MNT for DM by DrSelim

Medical Nutrit ion Medical Nutrit ion Therapy in Diabetes Therapy in Diabetes

Dr Shahjada SelimDepartment of Endocrinology

Bangabandhu Sheikh Mujib Medical UniversityEmail: [email protected]

mailto:[email protected]

ADA/AACE Diabetes Management Algorithm 2015

The major components of the treatment of diabetes The major components of the treatment of diabetes are:are:

Management of DMManagement of DM

Expected Outcomes of Expected Outcomes of MNT in DiabetesMNT in Diabetes

↓ ↓ of 1% of A1C in patients with newly of 1% of A1C in patients with newly diagnosed Type 1 diabetesdiagnosed Type 1 diabetes

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

↓ ↓ of about 1% of A1C in persons with of about 1% of A1C in persons with Type 2 diabetes of 4-year durationType 2 diabetes of 4-year duration

↓ ↓ LDL-C by 15-25 mg/dL in 3-6 monthsLDL-C by 15-25 mg/dL in 3-6 months

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

MNT in Type 1 DiabetesMNT in Type 1 Diabetes

Insulin therapy should be integrated Insulin therapy should be integrated into an individual’s dietary and into an individual’s dietary and physical activity pattern.physical activity pattern.

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

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

MNT in Type 1 DiabetesMNT in Type 1 Diabetes

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

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


MNT Strategies in Type MNT Strategies in Type 2 Diabetes2 Diabetes Implement lifestyle changes that Implement lifestyle changes that

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


MNT Strategies in Type MNT Strategies in Type 2 Diabetes2 Diabetes

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


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

fruits, vegetables, whole grains, fruits, vegetables, whole grains, legumes, and low fat milk is encouraged legumes, and low fat milk is encouraged for good health.for good health.

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

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

Carbohydrate and DiabetesCarbohydrate and Diabetes

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


Carbohydrate and Carbohydrate and DiabetesDiabetes

The use of glycemic index and load The use of glycemic index and load may provide a modest additional may provide a modest additional benefit over that observed when total benefit over that observed when total CHO is considered alone.CHO is considered alone.


Glycaemic Index

The area under the curve for the increase in blood glucose after the injection of 50 gm of carbohydrate in the food during the 2 hr post prandial period relative to the same amount of carbohydrate from a reference food (i.e.glucose) tested in the same individual under the same conditions and using the initial blood glucose concentration as a baseline.

Glycaemic IndexGlycaemic Index

In simple words, the glycaemic index is a way Of ranking carbohydrate containing foods according to the extent to which they raise blood sugar levels after eating.Formula – Incremental area of the test food GI = --------------------------------------------- x 100 Incremental area of the glucose

Glycemic IndexGlycemic Index

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

Glycemic IndexGlycemic Index

Influenced by various factorsInfluenced by various factors Starch structureStarch structure Fiber contentFiber content Cooking methodsCooking methods Degree of processingDegree of processing Whether it is eaten in the context of a mealWhether it is eaten in the context of a meal Presence or absence of fatPresence or absence of fat A given food can elicit highly variable A given food can elicit highly variable

responsesresponses

GI of different foodsGrains, Cereal products GI

Bread (white) 69

Bread (whole meal) 72

Millet 71

Rice (brown) 66

Rice (white) 72

Sponge cake 46

Breakfast cereals GI

All bran 51

Cornflakes 80

Root Vegetables GI

Beetroot 64

carrots 92

Potato 75

Sweet potato 48

GI of different foodsDried legumes GI

Kidney beans 29

Soya beans 15

Chick peas 36

Lentils 29

Fruits GI

Apples 39

Banana 62

Oranges 40

Orange juice 46

Raisins 64

Sugars GI

Fructose 20

Maltose 105

Sucrose 59

Glucose 100

GI of different foods

Dairy products GI

Ice-cream 36

Milk (skim) 32

Milk (whole) 34

Miscellaneous GI

Honey 87

Peanuts 13

Potato crisps 51

Tomato soup 38

Sausages 28

Fish fingers 38

Fiber and DiabetesFiber and Diabetes

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

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

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

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


Nutrit ive Sweeteners: Nutrit ive Sweeteners: FructoseFructose

Delivers 4 kcals/gramDelivers 4 kcals/gram Has lower glycemic index than sucrose or Has lower glycemic index than sucrose or

starchstarch Large amounts may negatively affect lipidsLarge amounts may negatively affect lipids No advantage to substituting it for sucroseNo advantage to substituting it for sucrose Found naturally in foods such as fruits and Found naturally in foods such as fruits and

vegetablesvegetables

Nutrit ive Sweeteners: Nutrit ive Sweeteners: Sugar AlcoholsSugar Alcohols Sorbitol, mannitol, xylitol, isomalt, Sorbitol, mannitol, xylitol, isomalt,

lactitol, hydrogenated starch lactitol, hydrogenated starch hydrolysateshydrolysates

Lower glycemic response, lower calorie Lower glycemic response, lower calorie content than sucrosecontent than sucrose

Nutrit ive Sweeteners: Nutrit ive Sweeteners: Sugar AlcoholsSugar Alcohols Not water-soluble so often combined Not water-soluble so often combined

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

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

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

Non-Caloric SweetenersNon-Caloric Sweeteners

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

Aspartame (NutraSweetAspartame (NutraSweet®®))

Acesulfame potassium, Acesulfame potassium, acesulfame-K (Sweet Oneacesulfame-K (Sweet One®®))

Sucralose (SPLENDASucralose (SPLENDA®®))

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

Nonnutrit ive SweetenersNonnutrit ive Sweeteners

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

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

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

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

Noncaloric Sweeteners: Noncaloric Sweeteners:

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

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

Recommended Daily Nutrient Sources

Nutrient Consensus guidelines

Carbohydrates 50-60 % of total energy

Proteins 15-20 % of total energy

Fats

Total fat < 30 % of total energy

Saturated fatty acids

< 10 %

Trans fatty acids < 1 %

PUFAs 5-8 %

MUFAs 10-15 %

Source : National Consensus Dietary Guidelines For Healthy Living and prevention of obesity, diabetes and related diseases (2009)

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

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

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


Protein and DiabetesProtein and Diabetes

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

Dietary FatDietary Fat

Saturated Fat: <7% of total caloriesSaturated Fat: <7% of total calories Cholesterol: <200 mg/day in people with Cholesterol: <200 mg/day in people with

diabetesdiabetes Minimize intake of trans-fatty acids.Minimize intake of trans-fatty acids. Two or more servings of fish per week Two or more servings of fish per week

providing n-3 polyunsaturated fatty acids providing n-3 polyunsaturated fatty acids are recommended.are recommended.


MFA vs CHOMFA vs CHO

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

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

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

Optimal Mix of MacronutrientsOptimal Mix of Macronutrients

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

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

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


Fiber and PhytoesterolsFiber and Phytoesterols

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

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

Energy Balance and Energy Balance and ObesityObesity

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


Energy Balance and Energy Balance and ObesityObesity

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

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


Energy Balance, Overwt Energy Balance, Overwt and Obesityand Obesity

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

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

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

Energy Balance and Energy Balance and ObesityObesity Bariatric surgery may be considered for Bariatric surgery may be considered for

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

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


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

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

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

Overtreatment of hypoglycemia should be Overtreatment of hypoglycemia should be avoidedavoided

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

Obesity and PrognosisObesity and Prognosis

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

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

AlcoholAlcohol

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

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

AlcoholAlcohol

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

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


AlcoholAlcohol

In individuals with diabetes, moderate In individuals with diabetes, moderate alcohol consumption (when ingested alcohol consumption (when ingested alone) has no acute effect on glucose alone) has no acute effect on glucose and insulin concentrations, but and insulin concentrations, but carbohydrate coingested with alcohol (as carbohydrate coingested with alcohol (as in a mixed drink) may raise blood in a mixed drink) may raise blood glucose.glucose.


AlcoholAlcohol

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

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

AlcoholAlcohol For individuals with diabetes, light to For individuals with diabetes, light to

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

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

MicronutrientsMicronutrients

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



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



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



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


““Diabetes” SupplementsDiabetes” Supplements


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

healthy heart. healthy heart. Chromium Picolinate: Necessary for Chromium Picolinate: Necessary for

proper carbohydrate metabolism. proper carbohydrate metabolism. Selenium: Antioxidant - Helps protect Selenium: Antioxidant - Helps protect

the body from free radicals. the body from free radicals.


Lutein: promotes eye health Lutein: promotes eye health Folic Acid: Helps maintain heart Folic Acid: Helps maintain heart

health. health. Vitamin C: Antioxidant - Boosts the Vitamin C: Antioxidant - Boosts the

immune system. immune system. Alpha Lipoic Acid: Antioxidant - Alpha Lipoic Acid: Antioxidant -

Stimulates other antioxidantsStimulates other antioxidants VanadiumVanadium Resveratrol Resveratrol


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

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



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


SodiumSodium

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

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

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

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

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

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

assessmentassessment– Re-evaluate every 3-6 monthsRe-evaluate every 3-6 months

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

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

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

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

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

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

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

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

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

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

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

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

insufficient to achieve goalsinsufficient to achieve goals

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

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

Persons >55 yr, active Persons >55 yr, active women, sedentary menwomen, sedentary men

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

Active men, very active Active men, very active womenwomen

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

Thin or very active menThin or very active men 20 kcals/lb or 40 kcals/kg20 kcals/lb or 40 kcals/kg

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

Goals of MNT for Goals of MNT for Prevention and Treatment Prevention and Treatment of Diabetesof DiabetesAchieve and maintain Achieve and maintain Blood glucose levels in the normal range, Blood glucose levels in the normal range,

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

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

or as close to normal as is safely or as close to normal as is safely possiblepossible..

Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2012.

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

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

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

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

Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2012.

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

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

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


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

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

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


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

diabetes and other diabetes and other pertinent medical pertinent medical historyhistory

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

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

Blood pressureBlood pressure Clearance for Clearance for

exerciseexercise

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

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

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

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

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

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

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

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

exerciseexercise Usual sleep habitsUsual sleep habits

Basic Strategies for Basic Strategies for Type 1 DiabetesType 1 Diabetes

For individuals with type 1 diabetes, For individuals with type 1 diabetes, insulin therapy should be integrated into insulin therapy should be integrated into an individual’s dietary and physical an individual’s dietary and physical activity pattern.activity pattern.

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


Basic Strategies for Basic Strategies for T1DMT1DM For individuals using fixed daily insulin For individuals using fixed daily insulin

doses, carbohydrate intake on a day-to-doses, carbohydrate intake on a day-to-day basis should be kept consistent day basis should be kept consistent with respect to time and amount.with respect to time and amount.

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


Basic Strategies for Basic Strategies for T2DMT2DM Encourage weight loss.Encourage weight loss. Moderate calorie restriction (250–500 Moderate calorie restriction (250–500

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

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

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

Food Guide PyramidFood Guide Pyramid

Use basic guideUse basic guide Use diabetes-Use diabetes-

specific guidespecific guide

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

Recommendations for Recommendations for Weight ManagementWeight Management

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

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

The Diabetes Meal PlanThe Diabetes Meal Plan

The meal plan should be based onThe meal plan should be based on– the patient’s current eating habitsthe patient’s current eating habits– diabetes medications, if any diabetes medications, if any – current weight statuscurrent weight status– collaborative goals (e.g., does the collaborative goals (e.g., does the

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

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

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

Lipid levels and Lipid levels and glycemic controlglycemic control

Patient goals.Patient goals.

Meal PlanMeal Plan

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

Evaluate current meal pattern and scheduleEvaluate current meal pattern and schedule Adjust meal plan to promote treatment goals Adjust meal plan to promote treatment goals

(energy, fat, carbohydrate distribution)(energy, fat, carbohydrate distribution) Evaluate based on standard meal planning Evaluate based on standard meal planning

standards (e.g. Food Guide Pyramid)standards (e.g. Food Guide Pyramid)

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

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

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

recordsrecords Adjust plan as necessaryAdjust plan as necessary

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

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

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

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

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

frequent meals and snacks, especially frequent meals and snacks, especially if taking an insulin secretagogueif taking an insulin secretagogue

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

Meal Plan: InsulinMeal Plan: Insulin

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

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

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

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

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

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

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

at desirable weightat desirable weight Must still address energy needs and Must still address energy needs and

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

Managing Acute Managing Acute ComplicationsComplications

HypoglycemiaHypoglycemia

Low blood glucoseLow blood glucose Common side effect of insulin therapyCommon side effect of insulin therapy Sometimes affects patients taking Sometimes affects patients taking

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

Hypoglycemia SymptomsHypoglycemia Symptoms

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

Hypoglycemia TreatmentHypoglycemia Treatment

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

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

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

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


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

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

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

15 g glucose15 g glucose Glucagon injection may be prescribed for Glucagon injection may be prescribed for

pts at risk for severe hypoglycemiapts at risk for severe hypoglycemia



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

Standards of Medical Care for Diabetes Diabetes Care 31:S3-S4, 2012

Causes of HypoglycemiaCauses of Hypoglycemia

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

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

snackssnacks

Causes of HypoglycemiaCauses of Hypoglycemia

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

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

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

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

utilizationutilization Body uses fat for energy, forming ketonesBody uses fat for energy, forming ketones Acidosis results from Acidosis results from ↑ ↑ production and ↓ production and ↓

utilization of fatty acid metabolitesutilization of fatty acid metabolites

Diabetic KetoacidosisDiabetic Ketoacidosis

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

Presence of ketones in blood and Presence of ketones in blood and urineurine

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

Can lead to coma and deathCan lead to coma and death Often occurs during acute illness (flu, Often occurs during acute illness (flu,

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

DKA Prevented byDKA Prevented by

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

DKA TreatmentDKA Treatment

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

Sick Day Guidelines Sick Day Guidelines

Take usual doses of 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.

– 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 Guidelines

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

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

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

30 minutes. If vomiting continues, health 30 minutes. If vomiting continues, health care team should be notifiedcare team should be notified

Sick Day GuidelinesSick Day Guidelines

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

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

Waning Insulin ActionWaning Insulin Action

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

dosesdoses

Dawn PhenomenonDawn Phenomenon

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

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

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

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

Somogyi EffectSomogyi Effect

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

Hepatic glucose production is stimulatedHepatic glucose production is stimulated Usually caused by excessive exogenous Usually caused by excessive exogenous

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

intermediate insulin at bedtime, or switch to intermediate insulin at bedtime, or switch to a long-acting insulina long-acting insulin

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

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

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

insulin to correct the hyperglycemiainsulin to correct the hyperglycemia

Long Term Long Term ComplicationsComplications

Macrovascular DiseaseMacrovascular Disease

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

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

Produces metabolic changes called Produces metabolic changes called metabolic syndromemetabolic syndrome

Macrovascular DiseaseMacrovascular Disease

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

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

Women in particular are at riskWomen in particular are at risk

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

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

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

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

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

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

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


DyslipidemiaDyslipidemia

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

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

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

DyslipidemiaDyslipidemia

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

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

If HDL-C is <40 mg/dL, fibric acid treatmentIf HDL-C is <40 mg/dL, fibric acid treatment Aspirin therapy in adult pts with diabetes Aspirin therapy in adult pts with diabetes

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

Dyslipidemia MNTDyslipidemia MNT

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

Substitute CHO or MFASubstitute CHO or MFA

NephropathyNephropathy

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

American Diabetes Association Standards of medical care in diabetes. Diabetes Care 30:S4-S36, 2012

NephropathyNephropathy

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

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

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

Nephropathy ScreeningNephropathy Screening

Perform an annual test for Perform an annual test for microalbuminuria in type 1 diabetic microalbuminuria in type 1 diabetic patients with diabetes duration >5 patients with diabetes duration >5 years and in all type 2 diabetes pts (E)years and in all type 2 diabetes pts (E)

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

Nephropathy TreatmentNephropathy Treatment

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

MNT: optimize BG control and BP; MNT: optimize BG control and BP; limit protein to .8-1.0 g/kg in individuals limit protein to .8-1.0 g/kg in individuals in early stage of CKD and to .8 g/kg in in early stage of CKD and to .8 g/kg in later stages is recommended (B)later stages is recommended (B)


RetinopathyRetinopathy

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

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

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

NeuropathyNeuropathy

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

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

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

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

GastroparesisGastroparesis

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

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

Can affect blood glucose controlCan affect blood glucose control

Gastroparesis TreatmentGastroparesis Treatment

Small, frequent mealsSmall, frequent meals Low in fiber and fatLow in fiber and fat Liquid meals if necessaryLiquid meals if necessary Adjustments in insulin administrationAdjustments in insulin administration May need to take insulin after the mealMay need to take insulin after the meal Frequent blood glucose monitoringFrequent blood glucose monitoring

Nutrit ion Intervention Nutrit ion Intervention ResourcesResources

Dietary Guidelines Dietary Guidelines for Americansfor Americans

Guide to good Guide to good eatingeating

Food Guide Food Guide PyramidPyramid

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

Healthy food Healthy food choiceschoices

Healthy eatingHealthy eating

Single-topic Single-topic diabetes resourcesdiabetes resources

Individualized Individualized menusmenus

Month of mealsMonth of meals Exchange lists for Exchange lists for

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

Metabolic Syndrome Metabolic Syndrome and Diabetes and Diabetes PreventionPrevention

Metabolic SyndromeMetabolic Syndrome

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

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

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

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

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

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

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

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

Finnish Diabetes Prevention Finnish Diabetes Prevention StudyStudy

Finnish Diabetes Finnish Diabetes Prevention Study Prevention Study ResultsResults

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

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

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

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

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

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

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

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

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

Prevention/Delay of Prevention/Delay of Type 2 DiabetesType 2 Diabetes

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


Prevention/Delay of Prevention/Delay of Type 2 DiabetesType 2 Diabetes

Individuals at high risk for type 2 diabetes Individuals at high risk for type 2 diabetes should be encouraged to achieve the U.S. should be encouraged to achieve the U.S. Department of Agriculture (USDA) Department of Agriculture (USDA) recommendation for dietary fiber (14 g recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). grains (one-half of grain intake).

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


Prevention/Delay of T2DMPrevention/Delay of T2DM

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

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

Standards of Medical Care for Diabetes. Diabetes Care 31:S12-S54, 2012

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MNT for DM by DrSelim