Diabetes & Endocrine Center Dana Armstrong, RD, CDE ...• For many obese with T2D, weight loss of at least 5% is needed to produce beneficial outcomes in glycemic control, lipids,

Diabetes & Endocrine CenterSalinas Valley Medical Clinic

Dana Armstrong, RD, CDE

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MEDICAL NUTRITION THERAPY Dana Armstrong, RD, CDEDirector, Diabetes ServicesDiabetes & Endocrine CenterSalinas Valley Medical Clinic

MNT Recommendations

1. Promote/support healthful eating patterns, emphasizing a variety of nutrient dense foods, in appropriate portion sizes, to improve overall health and:

• Achieve/Maintain body weight goals

• Attain INDIVIDUALIZED glycemia, blood pressure and lipid goals

• Delay or prevent the complications of diabetes

MNT Recommendations

2. Individualized, consideration given to:

• Personal and cultural food preferences

• Health literacy and numeracy

• Access to healthful food choices

• Barriers, willingness and ability to make behavior changes

• Health status and health goals



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MNT Recommendations3. Maintain the pleasure of eating by:

• Provide nonjudgmental messages about food choices• Limiting food choices only when indicated by scientific

evidence4. Provide practical tools for day-to-day meal planning;

don’t focus on individual macronutrients, micronutrients or a single food

MNT Recommendations

• ALL PWD offered a referral for individualized MNT by a RD knowledgeable and skilled in providing diabetes-specific MNT

• Study with 18,404 PWD

• Only 9.1% had one or more

nutrition visits IN NINE YEARS!

• PWD & providers not aware these services are available

Effect of MNTDrop in HbA1C

Type 1 1.0% - 1.9% Type 2 0.3 to 2.0%

Higher reductions in type 2 diabetes of shorter durationSustained when RD provided

ongoing visits

Drop in Lipids

Triglycerides 11-31%

LDL Cholesterol 7-22%

Total Cholesterol 7-21%



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PRIMARYPREVENTION

Nutrition Recommendations and Interventions for the Prevention of Diabetes

Energy Balance, Overweight & Obesity• Modest weight loss improves insulin resistance

• Recommended for all who have or are at risk for diabetes• Decreases free fatty acid mobilization

• Structured program• Lifestyle change, regular physical activity and

reduce energy and fat intake

• Maintaining wt loss for 5 yrs associated with sustained improvements in A1C & lipids

Power in Prevention• Prevent/delay diabetes

• wt, cut fat and calorie intake, physical activity

• 5-7% wt prevents or delays DM by nearly 60%

• If ≥60, lifestyle changes chances of DM by 70%

30.3 M withDiabetes

84.1 M withPre-Diabetes



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Free Fatty Acids & Insulin Resistance• Most obese individuals have elevated levels of FFAs which

cause peripheral (muscle) and hepatic insulin resistance• FFAs inhibit insulin-stimulated glucose uptake and glycogen

synthesis due to intramyocellular lipids (fat inside the cells)• With increased lipotoxicity, chronic diseases associated

with insulin resistance increase (diabetes, heart disease)• The levels and composition of fat in the diet can have a

significant role in insulin resistance Sears and Perry Lipids in Health and Disease (2015) 14:121

Energy Balance, Overweight & Obesity• To decrease wt, fat the most important nutrient to restrict

• 9 cal/gram in fat vs. 4 cal/gram in protein and carbohydrates• 500 calories/day (3500 calories/wk) = 1 pound/wk

• Exercise - modest effect on weight loss• Improves insulin sensitivity• Acutely lowers blood glucose• Important in long-term maintenance of weight loss

Body Mass Index

0

5

10

15

20

25

30

35

40

45

50

Obese

Overweight

Normal

Underweight

_______________

_______________

_______________

_______________



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BMI – Asian Americans• Cut point for screening for pre-DM and DM2 is 23 kg/m2

(vs. 25 kg/m2)

• At increased risk for DM at lower BMI levels relative to the general population (screenat23.org)

Primary Prevention - QuestionMartha, 5’3”, 158 lbs (BMI 28), has an elevated A1C of 6.3% and does not want to start medication. What’s her best option?

A. Lose 5-10 poundsB. Lose 8-11 poundsC. Decrease her calorie intake by 5-10%D. Decrease her fat intake by 8-11%

Insulin Resistance - QuestionMartha’s central obesity increases her insulin resistance by which of the following mechanisms?

A. Decreased lipolysis in visceral fat cellsB. FFA inhibition of glucose uptake and glycogen synthesis C. Decreased glucose output by the liverD. Inactivation of insulin in the pancreas



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Body Mass IndexMartha’s BMI places her in which weight category?

A. UnderweightB. Normal weightC. OverweightD. Obese

OBESITY MGT FOR TX OF TYPE 2 DIABETES

Diet, Activity and Behavioral Therapy

People who have Overweight or Obesity• Mgt/Wt ↓important for people with T1D, T2D, prediabetes• Intensive lifestyle intervention with frequent follow-up• Wt loss can delay progression from prediabetes to T2D and

is beneficial to the mgt of T2D



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People who have Overweight or Obesity• Reduced calorie interventions show ↓ A1C of 0.3%-2.0%, ↓ meds, quality of life in adults with T2D

• Sustained wt loss (>5 yrs) associate with sustained improvements in A1C and lipid levels

• Focus on 500-750 calorie/day deficit• 1200-1500 calories/day for women• 1500-1800 calories/day for men

People who have Overweight or Obesity• For many obese with T2D, weight loss

of at least 5% is needed to produce beneficial outcomes in glycemic control, lipids, and blood pressure

• Clinical benefits of weight loss are progressive and more intensive weight loss goals (15%) may be appropriate to maximize benefit depending on need, feasibility, and safety

Assessment and Recommendations• BMI calculated and documented at each patient encounter• Providers advise patients who are overweight/obese of

increased risk of CVD and death• Providers assess readiness to achieve weight loss then

jointly determine weight loss goals • Intervention strategies: Diet, exercise, behavior change,

medication therapy and bariatric surgery



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Pharmacotherapy Recommendations• When choosing glucose-lowering meds, consider effect on

weight• Overall, minimize use of any meds associated with wt gain• Weight loss medications may be effective as adjuncts to

diet/ex/behavior change – weigh benefits vs risks• If meds used, if <5% wt loss after 3 months, med should be

discontinued

Cost Per Pound*

Medication $$$ per month**

Ave Wtloss at

ONE year

$$$ / lb lost at ONE year Common Side Effects

Adipex(phentermine)

$56.00 ($41-82)

5.5 lb(6.1%)

$122.18/lb($110.16/1%)

Sympathomimetic amine anorectic: dry mouth, insomnia, dizziness, irritability

Xenical(orlistat) $748 7.48 lb

(9.6%)$1200.00/lb

($935.00/1%)

Lipase inhibitor: abdominal pain, oily stool, headache, fecal urgency, back pain

Belviq(lorcaserin) $318 7.04 lb

(4.5%)$542.05/lb

($942.22/1%)Serotonin agonist: fatigue, hypoglycemia, headache

*Diabetes Care Volume 42, Supplement 1, January 2019 pg S84-85 **Average wholesale price

Cost Per Pound*

Medication $$$ per month**

Ave Wtloss at ONE yr

$$$ / lb lost at ONE year Common Side Effects

Osymia(phentermine & topiramate)

$223 19.58 lb(9.8%)

$136.67/lb($273.06/1%)

Amine anorectic/antiepileptic: paresthesia, xerostomia, constipation, headache

Contrave(naltrexone &

bupropion)$334 9.02

(5.0%)$444.35/lb

($801.60/1%)

Opioid antag & antidepressant: nausea, constipation, headache,vomiting

Saxenda(liraglutide)

$1441 12.98(6.0%)

$1332.20/lb($2882.00/1%)

GLP1: hypoglycemia, nausea, vomiting, diarrhea, constipation, headache

*Diabetes Care Volume 42, Supplement 1, January 2019 pg S84-85 **Average wholesale price



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Bariatric Surgery • Recommended:

• BMI ≥40 (≥37.5 for Asian Am) regardless of DM control or complexity of med mgt

• BMI 35-39.9 (32.5-37.4 for Asian Am) if DM not well controlled despite optimal medications & lifestyle changes

Bariatric Surgery • Considered

• BMI 30-34.9 (27.5-32.4 for Asian Am) if DM not well controlled despite optimal medications & lifestyle changes)

• Adolescents with DM2 and a BMI >35 with uncontrolled glycemia and/or serious comorbidities despite lifestyle and pharmacologic interventions

Bariatric SurgeryAdvantages• Near/complete normalization of

glycemia in 30-63% of pts 1 to 5 years after surgery

• Youth, shorter diabetes duration (<8 yrs), lower A1C, nonuse of insulin associated with higher post-surgery remission rates

• Additional health benefits beyond improved glycemia

Disadvantages• Costly (but possibly cost effective)

• Long-term issues: dumping syndrome, anemia, osteoporosis, vitamin/mineral deficiencies, and rarely, severe hypoglycemia

• Increased rates of depression and other major psychiatric disorders

• DM recurrence in 35-50% of pts after 8 years



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Bariatric Surgery• Performed in high-volume centers with multidisciplinary

teams with experience in mgt of DM and GI surgery

• Need life-long lifestyle support and medical monitoring

• Long-term benefits, cost-effectiveness, and risks in pre-diabetes and diabetes continues to be studied

• Does not address the root causes -- what we eat, our sedentary lifestyle and the social and environmental conditions that drive obesity and disease

SECONDARYPREVENTIONNutrition Recommendations for the Management of Diabetes

CARBOHYDRATES, PROTEINS & FATS

Macronutrients of Medical Nutrition Therapy



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Carbohydrates• Evidence inconclusive for ideal amount of

carbohydrates per day• Important source of energy, fiber, vitamins

and minerals• Important in dietary palatability• Emphasize nutrient-dense CHO sources high

in fiber, including vegetables, fruits, legumes and whole grains

Carbohydrates in Diabetes Management• Amount ingested - primary

determinant of postprandial response

• Monitoring intake - key strategy in achieving glycemic control

• Type of carbohydrate also affects response

Intrinsic Variables Effect Blood Glucose Values• Type of food ingested• Type of starch

• Amylose vs. amylopectin• Style of preparation

• Cooking method and time• Amount of heat or moisture used

• Ripeness• Degree of processing



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Type of Starch

Long Grain:Basmati Rice Jasmin Rice

Short Grain:Sushi RiceSticky Rice

AMYLOPECTIONAMYLOSE

Pasta raises blood sugar faster when it is overcooked.

• Drain pasta when it reaches the chewy texture known in Italian as al dente – this will moderate the starch’s effect on blood glucose

• The longer pasta cooks, the more water-logged its molecules become, making it easier for the body to break it down into glucose

TrueFalse

Extrinsic Variables Effect Blood Glucose Values• Fasting or pre-prandial blood glucose level• Macronutrient distribution of the meal

• More fat, more insulin resistance• True for both type 1 and type 2

• Available insulin• Degree of insulin resistance



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Fiber• Made up of complex carbohydrates

• So complex cannot be broken down or take a long time to break down

• The LONGER it takes to break down, the LONGER it takes the glucose to hit your blood

• GOAL: 14 grams/1000 kcal

Fiber Goal: 25 grams/day (minimum)HIGH FIBER (1 CUP) LOW/NO FIBER21 grams All Bran/Fiber One Cereal 1 gram Cheerios (1 cup)15 grams Beans/Peas/Lentils 0 grams Meat/Fish/Chicken12 grams Corn 0 grams Eggs10 grams Farro 0 grams Oil/Butter/Margarine7 grams Baked potato 1 grams Potato chips (14 chips)6 grams Barley /WW Spaghetti 2 grams White Pasta (1 cup)4-5 grams Oatmeal/Brown Rice 1 gram White Rice (1 cup)4-5 grams Most vegetables 1 gram V-8 Juice (1 cup)3-4 grams Most fruits 0 grams Juice with pulp

Caloric Density – Fiber FILLS UP the stomach with very few calories

400 calories of oil

400 calories of beef

400 calories of vegetables

Every 14 grams of fiber added to the diet cuts calorie intake by 10 percent (because stomach fills up sooner)



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Including fiber, fat, or anything acidic in a meal can moderate CHOs’ effect on blood glucose.

• Fat & fiber are broken down, digested more slowly than other nutrients and slow absorption of CHOs into the blood

• Acidic foods, such as vinegar, have a confirmed but less-well-understood moderating effect on glycemic response

TrueFalse

Sweeteners• Those that HAVE calories

• Nutritive sweeteners• Reduced calorie sweeteners

• Those that HAVE NO calories • Nonnutritive sweeteners

Nutritive Sweeteners - Sucrose• Does not need to be restricted by PWD• Care taken to avoid excess energy intake• Does not glucose more than isocaloric amounts of starch• Broken down into glucose and fructose

• Fructose metabolized almost completely in the liver; directed toward replenishment of liver glycogen & triglyceride synthesis

• Glucose passes through the liver and goes to the muscle where it is metabolized for energy and to fat cells for storage

• Sugar free = No sucrose



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Nutritive Sweeteners - Fructose• Lower postprandial response

• Metabolism occurs primarily in the liver

• Not recommended as sweetening agent

• May adversely effect lipids

• No reason to avoid naturally occurring fructose in fruits & vegs

• Usually accounts for only 3-4% of energy intake

Reduced Calorie Sweeteners: Sugar Alcohols• Lower postprandial response than

fructose, sucrose or glucose• Not completely absorbed so contributes

fewer calories • Subtract ½ of sugar alcohol grams from

total carbohydrate grams

Reduced Calorie Sweeteners: Sugar Alcohols• Produce unpleasant side effects: diarrhea, bloating, gas• Sorbitol, maltitol, erythritol, isomalt, xylitol, lactitol,

mannitol, tagatose



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High Intensity FDA Approved Sweeteners

Non-Nutritive Sweeteners• Saccharin• Acesulfame potassium• Sucralose• Neotame• Advantame

Nutritive Sweeteners*• Aspartame

*Considered nutritive as it contains more than 2% of the calories in an equivalent amount of sugar, as opposed to non-nutritive sweeteners that contain less than 2% of the calories in an equivalent amount of sugar.

GRAS Sweeteners• Siraitia Grosvenorii• Stevia

Multiplier of Sweetness Compared to SucroseSWEETENER BRAND NAME MULTIPLIERSwingle Fruit Extract Nectresse/Monk Fruit in Raw/PureLo 100-250 xAcesulfame K+ Sweet One/Sunett 200 xAspartame Nutrasweet/Equal/Sugar Twin 200 xStevia Truvia/PureVia/Enliten 200-400 xSaccaharin Sweet ‘N Low/Sweet Twin 200-700 xSucralose Splenda 600 xNeotame Newtame 7-13,000 xAdvantame No brand name yet 20,000 x

www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm397725.htm

If a product says “sugar-free” on the label, it is also low in CHOs.

• Definition of sugar-free = no sucrose• A product can be “sugar-free” but have plenty of carbs• Pillsbury Sugar Free Milk Chocolate Brownies® contains 24

grams of carbs per one brownie

TrueFalse



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High Intensity FDA Approved Sweeteners• For PWD accustomed to sugar-sweetened products, may

be an acceptable substitute in moderation

• Do not have significant effect on glycemic control but can reduce overall calorie/CHO intake

• Most studies show benefits with wt loss, but some research suggests an association with weight gain

High Intensity FDA Approved Sweeteners• For those who consume SSBs regularly, a low-cal or

nonnutritive-sweetened beverage may serve as a short-term replacement strategy

• Overall, people encouraged to decrease both SSB and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake

Dietary Fats• Need fat in diet for absorption of fat-soluble vit A, D, E and

K, function of nerves & brain, healthy skin and body cells• Able to obtain from food – do not need to ADD it to food• Major source of calories• Increases insulin resistance – the

more fat in diet, the more insulin required to manage glucose



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Dietary Fat Insulin Resistance Inflammation • Fat in diet causes insulin

resistance• Leads to chronic inflammation• Inflammation is one of the

MAIN reasons people with diabetes have heart attacks, strokes, kidney issues and other problems

Fatty Acid Synthesis Configures the Plasma Membrane for Inflammation in Diabetes, November 2, 2016,Nature 539, 294-298.

Healthy Dietary Fats• A Mediterranean-style eating

pattern – rich in polyunsaturated & monounsaturated fats – can improve both glycemic control and blood lipids

Healthy Dietary Fats – Mono & Polyunsaturated• Unprocessed – no machine involved

• Mono: Avocados, edamame, olives, raw nuts, sesame seeds • Poly: Walnuts, sunflower seeds, fish (salmon, albacore tuna)• All excepting for fish contain fiber • Natural state, with all vitamins and nutrients

• Processed – not in an original form• Mono: Olive, canola, and peanut oils• Poly: Sesame, corn, soybean, safflower oils• Fewer vitamins and nutrients• No fiber



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Healthy Dietary Fats - Omega-3 Fatty Acids• Eating foods rich in long-chain n-3 fatty acids is

recommended to prevent or treat cardiovascular disease• Two or more servings of fish/week

• Fatty fish: wild salmon, mackerel, sardines, herring, anchovies, rainbow trout, albacore tuna (NOT commercially fried fish filets)

• Fish frequently displaces high-saturated fat-containing foods from the diet

Plant sources of Omega 3’s• Green leafy vegetables, seeds, whole

grains, beans and nuts• Richest sources

• Ground flaxseed (flax meal) • Walnuts • Soybeans • Mung Beans

Unhealthy Dietary Fats• Type of fats consumed more

important than total amount of fat in regards to metabolic goals and CVD risk

• Percentage of total calories from saturated fats should be limited and trans fats should be avoided



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Saturated Fats• Animal products main source

• Meat, chicken, pork, fish, poultry skin, cheese, butter, dairy products

• Plant products• Palm, coconut and palm kernel oil

• Solid at room temperature

Trans Fat• Made when manufacturers add hydrogen to

vegetable oil – called “hydrogenation”

• Turn liquid oils into solid fats like shortening and hard margarine

• Hydrogenation increases the shelf life and flavor stability of foods containing these fats

Trans Fats

• Strong link between trans fat and heart disease

• LDL

• HDL

• May increase weight gain and abdominal fat

• May contribute to type 2 diabetes



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• Listed under TOTAL FAT• Loophole

• IF there is less than .5 grams of trans fat in a SERVING• Can be listed as “0” grams and state “trans fat free” on label• Manufacturers just decrease the serving size

• Look for the words “hydrogenated” or “partially hydrogenated”

Spotting a Trans Fat –Look on the Label

Dietary Fat• Primary goal is to reduce risk for CVD

• Increase unsaturated fats• Limit saturated fats (7% of calories)• Dietary cholesterol <200 mg/day• Avoid trans fats

•↓ animal products, added fats, and processed foods as much as possible

• Replace with unsaturated fats and not with refined CHOs

QUESTION: WHEN CAN A FOOD HAVE ZERO

CALORIES AND ZERO CALORIES FROM FAT YET BE 100% FAT?

ANSWER: WHEN IT’S A FDA APPROVED

FOOD LABEL!!

9:00



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Protein in DM Management• Typical intake 1-1.5 g/kg body

weight/d or 15-20% of total calories• Protein intake goals should be

individualized based on current eating patterns

• Some research has found successful management of DM2 and increased satiety with meal plans including 20-30% of total calories from protein

Protein in DM Management

No Kidney Disease

• No evidence adjusting daily level of protein intake will improve health in PWD w/o DM kidney disease

• Research inconclusive regarding ideal amount of protein

Kidney Disease (+RMA/↓GFR)

• Maintained intake at 0.8 g/kg body weight/day

• Reducing amt further not recommended as it does not alter glycemic measures, CVD risk measure or course of GFR decline

ProteinAVERAGE Need/Day Intake/Day

Man 56 grams 102 gramsWoman 45 grams 70 grams

VERY EASY to get all the protein needed in a day



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Protein in DM Management• Protein intake can ENHANCE or INCREASE insulin response

to dietary carbohydrates in Type 2 diabetes • Carbohydrate sources high in protein

(i.e. milk and nuts) SHOULD NOT be used to treat acute or prevent nighttime hypoglycemia due to potential concurrent rise in endogenous insulin

High Protein (Low Carb) Diets• May result in improved glycemia• Challenges with long-term sustainability• Can reduce antihyperglycemic meds for patients with DM2• Not recommended for pregnant/lactating women or

people with/at risk for disordered eating or renal disease• Used with caution in patients taking SGLT2 inhibitors due

to potential risk of ketoacidosis

Optimal Mix of Macronutrients• No ideal percentage of calories from

CHOs, protein and fat for all PWD• Distribution based on individualized

assessment of eating patterns, preferences & metabolic goals

• Emphasis on healthful eating patterns with nutrient-dense foods and less focus on specific nutrients



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Dietary Reference Intakes• To meet the body’s daily nutritional

needs while minimizing risk for chronic diseases• 45-65% calories from carbs • 10-35% calories from protein• 20-35% calories from fat

HEALTHYEATING PATTERNS

Specific Concept Recommendations

Eating Patterns• All members of health care team need to be

knowledgeable of nutrition therapy principles and supportive of implementation

• Emphasis: nutrient-dense foods• Examples of patterns with positive results:

• Plate Method• DASH Diet

• Mediterranean Diet• Plant-based Diet



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Plate Method• Simple/effective approach to glycemia

and wt mgt emphasizing portion control and healthy food choices

• Visual guide showing how to control calories (small plate), CHOs (limited to ¼ of plate) and emphasizes low-CHO, non starchy vegetables

• Consider for DM2 not on insulin, those with limited health literacy/numeracy or older and prone to hypoglycemia

Too Simple? Industry Influence?

French Fries

Apple Juice

White Bread BunIce Cream

Hamburger

Harvard School of Public Health

health.harvard.edu

www.hsph.harvard.edu/nutritionsource



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DASH Diet• Sodium intake 1,500-2300 mg per day• Focus on fruits & vegetables (8–10 servings/day), whole

grains (6-8 servings/day), low-fat dairy (2–3 servings/day), nuts & seeds (4-5 servings/week)

• Limit lean meat, poultry and fish to 6 servings/week• Avoid excessive alcohol consumption

www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf www.nhlbi.nih.gov/health/health-topics/topics/dash

(Dietary Approaches to Stop Hypertension)

Mediterranean Diet Hallmarks• Fresh vegetables

• Fresh fruits

• Legumes

• Tree nuts

• Cereals (bread, pasta and rice)

• Olive oil as main culinary fat

• Aromatic herbs and spices

• Frequent intake of fish and shellfish

• Moderate consumption of wine with meals

• Low intake of meat and animal products, milk and milk products and simple sugars

Whole Food Plant-Based Diets

Minimally processed and unrefined. The whole plant as much as possible.



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Educate YourselfVideos• Dr. Michael Greger: Uprooting

Leading Causes of Death• Dr. Caldwell Esselstyn: Treating the

Cause• Forks Over Knives (documentary)

Online Education • NutritionCME.org (free)• eCornell – Certificate in Plant-based

Nutrition• NutritionFacts.org (weekly video)

Books• The China Study - T. Colin

Campbell• Prevent & Reverse Heart

Disease – Caldwell Esselstyn• Prevent & Reverse Diabetes –

Neal Barnard• Pleasure Trap – Doug Lisle• Engine 2 Diet – Rip Esselstyn



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Educate Your Patients• Give your patients the

information so they know they have this option

• Teach them about plant-based nutrition

• Provide support• 21DayKickStart.org• Forks Over Knives• The Power Plate

The Micronutrients of Medical Nutrition Therapy

versus

Micronutrients

• No clear evidence of benefit from vitamin/mineral supplementation in PWD who do not have underlying deficiencies

• Metformin associated with B12 deficiency• Periodic B12 testing is suggested

particularly in PWD with anemia or peripheral neuropathy



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Micronutrients in Diabetes Management• Focus on nutrition counseling rather than micronutrient

supplementation in order to reach metabolic control• Select groups may need a multivitamin supplement

• Elderly• Pregnant or lactating women• Strict vegetarians/vegans• Those on calorie-restricted diets• Post-RYGB (B12, iron, Vit D)

Lower Glucose Levels• alpha lipoic acid • bitter melon • chromium • cinnamon• devil’s claw • fenugreek

• garlic• ginseng• horse chestnut • panax• psyllium

ASK YOUR PATIENTS WHATSUPPLEMENTS THEY TAKE!

HandoutFromBev



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ALCOHOL IN DIABETES MANAGEMENT

Alcohol is a type of carbohydrate.

• Alcohol is a unique substance• Body processes alcohol before it metabolizes fat, protein or CHOs• A 5-ounce glass of wine typically contains 110 calories, 5 grams of

carbs, and about 13 grams of alcohol (which accounts for 91 of the calories)

TrueFalse

Alcohol in DM Management• Discussed with diabetes mgt team• Abstention

• History of alcohol abuse or dependence• Women during pregnancy• Medical problems

• Liver disease• Pancreatitis• Advanced neuropathy• Severe hypertriglyceridemia



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Alcohol in DM Management• Moderate alcohol consumption has no acute effect on

glucose and insulin concentrations• Carbohydrate co-ingested with alcohol (mixed drink) may

raise blood glucose• Limit intake

• One drink/day for women• Two drinks/day for men

Alcohol in DM Management• What is a drink?

• 5 ounces of wine• 12 ounces of beer• 1½ ounces of a distilled spirit

• ~15 grams alcohol/drink• 7 calories/gram of alcohol

Alcohol in DM Management• Hyperglycemia

• Excessive amounts (>2 drinks per day) on a consistent basis

• Hypoglycemia• Evening consumption may increase the risk of nocturnal

and fasting hypoglycemia, especially in Type 1 diabetes• Consume alcohol with food if using insulin or insulin

secretagogues



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Sugars - QuestionWhich of the following is true about sucrose digestion?A. Sucrose is broken down into glucose & fructose, and the

fructose is metabolized almost completely in the liverB. Sucrose is broken down into glucose & maltose, and the

glucose is metabolized almost completely in the liverC. Sucrose is broken down into glucose & fructose, and the

glucose is metabolized almost completely in the liverD. Sucrose is broken down into glucose & maltose, and the

maltose is metabolized almost completely in the liver

Fats - QuestionOlive oil and canola oil are good sources of:

A. Monounsaturated fatsB. Polyunsaturated fatsC. Saturated fatsD. Trans fats

Fats - QuestionWhich has the most saturated fat per ounce:

A. ChickenB. OlivesC. PeanutsD. Soybean oil



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Fat Distribution

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Chicken Olives Peanuts Soybean Oil

PolyunsaturatedMonounsaturatedSaturated

Kidney Disease - QuestionWhich dietary modification is beneficial for individuals with diabetes and early stage (+RMA, ↓GFR) kidney disease?

A. No modification necessaryB. Reduce protein to 0.8 kg/body weight/dayC. Reduce protein to 0.7 g/kg body weight/dayD. Limit protein to 4 ounces per day

Supplements - Question

You are seeing Brad for nutrition counseling. You perform an assessment and discover he is taking several dietary supplements, which include ginkgo biloba, bilberry, and milk thistle. He says they are very expensive and wants to know if he should continue to take the supplements.



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Supplements - QuestionYour best advice to Brad would be that:

A. Complementary therapies are generally safe because they are “natural”

B. The have a low risk of side effectsC. There is insufficient research to support universal use in

individuals with diabetesD. Supplements are regulated by the FDA

John’s Story

John, who has had type 1 for 25 years and wears and insulin pump, is out celebrating a friend’s birthday at a bar. He’s had 4 rum and cokes and some appetizers. He’s taken insulin for his carbohydrates while he’s been out. When he gets home he checks his blood sugar and he is 162.

Alcohol - QuestionDrinking alcohol puts John at risk for:

A. DKA due to ketone production which occurs with alcohol

B. High blood sugars later during the night or the next day due to gluconeogenesis

C. Hyperglycemia from the alcohol and appetizersD. Hypoglycemia



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SPECIFIC POPULATIONS

Nutrition Interventions for Children & Youth, PWD on Insulin, Pregnancy, Older Adults, Celiac Disease and Eating Disorders

Nutrition Intervention: Youth with Type 1

• Adequate energy to ensure normal growth and development

• Integrate insulin regimes into usual eating and physical activity habits

• New concern – about 25% of new diagnosis now are overweight

Nutrition Intervention: Youth with Type 2• Family and patient must prioritize changes

in eating and physical activity • When insulin not required, metformin

recommended• Victoza approved for use ≥10 yrs old• TODAY study suggested combo tx required

within 2 yrs of diagnosis• Comorbidities may already be present on dx



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Lifestyle Therapy in Youth• Nutrition

• No medication will control blood glucose in the face of uncontrolled eating

• Unlike current approach to type 1 diabetes, fat intake probably should be addressed initially

• Exercise• Increase peripheral glucose utilization

by muscle, decrease body fat• ≥ 60 min physical activity/day

Nutrition Intervention: T1D/T2D on Insulin• Integration of insulin regimen into lifestyle• For those on flexible insulin program,

provide education on carb counting and fat for all meals and snacks

• For those on fixed insulin program, focus on consistent carb intake considering timing and amount to improve BG control and reduce risk of hypo

Nutrition Intervention: MDI/CSII

• Planned Exercise• Adjustment of insulin dose

• Unplanned Exercise• Extra carbohydrate may be needed



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Nutrition Intervention: Pregnancy• Dietitian

• Referral within 48 hours of dx• MNT initiated within 1 week of dx

• Adequate calories for appropriate wt gain• Noncaloric sweeteners if used in moderation• Weight loss not recommended

Pre-pregnancy BMI and Weight Gain

28 2515 15

40 3525

0

5

10

15

20

25

30

35

40

45

Underweight(BMI <18.5)

Normal weight(BMI 18.5-24.9)

Overweight(BMI 25-29.9)

Obese (BMI ≥ 30)

Wei

ght G

ain

(Lbs

)

Nutrition Intervention: Pregnancy• Dietary Reference Intake recommends

a minimum of:• 175 grams/day of carbohydrates• 71 grams/day of protein• 28 grams/day of fiber

• Amount and type of CHO will impact glucose levels, especially post-meal



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Nutrition Intervention: Pregnancy• Focus on food choices for appropriate weight

gain, normoglycemia and absence of ketones• After delivery

• High risk Type 2 diabetes• Lifestyle modifications to ↓ wt and ↑ physical activity• Within 5 yrs - 60% will have T2D and within 30 yrs almost

100% will have T2D• T1D diagnosed in 2% of women with GDM (after delivery)

Nutrition Intervention: Older Adults• Obese older adults may benefit from

modest wt loss of 5-10%• Evaluate nutrition status if involuntary wt

change >10 lbs or 10% of body weight in <6 months

• Daily vitamin supplement may be appropriate, especially with reduced calorie intake

Celiac Disease• 1.6-16.4% of T1D (0.3-1.0% general population)• Destruction of small intestine villi with exposure to gluten• Interferes with nutrient absorption • Diagnosis via blood tests and a biopsy of the small intestine

• Screen for IgA tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels

• Screen for tTG-IgG or DGA-IgG antibodies if IgA deficient



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Celiac Disease• Digestive symptoms more common in

infants and young children• abdominal bloating, diarrhea, vomiting,

constipation, weight loss• Digestive symptoms less likely in adults

• Anemia, fatigue, bone loss, depression, missed periods, infertility or recurrent miscarriage, skin rash

Celiac Disease• Treatment – gluten free diet

• ALL forms of wheat (including durum, semolina, spelt/faro) and related grains (rye, barley and triticale) MUST be eliminated

• This is a lifetime requirement

• Referral to a dietitian• Food selection, label reading, and other strategies to help

manage the disease

GF Whole Grains & Starches• Quinoa• Potatoes• Beans & Peas• Cassava• Corn• Oats*

• Job’s Tears (Hato Mugi)

• Montina(Indian rice grass)

• Sorghum• Teff

• Flax• Amaranth• Millet• Rice• Wild rice• Buckwheat

*Oats are inherently gluten-free, but are frequently contaminated with wheat during growing or processing. Several companies (Bob’s Red Mill, Cream Hill Estates, GF Harvest and Avena Foods) are currently among those that offer pure, uncontaminated oats.



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Nutrition Intervention: Eating Disorders• Seen 10 times more often in women with Type 1 vs. men

with Type 1• One third to half of all women with T1D take less insulin

than needed to control weight• Behavior compromises self-care and metabolic control• Care enormously complicated • Often undiagnosed and untreated

Eating Disorders: Clinical Diagnosis• Bulimia Nervosa

• Binge eating followed by purging• Anorexia Nervosa

• Severe, self imposed restriction on intake, often combined with extreme exercise

• Diabulimia• Not a recognized medical condition• Insulin omission as a tactic to lose weight

Eating Disorders: Clinical Presentation• Weigh less than 85%

of normal

• Intense fear of becoming fat

• Sees self as fat, even though thin

• Extreme exercise

• Misses 3 consecutive menstrual cycles

• Anxiety about or avoidance of being weighed

• Frequent and severe hypoglycemia

• Binging with alcohol

• Severe stress in the family

• Feels unable to stop or control eating

• Denies seriousness of low body wt

• Binge eats 2x’s a week for 3 months

• Frequent DKA

• Excessive exercise

• Use of diet pills, laxatives



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Question - GDMSara has just been diagnosed with gestational diabetes. Her current weight is 176 lbs and her pre-pregnancy BMI was 28. She should be referred to a dietitian for initial MNT:

A. Only if she was overweight at diagnosis

B. Within 48 hours of diagnosis

C. Within 1 week of diagnosis

D. Within 3 weeks of diagnosis

Question - GDMThe recommended total weight gain for Sara’s pregnancy is:

A. 15 poundsB. 15 to 25 poundsC. 25 to 35 poundsD. 28 to 40 pounds

GDM - QuestionDietary Reference Intake for carbohydrate for pregnant women is:

A. 130 grams per dayB. 150 grams per dayC. 175 grams per dayD. 200 grams per day



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Question - Eating DisordersJan is an aerobics instructor with type 1 diabetes on CSII. She teaches 4 classes per day, 6 days a week. She weighs 110 lbs (BMI = 17), and fasting glucose in clinic today is 327 mg/dL. Jan’s BMI places her in which weight category?

A. UnderweightB. Normal weightC. OverweightD. Obese

Question - Body Mass IndexWhich is most important when evaluating her diabetes control?

A. She should eat a snack before each class she teachesB. Her high blood sugar is due to the end of her

honeymoon periodC. She needs to increase her basal rateD. A psychiatrist should be consulted to evaluate her for an

eating disorder

TERTIARYPREVENTION

Nutrition Recommendations for Controlling Diabetes Complications



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Treatment & Management of CVD Risk*• Target A1C as close to normal as

possible without significant hypoglycemia

• Diet high in vegetables, fruits, whole grains and nuts

• Diet low in saturated and trans fats and cholesterol

*Epidemiology of Diabetes Interventions and Complications – follow-up to the DCCT

Treatment & Management of CVD Risk• Sustained weight loss of ≥ 5% is

needed to maintain a decrease in triglycerides

• Sustained weight loss of ≥ 10% is needed to maintain a decrease in total cholesterol and LDL cholesterol

Treatment & Management of CVD Risk - HTN• Predictive of progression of micro/macrovascular

complications• For pts with BP >120/80, lifestyle interventions include:

• Weight loss• Restricting Na+ (<2300 mg/day)• Increase consumption of fruits & vegetables (8-10/day) and LF

dairy products (2-3/day) – DASH Diet• Avoid excessive alcohol consumptions• Increase physical activity



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Biggest BP Bang for the Buck

0

5

10

15

20

25

10 kg Weight Loss(5-20 point drop)Restrict Salt to 2.4 g/day(2-8 point drop)Alcohol ≤ 2 drinks/day (2-4 point drop)Aerobic Ex 30 min/day(4-9 point drop)

DROP IN SBP

Sodium Sources

Processed &

Prepared Foods77%

Natural Sources

12%

Added While

Cooking5%

Added While Eating

6%

Nutrition Intervention: Gastroparesis• GASTROPARESIS – The stomach’s ability to move food into

the small intestine is impaired; up to 50% of people with diabetes will develop gastroparesis. The slow stomach emptying characteristic of this condition can cause nausea, vomiting, a feeling of fullness after eating a small amount of food, bloating, discomfort in the upper abdomen, and a lack of appetite. These symptoms can also be accompanied by erratic blood glucose levels.



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Nutrition Intervention: Gastroparesis• Referral to a dietitian for a low-fat,

low-fiber diet• Avoid high-fat and high-fiber foods

• Fat naturally slows digestion• Fiber is difficult to digest

• Take fluids throughout the meal and sit upright for 1-2 hours after meals

Nutrition Intervention: Gastroparesis• Small, frequent meals

• Reduces the distention of the stomach• Increase number of meals to 4-6 per day

to maintain adequate nutritional intake• May be necessary to consume a liquid

or pureed diet

• Chew food well before swallowing• Low intensity exercise after eating

Nutrition Intervention: Gastroparesis• Daily multivitamin/mineral supplement

if dietary intake is inadequate• Use foods absorbed in the mouth to

treat hypoglycemia (glucose tabs, glucose gels, hard candies)

• Adjust timing of insulin injections• Keep BGs <200 improves stomach

emptying



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High Blood Pressure - QuestionJohn, 5’10”, 195 lbs (BMI 28), has high blood pressure (148/94) and does not want to start medication. What’s his best option?

A. Lose 20 poundsB. Restrict sodium intakeC. Exercise 20 minutes a day, x/weekD. Decrease his wine to less than 3 glasses a day

Meg’s StoryYou are seeing Meg for nutrition counseling, including basic carbohydrate counting. She has a 5 year history of type 2 diabetes and currently weighs 280 lbs. Her total cholesterol is 224 and LDL is 130. During your assessment she shares with you that she is anxious most of the time, but not about anything specifically; she feels that this is causing her to overeat and not be able to lose weight.

Learning - QuestionWhich of the following learning objectives do you establish?

A. Identify carbohydrate foodsB. Record food intake for 1 monthC. Drink non-caloric beverages instead of sodaD. Eat 3 servings of carbohydrates at dinner each evening



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Weight Loss - QuestionMeg wants to know how many pounds she needs to lose to lower and maintain her total and LDL cholesterol levels. You tell her:

A. 14 lbsB. 20 lbsC. 28 lbsD. 40 lbs

Referral - QuestionYou should also consider referring Meg to a:

A. CardiologistB. More experienced dietitianC. Certified diabetes educatorD. Mental health professional

Gastroparesis - Question

Jane has type 1 diabetes and was recently diagnosed with gastroparesis. She is a runner and has not been able to exercise recently due to nausea, vomiting, bloating, and intestinal pain. She experiences lows about 3 times a week.



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Gastroparesis - Question

What hypoglycemia treatment should she use?A. JuiceB. Regular sodaC. Glucose tablets, gels or hard candiesD. Peanut butter crackersE. A, B and C

Gastroparesis - QuestionWhat beneficial modifications can Jane make?

A. Small, frequent meals; reduce fat and fiber intake; exercise after meals; adjust insulin timing.

B. Small, frequent meals; reduce fluid and fiber intake; increase carb intake; adjust insulin timing.

C. Small, frequent meals; reduce fat intake; increase fiber intake; exercise before meals; adjust insulin timing.

D. Small, frequent meals; reduce carb intake; reduce fiber intake; exercise after meals; adjust insulin timing.

MEAL PLANNING

Eating “By The Numbers”



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Tools

• Basic – Plate Method

• Food records - for individual assessment

• In Depth – Exchanges and Carbohydrate Counting

Food Records• Good place for patient and practitioner to start TOGETHER• Eat “normally” and test blood glucose levels pre and post

meal• Be sure to eat “favorite” foods

• Use written record for review• Evaluate effect of food on BG levels

Exchanges: Advantages• Gives emphasis on more than one

nutrient and the importance of the overall content of foods

• Encourages consistency in the timing and amount of meals and snacks

• People desiring to lose weight might find this approach useful



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Exchanges: Disadvantages• Level of understanding

needed to grasp the concept of "exchanging" foods

• Requires learning where an unlisted food fits into the plan

Exchange CHO Prot Fat Cals Examples

Starch 15 3 0-1 80⅓ c rice, pasta, beans,

½ c corn, peas, 1 oz bread, 1- 4” pancake

Fruit 15 0 0 60

sm apple or banana, ½ pear, 2 T. raisins, 1½ c strawberries,

½ to ⅓ c juice

Milk 12 8 Varies Varies 1 c milk, 1 c yogurt

Other 15 Varies Varies Varies

2” sq brownie, 2 small cookies, ½ c ice cream, 3 T SF or 1 T reg syrup

Exchange CHO Prot Fat Cals Examples

Veggies 5 2 0 25 1 c raw vegetables, ½ c cooked vegetables

Protein 0 7 1-8 35-100

1 oz fish, meat, chicken or cheese, ½ c tofu,

1 egg

Fat 0 0 5 45 1 tsp oil, butter, or mayo, 6 almonds or cashews

Free 0-5 0 0 0-25 SF gelatin, 2 tsp SF jam, coffee, tea, spices



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GENERAL RULE for SERVING SIZESExchange Category Measure

StarchCereals/Grains/Pasta/Potato ½ cup

Beans/Lentils/Peas/Rice ⅓ cup Bread/Roll/Crackers 1 ounce

Fruit

Fresh 1 small pieceDried ¼ cup

Juice/Canned/Applesauce ½ cupCubed Melon 1 cup


Milk

Skim, 1%, 2%, Whole 1 cupChocolate ½ cupIce Cream ½ cup

Yogurt 1 cup

Other CHOsCookies 2 small (1¾”) Granola ¼ cup

Cake 1½” square


VegetablesRaw 1 cup

Cooked ½ cupJuice ½ cup

ProteinMeats/Chicken/Fish 1 ounce

Cheese 1 ounceEgg 1



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FatAvocado 1/8

Butter/Margarine/Oil/Mayo 1 tspNuts/Seeds 1 Tbsp

FreeCoffee, tea Unlimited

SF Syrup 1-2 TbspSF Jam/Jelly 2 tsp

LABELS AND LABEL READING

THE OLD

THE NEW



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You are reading the previous label of granola cereal and planning your breakfast. You decide to eat 1½ cups of granola. How many grams of CHOs are you eating?

Serving Measurement Grams of CHOs

Carbohydrate Counting: Advantages• With the focus on carbohydrate,

food and insulin can be matched more precisely to improve glucose control

• Injected insulin can be matched to grams of carbohydrate eaten at any time during the day

• FLEXIBILITY

You need to take insulin for your 1½ cups of granola cereal. You use insulin pens and your carb ratio is 1:8. How much insulin are you going to take for the food? How much would you take if you used an insulin pump?

Delivery Method Ratio Insulin for the food

Insulin Pen 1:8

Insulin Pump 1:8



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Carbohydrate Counting: Disadvantages• With focus only on carbohydrate, easy to lose sight of

overall nutritional quality of foods

Carb References• Doctor’s Pocket Calorie, Fat and Carb

Counter• CalorieKing.com• Diabetesnet.com• Nutrition.gov• Bowes & Church: Food Portions

Commonly Used

Phon

e Ap

ps

Fooducate

Calorie King

My Fitness Pal

PCRM KickstartFitbit

Lose It!



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https://www.danatech.org/

NOTE: The 1 CUP measure is for your convenience ONLY! ALL information provided by the label is based on the WEIGHT (the information in parentheses) of the food serving.

Carbohydrate Factors• Precise way to calculate carbohydrates• Percentage of all food is carbohydrate• Based on WEIGHT not MEASURE• Need scale and a calculator• Example:

• 15% of the weight (in grams) of an apple is carbohydrate



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Article on Carb Factors

Scales – Do the Math For You

Kitrics Nutritional Scale Perfect Portions Scale

The BEST Label of All• SIMPLE FOODS do not have

complicated labels• No fine print or long words

you cannot pronounce on a banana or pear, a box of frozen spinach or a bag of navy beans!



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To Calculate Insulin You Need This Information

Item RequirementFood Carbohydrate Ratio

Grams of CHOs to Be Eaten

Blood Sugar Blood Sugar ReadingGoal Blood SugarCorrection Factor

You Calculate Insulin Know This Formula!• Needed to calculate total insulin needs for both food and

blood glucose levels• For pens/syringes, round up/down to nearest whole

number• Insulin pump calculations use decimal points

CARBS ÷ CARB RATIO + ( BG - GOAL

BG ) ÷ CORRECTION FACTOR

Your blood sugar is 187, your goal BG is 110 and you are eating the following for breakfast. How many grams of carbohydrates are you having and how much insulin will you need to take by syringe if your carb ratio is 1:9 and your correction is 1:36?

Food Amount CarbsEnglish Muffin 1

SF Strawberry Jam 3 Tbsp

Eggs, scrambled 2

Banana, large 1



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Your blood sugar is 187, your goal BG is 110 and you are eating the following for breakfast. How many grams of carbohydrates are you having and how much insulin will you need to take by syringe if your carb ratio is 1:9 and your correction is 1:36?

Item Calculation InsulinBrk = ____ grams 9

BG = 187

Goal = 110 110

Correction = 36 36

Exchanges - QuestionThe Nutrition Facts panel on a food package of cookies reveals 16 g of total carbohydrate and 3 grams of fat per serving. How many carbohydrate servings and fat servings are in 2 servings of the cookies?

A. 1 carb serving and 1/2 fat servingB. 1 carb servings and 1 fat servingC. 2 carb servings and 1 fat servingsD. 2 carb servings and 2 fat servings

Food Intake - QuestionGrace has type 2 diabetes that is controlled by lifestyle modification. Her typical weekday breakfast is ¼ cup egg substitute, 2 slices turkey bacon, 1 slice whole wheat toast with margarine, and ½ cup apple juice. Her 2 hr pp BG generally runs <140. She has noticed, that on weekends when she eats 2 pancakes with sugar-free syrup, ½ banana, and 1 cup skim milk her 2 hr pp generally runs higher. Why?



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Food Intake - AnswerA. Breakfast carbohydrate intake is higher on the weekend

B. Breakfast carbohydrate intake is lower on the weekend

C. Breakfast carbohydrate intake is equivalent at weekday and weekend meals, so physical activity must be lower on the weekends

D. Variation in meal timing is contributing to glucose variation

Food Intake - QuestionGrace’s husband Tom has type 1 diabetes. His insulin:carbratio is 7 and his correction factor is 32 with a target BG of 120. On weekdays his usual breakfast is also a ¼ cup egg substitute, 2 slices turkey bacon, 2 slices of whole wheat toast with margarine, and ½ cup apple juice. On Sundays he usually eats 3 pancakes with 3 T. sugar-free syrup, ½ banana, and 1 cup skim milk.

Insulin Requirement for BreakfastOn Wednesday morning his blood sugar is 235 mg/dL. How much insulin does he require for his breakfast?

A. 8 unitsB. 9 unitsC. 10 unitsD. 11 units



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Math Calculations

• ¼ c egg sub • 2 slices bacon• 2 slice toast • margarine • ½ c juice

• Total

• ___________• ___________• ___________• ___________• ___________

• ___________

Math Calculations

• Insulin for food _______ /_______ = ________

• BG over goal _______ - _______ = ________

• Insulin for BG _______ / _______ = ________

• Total _______ + _______ = ________

Insulin Requirement for Breakfast

On Sunday morning his blood sugar is 75 mg/dL. How much insulin does he require for his breakfast?

A. 9 units

B. 10 units

C. 11 units

D. No insulin as his blood sugar is low



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Math Calculations

• 3 pancakes • 3 T. SF syrup• ½ large banana• 1 cup milk

• Total

• __________• __________• __________• __________

• __________

Math Calculations

• Insulin for food _______ /_______ = ________

• BG over goal _______ - _______ = ________

• Insulin for BG _______ / _______ = ________

• Total _______ + _______ = ________

Insulin Requirement for BreakfastJohn’s carb ratio is 11 and his correction factor is 50 with a target BG of 100. His BG is 155 and he is eating 1 cup of oatmeal, ½ cup milk, and ¾ cup of strawberries. How much insulin does he need?

A. 3 units

B. 4 units

C. 5 units

D. 6 units



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Math Calculations

• 1 c oatmeal• ½ c milk• ¾ c strawberries

• Total

• __________• __________• __________

• __________

Math Calculations

• Insulin for food _______ /_______ = ________

• BG over goal _______ - _______ = ________

• Insulin for BG _______ / _______ = ________

• Total _______ + _______ = ________

~ Ayurvedic Proverb ~

When diet is poor, medicine is of no use.

When diet is pure, medicine is of no need.

11:25 – 11:30

Documents

Diabetes & Endocrine Center Dana Armstrong, RD, CDE ...• For many obese with T2D, weight loss of at least 5% is needed to produce beneficial outcomes in glycemic control, lipids,