MNT in Diabetes and Related Disorders. key components of diabetes management healthful eating pattern Regular physical activity pharmacotherapy

MNT in Diabetes and Related MNT in Diabetes and Related DisordersDisorders

key components ofkey components ofdiabetes managementdiabetes management

•healthful eating pattern•Regular physical activity•pharmacotherapy.

Goals of nutrition therapyGoals of nutrition therapyTo promote and support healthful

eating patterns, emphasizing a variety

of nutrient dense foods in appropriate portion sizes

Goals of nutrition therapyGoals of nutrition therapy

MNT Strategies in Type 2 MNT Strategies in Type 2 DiabetesDiabetesImplement lifestyle changes that

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

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

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

Carbohydrates in DiabetesCarbohydrates in DiabetesDietary pattern that includes CHO

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

Monitoring CHO, whether by CHO counting, exchange, or estimation remains a key strategy in achieving glycemic control (A)

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

Carbohydrate and Carbohydrate and DiabetesDiabetesSucrose-containing foods can be

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


Carbohydrate and Carbohydrate and DiabetesDiabetesThe use of glycemic index and

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


Glycemic IndexGlycemic Index

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

Glycemic IndexGlycemic IndexInfluenced by various factorsStarch structureFiber contentCooking methodsDegree of processingWhether it is eaten in the context of a

mealPresence or absence of fatA given food can elicit highly variable

responses

Glycemic Index and Glycemic Index and Glycemic Load of FoodsGlycemic Load of FoodsFood Glycemic Index Glycemic Load

Carrots 47 3

Potato baked 85 26

Sweet corn 60 11

Apple 38 6

Chocolate cake 38 20

Corn flakes 92 24

Oatmeal 42 9

Pumpkin 75 3

Sucrose 68 7Krause’s Food & Nutrition Therapy, 12th ed., Appendix 43

Fiber and DiabetesFiber and Diabetes

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

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

Sweeteners and DiabetesSweeteners and DiabetesSugar alcohols and nonnutritive

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


Nutritive Sweeteners: Nutritive Sweeteners: FructoseFructose

Delivers 4 kcals/gramHas lower glycemic index than

sucrose or starchLarge amounts may negatively

affect lipidsNo advantage to substituting it

for sucroseFound naturally in foods such as

fruits and vegetables

Nutritive Sweeteners: Sugar Nutritive Sweeteners: Sugar AlcoholsAlcohols

Sorbitol, mannitol, xylitol, isomalt, lactitol, hydrogenated starch hydrolysates

Lower glycemic response, lower calorie content than sucrose

Not water-soluble so often combined with fats in foods; often deliver as many calories as sucrose-sweetened foods

Unlikely to have a beneficial effect on blood sugars

In large quantities, may cause GI distress and diarrhea

Non-Caloric SweetenersNon-Caloric Sweeteners

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

Aspartame (NutraSweetAspartame (NutraSweet®®))

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

Sucralose (SPLENDASucralose (SPLENDA®®))

Nonnutritive SweetenersNonnutritive SweetenersNonnutritive SweetenersNonnutritive Sweeteners

Include aspartame, acesulfame K, sucralose, and saccharin

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

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

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

Include aspartame, acesulfame K, sucralose, and saccharin

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

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

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

Noncaloric Sweeteners: Noncaloric Sweeteners:

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

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

Protein and DiabetesProtein and DiabetesProtein and DiabetesProtein and Diabetes

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

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

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

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

Protein and DiabetesProtein and DiabetesHigh-protein diets are not recommended as

a method for weight loss at this time. The long-term effects of protein intake >20% of calories on diabetes management and its complications are unknown.

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


Dietary FatDietary FatSaturated Fat: <7% of total

calories (A)Cholesterol: <200 mg/day in

people with diabetesMinimize intake of trans-fatty

acids (E)Two or more servings of fish per

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


MFA vs CHOMFA vs CHO↑ CHO diet (>55% ) may ↑

triglycerides and postprandial glucose compared with ↑ MFA diet

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

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

Optimal Mix of Optimal Mix of MacronutrientsMacronutrients

The best mix of protein, CHO and fat varies depending on individual circumstances

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

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

Diabetes Care 31:S61-S78, 2008

Lipid Goals in DiabetesLipid Goals in DiabetesLDL cholesterol <100 mg/dlHDL cholesterol

Men >40 mg/dlWomen >50 mg/dl

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

Patients with diabetes should be treated to a diastolic blood 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 PhytoesterolsSoluble fiber: 3 grams of soluble

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

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

Energy Balance, Overwt Energy Balance, Overwt and Obesityand Obesity

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

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

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


Energy Balance, Overwt Energy Balance, Overwt and Obesityand Obesity

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

Weight loss medications may be considered in the treatment of overweight and obese individuals with type 2 diabetes and can help achieve a 5–10% weight 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 ObesityBariatric surgery may be

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

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


Energy Balance and Energy Balance and ObesityObesityImproved glycemic control with

intensive insulin therapy sometimes results in weight gain

Insulin therapy should be integrated into usual eating and exercise habits

Overtreatment of hypoglycemia should be avoided

Adjustments of insulin should be made for exercise

Obesity and PrognosisObesity and Prognosis

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

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

AlcoholAlcoholIn the fasting state, alcohol may

cause hypoglycemia in persons using exogenous insulin or insulin secretagogues

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

AlcoholAlcohol

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

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

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

AlcoholAlcoholOccasional use of alcoholic

beverages should be considered an addition to the regular meal plan, and no food should be omitted

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

AlcoholAlcoholAlcoholAlcohol

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

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

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

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

MicronutrientsMicronutrients

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

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

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

Diabetes Care 31:S61-S78, 2008

““Diabetes” SupplementsDiabetes” Supplements

““Diabetes” SupplementsDiabetes” Supplements

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

heart. Chromium Picolinate: Necessary for proper

carbohydrate metabolism. Selenium: Antioxidant - Helps protect the body

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

system. Alpha Lipoic Acid: Antioxidant - Stimulates other

antioxidantsVanadiumResveratrol

MicronutrientsMicronutrientsMicronutrientsMicronutrients

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

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

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

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

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

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

SodiumSodiumSodiumSodium

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

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

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

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

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

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

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

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

Goals of MNT for Diabetes Goals of MNT for Diabetes in Childrenin Children

Maintain normal growth and development◦ Evaluate using growth charts every 3-6 months

Base nutrition prescription on the nutrition assessment◦ Re-evaluate every 3-6 months

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

Review blood glucose records and revise medication 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 Add 100 kcals/yr to 1000 kcals up to 2000 kcals at age 102000 kcals at age 10

Girls 12-Girls 12-1515

>15 years>15 years

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

Calculate as for an adultCalculate as for an adult

Boys 12-Boys 12-1515

>15 yr>15 yr

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

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

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

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

MNT for Type 2 Diabetes MNT for Type 2 Diabetes in Youthin YouthCessation of excessive weight gainPromotion of normal growth and

development Encourage healthy eating habits and

increased activity for the whole familyAddress other health risk factorsAdd Metformin if lifestyle changes are

insufficient to achieve goals

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

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

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

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

Active men, very Active men, very active womenactive women

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

Thin or very active Thin or very active menmen

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

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

Basic MNT Self-Management Basic MNT Self-Management Skills for Persons with DMSkills for Persons with DM

Basic food and meal planning guidelinesPhysical activity guidelinesSelf-monitoring of blood glucose levelsFor insulin or insulin secretagogue users,

signs, symptoms, treatment, and prevention of hypoglycemia

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

Plans for follow-up and ongoing education

MNT Essential Self-MNT Essential Self-Management SkillsManagement Skills

Sources of CHO, pro, fat

Understanding nutrition labels

Modification of fat intake

Alcohol guidelinesUse of BG

monitoring data for problem solving

Recipes, menu ideas, cookbooks

Vitamin, mineral, botanical supplements

Behavior modification techniques

MNT Essential Self-MNT Essential Self-Management SkillsManagement Skills

Adjustments of CHO or insulin for exercise

Grocery shopping guidelines

Guidelines for eating out

Snack choicesMealtime

adjustments

Use of sugar-containing foods and non-nutritive sweeteners

Problem solving tips for special occasions

Travel schedule changes

Work shifts if applicable

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 Blood glucose levels in the normal

range, or as close to normal as is safely possible

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

Blood pressure levels in the normal range or as close to normal as is safely possibleNutrition 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 DiabetesTo prevent or at least slow the rate of

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

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

To maintain the pleasure of eating by only limiting food choices when indicated by scientific 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 SituationsFor youth with type 1 diabetes, youth

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

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


Effectiveness of MNT Effectiveness of MNT RecommendationsRecommendationsIndividuals who have pre-diabetes or

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

Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes (E)


Diabetes Assessment: Diabetes Assessment: Referral DataReferral DataAgeDiagnosis of

diabetes and other pertinent medical history

Medications, including diabetes and other pertinent meds

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

Blood pressureClearance for

exercise

Diabetes Assessment Diabetes Assessment DataData

Diabetes history: previous diabetes education, use of blood glucose monitoring, diabetes problems/ concerns

Food/nutrient history: current eating habits with beginning modifications

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

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

Diabetes Assessment Diabetes Assessment Data: Diet HistoryData: Diet History

Usual caloric intakeQuality of the usual dietTimes, sizes, and contents of meals

and snacksFood idiosyncrasiesRestaurant eatingWho usually prepares mealsEating problems/intolerancesAlcoholic beverage intakeSupplements used

Diabetes Assessment Diabetes Assessment Data: Daily ScheduleData: Daily ScheduleTime of wakingUsual meal and eating timesWork schedule or school hoursType, amount, and timing of

exerciseUsual sleep habits

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

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

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

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

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


Basic Strategies for Type 2 Basic Strategies for Type 2 DiabetesDiabetes

Encourage weight loss.Moderate calorie restriction (250–500

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

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

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

needed.

Food Guide PyramidFood Guide Pyramid

Use basic guide

Use diabetes-specific guide

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

Recommendations for Recommendations for Weight ManagementWeight Management

Make permanent changes in eating behavior.

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

The Diabetes Meal PlanThe Diabetes Meal PlanThe meal plan should be based

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

patient desire to lose weight?)

Macronutrients Based OnMacronutrients Based On

Patient’s current eating habits (CHO, fat, protein)

Lipid levels and glycemic control

Patient goals

Meal PlanMeal PlanEstimate current energy,

carbohydrate, protein, and fat intakeEvaluate current meal pattern and

scheduleAdjust meal plan to promote

treatment goals (energy, fat, carbohydrate distribution)

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

Meal Plan: Patient on MNT Meal Plan: Patient on MNT OnlyOnlyOften start with 3-4 CHO servings per

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

Evaluate feasibility of meal plan with patient

Trial meal plan and evaluate blood glucose records

Adjust plan as necessary

Examples of CHO Servings Examples of CHO Servings Mix and MatchMix and MatchApple, 1 smallFruit cocktail, ½ cNonfat milk, 1 cOrange juice, ½ cBread, 1 sliceOatmeal, ½ cPasta, 1/3 cPotatoes, ½ c

Brownie, 1 smallYogurt, frozen, ½

cCake, frosted, 2

inch square, (2 CHO)

Corn, ½ cBaked beans 1/3

cHummus 1/3 c

Meal Plan: Oral Meal Plan: Oral MedicationsMedicationsMay do well with smaller, more

frequent meals and snacks, especially if taking an insulin secretagogue

Snack servings should be taken from the meal plan

Meal Plan: InsulinMeal Plan: InsulinCan start with the meal plan and

devise an insulin regimen to fitMany patients require a bedtime

snack to prevent night-time hypoglycemia

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

Patients on rapid-acting insulin do not need a snack

Meal Planning: Meal Planning: Carbohydrate CountingCarbohydrate CountingFocuses on CHO as major driver of

post-prandial blood glucoseCan be used for intensive

management or for basic meal planning

May be most appropriate for Type 1 patients at desirable weight

Must still address energy needs and composition of overall diet

Allows increased flexibility1 carbohydrate serving = 15 grams

Managing Acute Managing Acute ComplicationsComplications

HypoglycemiaHypoglycemiaLow blood glucoseCommon side effect of insulin

therapySometimes affects patients

taking insulin secretagoguesCan be life-threatening

Hypoglycemia SymptomsHypoglycemia Symptoms

ShakinessSweatingPalpitationsHungerSlurred speechMental confusion, disorientationExtreme fatigue, lethargySeizures and unconsciousness

Hypoglycemia TreatmentHypoglycemia Treatment

Glucose of 70 mg/dL or lower should be treated immediately

A level of 60 to 80 mg/dL may require carbohydrate ingestion, deferral of exercise, change in insulin dosage

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

Protein does not help with treatment or prevent recurrence of hypoglycemia

Hypoglycemia TreatmentHypoglycemia Treatment

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

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

Repeat until BG is WNLIf next meal is >1 hour away, take

additional 15 g glucoseGlucagon injection may be prescribed

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

Hypoglycemia TreatmentHypoglycemia TreatmentIndividuals with hypoglycemia

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

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

Causes of HypoglycemiaCauses of HypoglycemiaMedication errorsExcessive insulin or oral

medicationsImproper timing of insulin in

relation to food intakeIntensive insulin therapyInadequate food intakeOmitted or inadequate meals or

snacks

Causes of HypoglycemiaCauses of HypoglycemiaDelayed meals or snacksIncreased exercise or activityUnplanned activitiesProlonged duration or increased

intensity of exerciseAlcohol intake without food

Diabetic Ketoacidosis Diabetic Ketoacidosis (DKA)(DKA)Caused by hyperglycemiaLife-threatening but reversibleSevere disturbances in carbohydrate,

protein, and fat metabolismCaused by inadequate insulin for

glucose utilizationBody uses fat for energy, forming

ketonesAcidosis results from ↑ production and

↓ utilization of fatty acid metabolites

Diabetic KetoacidosisDiabetic KetoacidosisElevated blood glucose levels

(≥250 mg/dL but usually <600 mg/dL)

Presence of ketones in blood and urine

Polyuria, polydipsia, hyperventilation, dehydration, fruity odor, fatigue

Can lead to coma and deathOften occurs during acute illness

(flu, colds, vomiting and diarrhea)

DKA Prevented byDKA Prevented bySMBGTesting for ketonesMedical interventionAppropriate sick day guidelines

DKA TreatmentDKA Treatment

Supplemental insulinFluid and electrolyte replacementMedical monitoring

Sick Day Guidelines Sick Day Guidelines Take usual doses of insulin

◦ Need for insulin continues or may increase during illness due to stress hormones

◦ During acute illnesses, testing of plasma glucose and ketones, drinking adequate amounts of fluids, and ingesting carbohydrate are all important. (B)

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

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


Sick Day GuidelinesSick Day GuidelinesIf regular foods are not tolerated,

liquid or soft CHO-containing foods (regular soft drinks, soup, juices, ice cream)◦ At least 50 grams (3-4 CHO choices) should

be consumed every 3-4 hoursAmple amounts of liquid should be

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

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

Sick Day GuidelinesSick Day Guidelines

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

Causes of Fasting Causes of Fasting HyperglycemiaHyperglycemiaWaning insulin action“Dawn” phenomenonSomogyi Effect (“rebound”

hyperglycemia)

Waning Insulin ActionWaning Insulin Action

Inadequate insulin dose overnightRequires adjustment of insulin

doses

Dawn PhenomenonDawn PhenomenonInsulin needs are lower in predawn

period (1-3 a.m.) than at dawn (4-8 a.m.)

Excessive hepatic glucose output overnight (type 2)

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

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

Somogyi EffectSomogyi EffectHypoglycemia followed by “rebound”

hyperglycemia as counter-regulatory hormones are secreted

Hepatic glucose production is stimulated

Usually caused by excessive exogenous insulin

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

Hyperosmolar Hyperosmolar Hyperglycemic StateHyperglycemic StateExtremely high blood glucose level

(600-2000 mg/dL) Absence of or small amounts of

ketonesProfound dehydrationPts have sufficient insulin to prevent

lipolysis and ketosisOccurs in older patients with type 2

diabetesTreatment: hydration and small doses

of insulin to correct the hyperglycemia

Long Term ComplicationsLong Term Complications

Macrovascular DiseaseMacrovascular DiseaseDisease of large blood vessels,

including cardiovascular diseasesBegins with insulin resistance,

which predates diabetes by several years

Produces metabolic changes called metabolic syndrome

Macrovascular DiseaseMacrovascular DiseaseIncludes coronary heart disease,

peripheral vascular disease, and cerebrovascular disease

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

Women in particular are at risk

Treatment and Mgt of CVD Treatment and Mgt of CVD riskriskTarget A1C as close to normal as

possible without significant hypoglycemia (B)

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

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


Treatment and Mgt of CVD Treatment and Mgt of CVD RiskRiskIn normotensive and hypertensive

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

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


DyslipidemiaDyslipidemia11-44% of adults with diabetesType 2: hypercholesterolemia

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

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

DyslipidemiaDyslipidemia

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

Pharmacologic therapy at LDL-C>130 mg/dL

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

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

Dyslipidemia MNTDyslipidemia MNT

Saturated fat should be limited to 7%

Substitute CHO or MFA

NephropathyNephropathyIn the US diabetic nephropathy

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

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

NephropathyNephropathyFirst symptom is

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

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

Albuminuria is a marker for increased CVD risk also

Nephropathy ScreeningNephropathy ScreeningPerform an annual test for

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

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

Nephropathy TreatmentNephropathy TreatmentGlucose and blood pressure

control should be optimizedMNT: optimize BG control and BP;

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


RetinopathyRetinopathyMost frequent cause of new

cases of blindness among adults 20-74 years

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

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

NeuropathyNeuropathy

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

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

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

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

GastroparesisGastroparesisDelayed or irregular contractions

of the stomachSymptoms include feelings of

fullness, bloating, nausea, vomiting, diarrhea, constipation

Can affect blood glucose control

Gastroparesis TreatmentGastroparesis TreatmentSmall, frequent mealsLow in fiber and fatLiquid meals if necessaryAdjustments in insulin

administrationMay need to take insulin after the

mealFrequent blood glucose

monitoring

Nutrition Intervention Nutrition Intervention ResourcesResourcesNutrition Intervention Nutrition Intervention ResourcesResources

Dietary Guidelines for Americans

Guide to good eatingFood Guide PyramidThe first step in

diabetes meal planning

Healthy food choicesHealthy eating

Dietary Guidelines for Americans

Guide to good eatingFood Guide PyramidThe first step in

diabetes meal planning

Healthy food choicesHealthy eating

Single-topic diabetes resources

Individualized menus

Month of mealsExchange lists for

meal planningCHO countingCalorie countingFat counting

Single-topic diabetes resources

Individualized menus

Month of mealsExchange lists for

meal planningCHO countingCalorie countingFat counting

Metabolic Syndrome and Metabolic Syndrome and Diabetes PreventionDiabetes Prevention

Metabolic SyndromeMetabolic SyndromeIntra-abdominal obesity (waist

circumference>40 inches in men and >35 inches in women)

DyslipidemiaHypertensionGlucose intoleranceCompensatory hyperinsulinemia↑ macrovascular complications

Metabolic Syndrome MNTMetabolic Syndrome MNT

Modest weight lossImproved glycemic controlRestricted saturated fatsIncreased physical activityIf weight is not an issue, add MFAFor ↑ triglycerides

◦high dose statins or fibric acid◦Fat restriction, fish oil

supplementation

Finnish Diabetes Prevention Finnish Diabetes Prevention StudyStudy522 middle-aged, overweight

persons with IGTRandomized to brief diet and

exercise counseling or intensive individualized instruction: goal 5% wt reduction, sfa<10% energy, fat <30% energy, fiber >15 grams/1000 kcals; physical 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 Prevention Finnish Diabetes Prevention StudyStudy

Finnish Diabetes Prevention Finnish Diabetes Prevention Study ResultsStudy 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 Program Diabetes Prevention Program (DPP)(DPP)Randomized 3234 persons (45%

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

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

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

Diabetes Prevention Diabetes Prevention ProgramProgramSubjects in lifestyle arm expected to

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

Subjects seen weekly for first 24 weeks, then monthly

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

Prevention/Delay of Type 2 Prevention/Delay of Type 2 DiabetesDiabetes

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


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

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

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


Prevention/Delay of Type 2 Prevention/Delay of Type 2 DiabetesDiabetesIn addition to lifestyle counseling,

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

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

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

MNT in Non-Diabetic MNT in Non-Diabetic HypoglycemiaHypoglycemia

Types of HypoglycemiaTypes of Hypoglycemia

Postprandial hypoglycemiaAlimentary hyperinsulinemiaIdiopathic reactive hypoglycemiaFasting hypoglycemiaFactitious hypoglycemia

Postprandial (Reactive) Postprandial (Reactive) HypoglycemiaHypoglycemiaBlood glucose levels fall below

normal 2-5 hours after eatingCaused by exaggerated insulin

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

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

documented postprandial hypoglycemia

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

Idiopathic Reactive Idiopathic Reactive HypoglycemiaHypoglycemiaNormal insulin secretion but

increased insulin sensitivityReduced response of glucagon to

acute hypoglycemiaRare, but often inappropriately

overdiagnosed

Fasting HypoglycemiaFasting HypoglycemiaUsually the result of a serious

underlying medical conditionCauses include hormone

deficiency states, certain drugs, insulinoma and other nonpancreatic tumors

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

Treatment of Hypoglycemic Treatment of Hypoglycemic SymptomsSymptomsEat small meals and snacks (5-6

small meals)Spread the intake of CHO through

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

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

Treatment of Hypoglycemic Treatment of Hypoglycemic SymptomsSymptomsAvoid beverages and foods

containing caffeineLimit or avoid alcoholic

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

Decrease fat intake (fat may increase insulin resistance)

PATIENT EDUCATIONPATIENT EDUCATION

T McD Kluyts 127

This is the cornerstone of effective diabetes care.

Sufficient time and resources should be made available in order to do this effectively.

RECORD DEGREE OF RECORD DEGREE OF CONTROLCONTROL

Patients with poor or brittle control, should be seen at least once a month.

Well controlled diabetics can be seen at longer intervals eg 2-4 monthly.

T McD Kluyts 128

WEIGHTWEIGHTAs obesity virtually always

accompanies type 2 diabetes, it should be targeted in its own right.

A weight loss of 5-10% should be the initial aim. It has been shown to improve insulin resistance and all its associated parameters

T McD Kluyts 129

T McD Kluyts 130

WeightWeight

BBody Mass Index (BMI) = Mass in ody Mass Index (BMI) = Mass in kg/Length in meterkg/Length in meter22

Optimal Acceptable

Action needed

BMI <25 20 - 26 >27

WEIGHTWEIGHTEvidence demonstrates

that:• structured, intensive

lifestyle programs

involving participant education,

• reduced dietary fat and energy intake,

• regular physical activity• and frequent participant

contact are necessary to produce long-term weight loss of >5% of starting weight.

T McD Kluyts 131

Exercise RecordExercise Record

The exercise parameters are as follow:•To reach a pulse rate of max – 20% for age and sex and maintain for 20 minutes at least

•3 times per week at least•Walking or running or cycling or swimming or any combination thereof

T McD Kluyts 132

Weight and diet recordWeight and diet record

This should include weekly weight measurements

Dietary notes where indicated to explain weight changes

Doctor/dietician’s comments

T McD Kluyts 133

Glucose control recordGlucose control record

The ideal would be twice daily blood-glucose recording: morning and evening. This might be impossible for unsubsidised patients

to attain, and daily urine testing will have to suffice as a minimum requirement.

Blood glucose should be done fasting in the mornings, and 2 hours postprandial at night.

Urine glucose should be measured fasting in the morning 1 hour after emptying the overnight bladder, and/or 15 minutes after emptying the 2 hour postprandial bladder in the evening.

T McD Kluyts 134

Nutrition Nutrition RecommendationsRecommendationsCarbohydrate

◦60-70% calories from carbohydrates and monounsaturated fats

Protein◦10-20% total calories

Nutrition Nutrition RecommendationsRecommendationsFat

◦ <10% calories from saturated fat◦ 10% calories from PUFA◦ <300 mg cholesterol

Fiber◦ 20-35 grams/day

Alcohol◦ Type I – limit to 2 drinks/day, with meals◦ Type II – substitute for fat calories

2003Diabetic Exchange 2003Diabetic Exchange ListsLists

Food Group CHO(grams)

Protein (grams)

Fat(grams)

Calories

Starch 15 3 0-1 80

Fruit 15 60

MilkSkimLow-FatWhole

121212

888

0-358

90120150

Other Carbohydrate

15 varies varies Varies

Nonstarchy Vegetables

5 2 0 25

2003 Diabetic Exchange 2003 Diabetic Exchange ListsListsFood Group

CHO Protein (grams)

Fat(grams)

Calories

MeatVery Lean 7 0-1 35

LeanMedium FatHigh Fat

777

358

5575100

Fat 5 45

2003 Diabetic Exchange 2003 Diabetic Exchange ListsLists

Carbohydrate Exchanges – 3 g. protein, 0-1 g. fat and 80 calories◦Bread: bagel, bread, English muffin, tortilla◦Cereal: cold and hot cereal, pasta, rice◦Starchy vegetables: corn, peas, potato,

squash◦Crackers and snacks◦Dried beans◦Starch prepared foods with fat: biscuits,

muffins

2003 Diabetic Exchange 2003 Diabetic Exchange ListsListsFruit Exchanges

◦15 grams carbohydrate and 60 calories

◦Fruit and fruit juiceVegetables

◦5 g. carbohydrate, 2. G protein and 25 calories

2003 Diabetic Exchange 2003 Diabetic Exchange ListsListsOther Carbohydrates

◦Exchanges and Serving size vary◦Angel food cake – 2 carbohydrates◦Cake, frosted – 2 carbohydrates, 1

fat◦Donut, plain cake - 1 ½

carbohydrates, 2 fats◦Potato chips – 1 carbohydrate, 2 fats

2003 Diabetic Exchange 2003 Diabetic Exchange ListsListsMilk – 12 g. carbohydrate, 8 g.

protein and 0-8 g. fatMeat and Meat SubstitutesVery Lean Meat (7 g protein, 0-1

g. fat and 35 calories)◦Chicken, turkey – white meat◦Shellfish (clams, crab, lobster,

shrimp)

2003 Diabetic Exchange 2003 Diabetic Exchange ListsListsLean Meat (7 g protein, 3 g. fat

and 55 calories)◦Select or choice beef, trimmed of fat◦Lean pork◦Poultry, turkey –dark meat

2003 Diabetic Exchange 2003 Diabetic Exchange ListsListsMedium Fat Meat (7 g protein, 5 g. fat and

75 calories)◦ Most beef products – corned beef, ribs, prime

grades◦ Ground turkey◦ Chicken – dark meat with skin

High Fat Meat (7 g protein, 8 g. fat and 75 calories)◦ All cheeses◦ Processed meats, hot dogs

Daily Meal PlanDaily Meal Plan

Time Exchanges Menus

8 AM ___Fruit exchanges___Starch exchanges___ Meat exchanges___ Milk exchanges___ Fat exchanges

10 AM

12:30 PM ___ Fruit exchanges___Starch exchanges___ Meat exchanges___ Milk exchanges___ Fat exchanges

6:30 PM ___ Fruit exchanges___Starch exchanges___ Meat exchanges___ Milk exchanges___ Fat exchanges

8 PM

Carbohydrate CountingCarbohydrate CountingA serving of carbohydrate is

considered 15 gramsA serving of fruit or starch or 3

servings of vegetable is = to 1 carbohydrate

One milk serving is considered equal to one carbohydrate

Carbohydrate CountingCarbohydrate CountingExample: Meal plan = 9

carbohydrate servings4 fruit and 5 starches oror3 fruit + 4 starches + 3

vegetables and 1 milk oror2 fruit + 4 starches + 3

vegetables and 2 milk

Daily Meal PlanDaily Meal Plan

Time Grams of Carbohydrate Menus

8 AM ___Carbohydrate choices___ Meat exchanges___ Fat exchanges

10 AM ___ Carbohydrate Choices

12:30 PM ___Carbohydrate choices___ Meat exchanges___ Fat exchanges

6:30 PM ___Carbohydrate choices___ Meat exchanges___ Fat exchanges

8 PM ____ Carbohydrate Choices

Exchange ListsExchange ListsExchange ListsExchange Lists Calories g CHO g Pro g Fat

Starch 80 15 3 0 -1

Fruit 60 15 0 0

Skim Milk 90 12 8 0 - 3

Low-fat Milk 120 12 8 5

Whole Milk 150 12 8 8

Vegetable 25 5 2 0

Very Lean Meat 35 0 7 0 - 1

Lean Meat 55 0 7 3

Medium Fat Meat 75 0 7 5

High Fat Meat 100 0 7 8

Fat 45 0 0 5

Starch GroupStarch GroupStarch GroupStarch Group15 g CHO

◦ 1 slice bread (Belgium 30g)

◦ small tortilla◦ small potato◦ 1/2 cup pasta (60g)◦ 1/2 cup corn (60g)◦ 1/3 cup rice (70g)◦ 3 cups popcorn (180g)

Fruit GroupFruit GroupFruit GroupFruit Group15 grams CHO

◦ small apple◦ small orange◦ 17 grapes◦ 1/2 grapefruit◦ 1 cup cantaloupe◦ 3 prunes◦ 4 ounces orange juice

(120g)

Milk GroupMilk GroupMilk GroupMilk Group15 g CHO each

◦ 1 cup milk (200ml)◦ 3/4 cup plain yogurt (150g)◦ 1 cup aspartame yogurt

(200g)

Vegetable Group Vegetable Group Vegetable Group Vegetable Group 5 grams CHO each

◦ 1 cup raw vegis (225g)◦ 1/2 cup cooked vegis

(100g)◦ 1/2 cup vegetable juice

(150ml)

Digestion TimingDigestion TimingDigestion TimingDigestion TimingPeak Post Prandial BG is typically

1-2 hours after a standard mixed meal.

Liquids (juice/soda) digest quicker.

High fat meals digest slower.

Meal PlanningMeal PlanningMeal PlanningMeal PlanningSet Carbohydrate Intake

◦specific amount of CHO set to match prescribed insulin regimen (less flexible)

Adjust Insulin to Desired Carbo Intake◦insulin to carbohydrate ratio

1 unit per 10-15 g carbohydrate 1 unit for every 50 mg/dl elevated above

target (above doses may vary)

Insulin Action TimesInsulin Action TimesInsulin Action TimesInsulin Action Times

Type of Insulin Start Peak Duration

Humalog “Lispro” 5-15 min 30-90 min 2-4 hrs

Novolog “Aspart” 5-15 min 30-90 min 2-4 hrs

Regular 30-60 min 2-3 hrs 3-6 hrs

NPH 2-4 hrs 4-10 hrs 10-16 hrs

Lente 3-4 hrs 4-12 hrs 12-18 hrs

Ultralente 6-10 hrs no peak 18-20 hrs

Glargine 1 hr no peak 24 hrs

Insulin Delivery Insulin Delivery Insulin Delivery Insulin Delivery SyringesInsulin PensInsulin Pump

◦delivers short acting insulin (sub-Q catheter)

◦adjustable basal rate (usually 0.5-1.0 u/hr)

◦programmable bolus for food or BG correction

Insulin PensInsulin PensInsulin PensInsulin Pens

Pre-filled with 300 units. Disposable.Dial dose in 1 unit increments up to 60 unit

dose.

Insulin PumpInsulin PumpInsulin PumpInsulin Pump

Programmable insulin pump◦ holds 300 units◦ insulin is delivered through sub-Q infusion set/tubing

Remote control◦ discrete dosing

ExerciseExerciseExerciseExerciseImproves insulin

sensitivityLowers Blood

GlucoseUses Glycogen

Stores◦ muscle◦ liver

Increases release of FFA from adipose

For Patients with BMI ≥25 For Patients with BMI ≥25 kg/mkg/m22……

Nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight

Weight loss of 5-10% of initial body weight

Improved insulin sensitivity, glycemic control, blood pressure control, lipid levels

Choose low glycemic index Choose low glycemic index carbohydratescarbohydrates

www.guidelines.diabetes.ca

Clinical assessment

Lifestyle intervention by Registered Dietitian

Initiate intensive lifestyle intervention or energy restriction + increased physical activity to achieve/maintain a healthy body weight

Provide counselling on a diet best suited to the individual based on preferences, abilities, and treatment goals using the advantages/disadvantages listed below

If not at target

Figure 1 – Nutritional management of hyperglycemia in type 2 diabetes

Continue lifestyle intervention and add pharmacotherapy

Timely adjustments to lifestyle intervention and/or pharmacotherapy should be made to attain target A1C within 2 to 3 months for lifestyle intervention alone or 3-6 months for

any combination with pharmacotherapy

2013

A1C = glycated hemoglobinCRP = C reactive proteinTC = total cholesterol

CHO = carbohydrateMUFA = monounsaturated fatty acidLDL = low-density lipoprotein

BP = blood pressureTG = triglyceridesFPG = fasting plasma glucose

GI = gastrointestinal = <1% decrease in A1CHDL = high-density lipoprotein

Properties of Macronutrients

Dietary interventions A1C Advantages Disadvantages

Hi-CHO (low-glycemic index [GI])

HDL-C, CRP, hypoglycemia

-

Hi-CHO (high fibre)

TC, LDL-C HDL-C, GI side effects

Hi-MUFA TG -

Lo-CHO TG Micronutrients, renal load

Hi-protein BP, TG, preserve lean mass

Micronutrients, renal load

Long chain omega 3 fatty acids

TG Methyl-Hg exposure, environmental impact

2013

Properties of Dietary Patterns

Dietary Pattern A1C Advantages Disadvantages

Vegetarian Diet LDL-C, HDL-C Vitamin B12

Mediterranean Diets BP, CRP, TC, HDL-C, TC:HDL-C, TG

none

DASH Weight, BP, CRP, LDL-C, HDL-C

none

Atkins diet Weight, TC, HDL-C, TC:HDL-C, TG

LDL-C, micronutrients, adherence

Protein Power Plan Weight Micronutrients, adherence, renal load

Ornish - Weight, LDL-C:HDL-C FPG, adherence

Weight Watchers - Weight, LDL-C:HDL-C FPG, adherence

Zone Diet - Weight, LDL-C:HDL-C FPG, adherence

Dietary Pulses TC, LDL-C GI side effects

Nuts LDL-C, apo-B, apo-B:apo-A1 none

Meal Replacements weight Temporary intervention

2013

Recommendations 1 and 2Recommendations 1 and 21. People with diabetes should receive nutrition

counseling by a registered dietitian to lower A1C levels [Grade B, Level 2, for type 2 diabetes; Grade D,

Consensus, for type 1 diabetes], and reduce hospitalization rates [Grade C, Level 2]

2. Nutrition education is effective when delivered in either a small group or one-on-one setting [Grade B, Level 2]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role-playing, and group discussions [Grade B, Level 2]

Recommendations 3 and Recommendations 3 and 44

3. Individuals with diabetes should be encouraged to follow Eating Well with Canada’s Food Guide in order to meet their nutritional needs [Grade D, Consensus]

4. In overweight or obese people with diabetes a nutritionally balanced, calorie reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A]

2013

Recommendations 5 and 6Recommendations 5 and 65. In adults with diabetes, the macronutrient

distribution as a percentage of total energy can range from 45-60% carbohydrate, 15-20% protein, and 20-35% fat to allow for individualization of nutrition therapy based on preference and treatment goals [Grade D, consensus]

6. Adults with diabetes should consume no more than 7% of total daily energy from saturated fats [Grade D, Consensus] and should limit intake of trans fatty acids to a minimum [Grade D, Consensus]

2013

2013

Recommendations 7 and Recommendations 7 and 88

7. Added sucrose or added fructose can be substituted for other carbohydrates as part of mixed meals up to a maximum of 10% of total daily energy intake, provided adequate control of BG and lipids is maintained [Grade C,

Level 3]

8. People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D,

Level 4]

Recommendation 9Recommendation 9

9. Dietary advice may emphasize choosing carbohydrate food sources with a low glycemic index to help optimize glycemic control [type 1 diabetes: Grade B, Level 2; type 2 diabetes:

Grade B, Level 2]

Recommendation 10Recommendation 10

10. Alternative dietary patterns may be used in people with T2DM to improve glycemic control, (including):• Mediterranean-style dietary pattern [Grade B,

Level 2]

• Vegan or vegetarian dietary pattern [Grade B, Level 2]

• Incorporation of dietary pulses (e.g., beans, peas, check peas, lentils) [Grade B, Level 2]

• Dietary Approaches to stop Hypertension (DASH) dietary pattern [Grade B, Level 2]

2013

Recommendations 11 and Recommendations 11 and 121211. An intensive lifestyle intervention program

combining dietary modification and increased physical activity may be used to achieve weight loss and improvements in glycemic control, and cardiovascular risk factors [Grade A, Level 1A]

12. People with type 1 diabetes should be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2]; or should maintain consistency in carbohydrate quantity and quality [Grade D, Level 4]

Recommendations 13Recommendations 13

13. People using insulin or insulin secretagogues should be informed of the risk of delayed hypoglycemia resulting from alcohol consumed with or after the previous evening’s meal [Grade C, Level 3] and should be advised on preventive actions such as carbohydrate intake and/or insulin dose adjustments, and increased BG monitoring [Grade D, Consensus].

CDA Clinical Practice CDA Clinical Practice GuidelinesGuidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients

Assessment of Health status must incorporate the entire Assessment of Health status must incorporate the entire bio – psycho-social aspects within the context of the bio – psycho-social aspects within the context of the environment.environment.v Health beliefv Health beliefv Personal habits sleep and wake patterns v Personal habits sleep and wake patterns v Recreational patternsv Recreational patternsv Nutritional patternsv Nutritional patternsv Stress and coping patternsv Stress and coping patternsv Socio-economic statusv Socio-economic statusv Environmental issuesv Environmental issuesv Occupational health patternsv Occupational health patternsv Self concept v Self concept v Cultural, spiritual etcv Cultural, spiritual etcv Family role and relationshipsv Family role and relationshipsv Sexualityv Sexualityv Social supportv Social supportv Emotional healthv Emotional health (Mallik et al 1998) (Mallik et al 1998)

The process of dietary The process of dietary assessment provides an assessment provides an opportunity to explain the types of opportunity to explain the types of dietary changes needed and to dietary changes needed and to explore how these may be met. explore how these may be met.

Documents

MNT in Diabetes and Related Disorders. key components of diabetes management healthful eating pattern Regular physical activity pharmacotherapy