 kcals/lb (50 Very physically active: 23 kcals/lb (50 kcals/kg)kcals/kg)

MNT for Type 2 Diabetes MNT for Type 2 Diabetes in Youthin 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 AdultsRequirements for AdultsObese and very inactive Obese and very inactive persons and chronic persons and chronic dietersdieters

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 menwomen, sedentary men

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

Active men, very active Active men, very active womenwomen

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

Thin or very active menThin or very active men 20 kcals/lb or 40 kcals/kg20 kcals/lb or 40 kcals/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-Management Basic MNT Self-Management Skills for Persons with DMSkills for Persons 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 prevention signs, symptoms, treatment, and prevention of hypoglycemiaof 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 for monitoring data for problem solvingproblem solving

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 or Adjustments of CHO or

insulin for exerciseinsulin for exercise Grocery shopping Grocery shopping

guidelinesguidelines Guidelines for eating Guidelines for eating

outout Snack choicesSnack choices Mealtime adjustmentsMealtime adjustments

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

Problem solving tips for Problem solving tips for special occasionsspecial occasions

Travel schedule Travel schedule changeschanges

Work shifts if Work shifts if applicableapplicable

Nutrition Self Management Nutrition Self Management for Diabetesfor Diabetes

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

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

or as close to normal as is safely possibleor as close to normal as is safely possible A lipid and lipoprotein profile that reduces A lipid and lipoprotein profile that reduces

the risk for vascular diseasethe risk for vascular disease Blood pressure levels in the normal range Blood pressure levels in the normal range

or as close to normal as is safely possibleor as close to normal as is safely possible

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

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

development of the chronic complications of development of the chronic complications of diabetes by modifying nutrient intake and diabetes by modifying nutrient intake and lifestylelifestyle

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

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

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

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

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

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


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

diabetes should receive individualized MNT; diabetes should receive individualized MNT; such therapy is best provided by a 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 to Nutrition counseling should be sensitive to the personal needs, willingness to change, the personal needs, willingness to change, and ability to make changes of the individual and ability to make changes of the individual with pre-diabetes or diabetes (E)with pre-diabetes or diabetes (E)


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 pertinent and other pertinent medsmeds

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 monitoring, education, use of blood glucose monitoring, diabetes problems/ concernsdiabetes problems/ concerns

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

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

Medications/supplements: medications Medications/supplements: medications taken, vitamin/mineral/supplement use, taken, vitamin/mineral/supplement use, herbal supplementsherbal 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 and Times, sizes, and contents of meals and

snackssnacks 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 exerciseType, amount, and timing of exercise Usual sleep habitsUsual sleep habits

Basic Strategies for Type Basic Strategies for Type 1 Diabetes1 Diabetes For individuals with type 1 diabetes, insulin therapy should be For individuals with type 1 diabetes, insulin therapy should be

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

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

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


Basic Strategies for Type Basic Strategies for Type 2 Diabetes2 Diabetes

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

kcal/day less) is associated with improved kcal/day less) is associated with improved control independent of weight loss.control independent of weight 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 guideUse basic guide 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 PlanThe Diabetes Meal Plan

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 patient collaborative goals (e.g., does the patient

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

Macronutrients Based OnMacronutrients Based On

Patient’s current eating Patient’s current eating habits (CHO, fat, habits (CHO, fat, protein)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 scheduleEvaluate current meal pattern and schedule 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 meal Often start with 3-4 CHO servings per meal

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

Evaluate feasibility of meal plan with patientEvaluate feasibility of meal plan with patient Trial meal plan and evaluate blood glucose Trial meal plan and evaluate blood glucose

recordsrecords Adjust plan as necessaryAdjust plan as necessary

Examples of CHO Examples of CHO Servings Mix and MatchServings Mix and Match 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, especially frequent meals and snacks, especially if taking an insulin secretagogueif taking an insulin secretagogue

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

Meal Plan: InsulinMeal Plan: Insulin

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

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

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

Patients on rapid-acting insulin do not need Patients on rapid-acting insulin do not need a snacka 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 or Can be used for intensive management or

for basic meal planningfor basic meal planning May be most appropriate for Type 1 patients May be most appropriate for Type 1 patients

at desirable weightat 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 therapyCommon side effect of insulin therapy Sometimes affects patients taking Sometimes affects patients taking

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

Hypoglycemia SymptomsHypoglycemia Symptoms

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

Hypoglycemia TreatmentHypoglycemia Treatment

Glucose of 70 mg/dL or lower should be Glucose of 70 mg/dL or lower should be treated immediatelytreated 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 exercise, carbohydrate ingestion, deferral of exercise, change in insulin dosagechange in insulin dosage

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

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


Ingestion of 15-20 grams of glucose (3 Ingestion of 15-20 grams of glucose (3 glucose tablets, ½ cup fruit juice or regular glucose tablets, ½ cup fruit juice or regular soft drink, 6 saltine crackers, 1 tbsp honey soft drink, 6 saltine crackers, 1 tbsp honey or sugar)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 for Glucagon injection may be prescribed for

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


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

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

Causes of HypoglycemiaCauses of Hypoglycemia

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 HypoglycemiaCauses of Hypoglycemia

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 glucose Caused by inadequate insulin for glucose

utilizationutilization Body uses fat for energy, forming ketonesBody uses fat for energy, forming ketones 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 glucose During acute illnesses, testing of plasma glucose

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

– Monitor BG and urine or blood ketones at least Monitor BG and urine or blood ketones at least 4x daily4x daily

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


Sick Day GuidelinesSick Day Guidelines

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

consumed every 3-4 hoursconsumed 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 team minutes. If vomiting continues, health care team should be notifiedshould be notified

Sick Day GuidelinesSick Day Guidelines

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

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

Waning Insulin ActionWaning Insulin Action

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

Dawn PhenomenonDawn Phenomenon

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

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

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

Treat with metformin (type 2) or taking an Treat with metformin (type 2) or taking an intermediate insulin at bedtime or using a intermediate insulin at bedtime or using a peakless insulin (glargine)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 stimulatedHepatic glucose production is stimulated Usually caused by excessive exogenous Usually caused by excessive exogenous

insulininsulin Decrease bedtime insulin doses, take Decrease bedtime insulin doses, take

intermediate insulin at bedtime, or switch to intermediate insulin at bedtime, or switch to a long-acting insulina 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 lipolysis Pts have sufficient insulin to prevent lipolysis

and ketosisand ketosis Occurs in older patients with type 2 diabetesOccurs in older patients with type 2 diabetes Treatment: hydration and small doses of Treatment: hydration and small doses of

insulin to correct the hyperglycemiainsulin to correct the hyperglycemia

Long Term ComplicationsLong Term Complications

Macrovascular DiseaseMacrovascular Disease

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

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

Produces metabolic changes called Produces metabolic changes called metabolic syndromemetabolic 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 earlier More common, occurs at an earlier age, more extensive and severe in age, more extensive and severe in people with diabetespeople 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, and Diets high in fruits, vegetables, and whole grains may reduce risk (C)whole grains may reduce risk (C)

For pts with heart failure, dietary For pts with heart failure, dietary sodium intake of <2000 mg/day may sodium intake of <2000 mg/day may reduce symptomsreduce symptoms


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 pressure.loss beneficially affects blood pressure.(C)(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 mg/dLdirected at lowering LDL-C to ≤ 100 mg/dL

Pharmacologic therapy at LDL-C>130 mg/dLPharmacologic therapy at LDL-C>130 mg/dL If HDL-C is <40 mg/dL, fibric acid treatmentIf HDL-C is <40 mg/dL, fibric acid treatment 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 be Saturated fat should be limited to 7%limited to 7%

Substitute CHO or MFASubstitute CHO or MFA

NephropathyNephropathy

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

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

NephropathyNephropathy

First symptom is microalbuminuria First symptom is microalbuminuria (>30 mg daily or 20 mcg/minute)(>30 mg daily 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 increased Albuminuria is a marker for increased CVD risk alsoCVD risk also

Nephropathy ScreeningNephropathy Screening

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 (E)years and in all type 2 diabetes pts (E)

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

Nephropathy TreatmentNephropathy Treatment

Glucose and blood pressure control Glucose and blood pressure control should be optimizedshould be optimized

MNT: optimize BG control and BP; limit MNT: optimize BG control and BP; limit protein to .8-1.0 g/kg in individuals in protein to .8-1.0 g/kg in individuals in early stage of CKD and to .8 g/kg in early stage of CKD and to .8 g/kg in later stages is recommended (B)later stages is 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 have with Type 1 and >60% of Type 2 have some retinopathysome 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 patients Nerve damage; affects 60-70% of patients with Type 1 and Type 2 diabeteswith Type 1 and Type 2 diabetes

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

Sexual dysfunction: erectile dysfunction in 35-Sexual dysfunction: erectile dysfunction in 35-75% of men with diabetes75% of men with diabetes

GastroparesisGastroparesis

Delayed or irregular contractions of Delayed or irregular contractions of the stomachthe stomach

Symptoms include feelings of fullness, Symptoms include feelings of fullness, bloating, nausea, vomiting, diarrhea, bloating, nausea, vomiting, diarrhea, constipationconstipation

Can affect blood glucose controlCan affect blood glucose control

Gastroparesis TreatmentGastroparesis Treatment

Small, frequent mealsSmall, frequent meals Low in fiber and fatLow in fiber and fat Liquid meals if necessaryLiquid meals if necessary Adjustments in insulin administrationAdjustments in insulin administration 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 ResourcesResources

Dietary Guidelines Dietary Guidelines for Americansfor Americans

Guide to good Guide to good eatingeating

Food Guide Food Guide PyramidPyramid

The first step in The first step in diabetes meal diabetes meal planningplanning

Healthy food Healthy food choiceschoices

Healthy eatingHealthy eating

Single-topic Single-topic diabetes resourcesdiabetes resources

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 Preventionand Diabetes Prevention

Metabolic SyndromeMetabolic Syndrome

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

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

Metabolic Syndrome MNTMetabolic Syndrome MNT

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 supplementationFat restriction, fish oil supplementation

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

with IGTwith IGT Randomized to brief diet and exercise Randomized to brief diet and exercise

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

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 written recommendations including written information and an annual 20-30 information and an annual 20-30 minute individual sessionminute individual session

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

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

weight loss of at least 7% and to perform weight loss of at least 7% and to perform 150 minutes of physical activity/week150 minutes of physical activity/week

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

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

Prevention/Delay of Type Prevention/Delay of Type 2 Diabetes2 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 Type Prevention/Delay of Type 2 Diabetes2 Diabetes Individuals at high risk for type 2 diabetes should Individuals at high risk for type 2 diabetes should

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

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


Prevention/Delay of Type Prevention/Delay of Type 2 Diabetes2 Diabetes In addition to lifestyle counseling, metformin In addition to lifestyle counseling, metformin

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

Monitoring for the development of diabetes Monitoring for the development of diabetes in those with pre-diabetes should be in those with pre-diabetes should be performed every year. (E) 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 (Reactive) Postprandial (Reactive) HypoglycemiaHypoglycemia Blood glucose levels fall below normal Blood glucose levels fall below normal

2-5 hours after eating2-5 hours after eating Caused by exaggerated insulin Caused by exaggerated insulin

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

Alimentary Hyperinsulinism Alimentary Hyperinsulinism (dumping syndrome)(dumping syndrome)

Most common type of documented Most common type of documented postprandial hypoglycemiapostprandial hypoglycemia

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 increased Normal insulin secretion but increased

insulin sensitivityinsulin 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 deficiency Causes include hormone deficiency states, certain drugs, insulinoma and states, certain drugs, insulinoma and other nonpancreatic tumorsother nonpancreatic 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 SymptomsHypoglycemic Symptoms Eat small meals and snacks (5-6 small Eat small meals and snacks (5-6 small

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

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

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

Treatment of Treatment of Hypoglycemic SymptomsHypoglycemic Symptoms Avoid beverages and foods containing Avoid beverages and foods containing

caffeinecaffeine Limit or avoid alcoholic beverages; Limit or avoid alcoholic beverages;

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

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

mnt in diabetes and related disordersblood pressure goals in diabetes patients with diabetes should...

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