MNT in Diabetes and Related Disorders

1
MNT in Diabetes and Related Disorders
2
Expected Outcomes of MNT in Diabetes

• of 1 of A1C in patients with newly diagnosed
  Type 1 diabetes
• of about 2 of A1C in persons with newly
  diagnosed Type 2 diabetes
• of about 1 of A1C in persons with Type 2
  diabetes of 4-year duration
• LDL-C by 15-25 mg/dL in 3-6 months

Nutrition recommendations and interventions for
diabetes. Diabetes Care 200730S48-S65
3
MNT in Type 1 Diabetes

• Insulin therapy should be integrated into an
  individuals 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 CHO
  content of the meals and snacks (A)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 30 S48-65 2007
4
MNT in Type 1 Diabetes

• For individuals using fixed daily insulin doses
  CHO 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 CHO may
  be needed (E)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 30 S48-65 2007
5
MNT Strategies in Type 2 Diabetes

• Implement 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
6
Carbohydrates in Diabetes

• Dietary 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 31S61-S78 2008
7
Carbohydrate and Diabetes

• Sucrose-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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
8
Carbohydrate and Diabetes

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

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
9
Glycemic Index

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

10
Glycemic Index

• Influenced by various factors
• Starch structure
• Fiber content
• Cooking methods
• Degree of processing
• Whether it is eaten in the context of a meal
• Presence or absence of fat
• A given food can elicit highly variable responses

11
Glycemic Index and Glycemic Load of Foods
Krauses Food Nutrition Therapy 12th ed.
Appendix 43
12
Fiber 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

13
Sweeteners and Diabetes

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

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
14
Nutritive Sweeteners Fructose

• Delivers 4 kcals/gram
• Has lower glycemic index than sucrose or starch
• Large amounts may negatively affect lipids
• No advantage to substituting it for sucrose
• Found naturally in foods such as fruits and
  vegetables

15
Nutritive Sweeteners Sugar Alcohols

• 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

16
Non-Caloric Sweeteners

• Saccharin  (SweetN Low)
• Aspartame (NutraSweet)
• Acesulfame potassium acesulfame-K (Sweet One)
• Sucralose (SPLENDA)

17
Nonnutritive 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

18
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

19
Protein 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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
20
Protein 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.
  (E)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
21
Dietary Fat

• Saturated Fat
• Cholesterol
• Minimize intake of trans-fatty acids (E)
• Two or more servings of fish per week providing
  n-3 polyunsaturated fatty acids are recommended
  (B)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
22
MFA 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

23
Optimal Mix of Macronutrients

• 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 management

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
24
Lipid Goals in Diabetes

• LDL cholesterol
• HDL cholesterol
• Men 40 mg/dl
• Women 50 mg/dl
• Triglycerides

American Diabetes Assoc. Standards of Medical
care for Adults with Diabetes. Diabetes Care 30
(supplement 1) 2007. Accessed 2/13/07
25
Blood Pressure Goals in Diabetes

• Patients with diabetes should be treated to a
  systolic blood pressure
• Patients with diabetes should be treated to a
  diastolic blood pressure of

American Diabetes Assoc. Standards of Medical
Care in Diabetes-2007. Diabetes Care 30
(supplement 1) 2007. Accessed 2/14/07
26
Fiber and Phytoesterols

• Soluble 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

27
Energy Balance Overwt and 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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
28
Energy Balance Overwt and 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 510
  weight loss when combined with lifestyle
  modification. (B)

American Diabetes Association Nutrition
Recommendations and interventions for Diabetes
Diabetes Care 31S61-S78 2008
29
Energy Balance Overweight and Obesity

• Bariatric surgery may be considered for
  individuals with type 2 diabetes and BMI35 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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
30
Energy Balance and Obesity

• Improved 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

31
Obesity 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

32
Alcohol

• In 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

33
Alcohol

• 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 31S61-S78 2008
34
Alcohol

• Occasional 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

35
Alcohol

• 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

36
Micronutrients

• 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 31S61-S78 2008
37
Diabetes Supplements
38
Diabetes 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
  antioxidants
• Vanadium
• Resveratrol

39
Micronutrients

• 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 31S61-S78 2008
40
Sodium

• Association between hypertension (HTN) and both
  types of diabetes mellitus (DM)
• Same intake as general population is recommended
  for otherwise healthy people with DMless than
  3000 mg/day
• For people with mild HTN and diabetesshould have
  less than 2400 mg/day
• For people with more serious HTN or edematous
  clients with nephropathy recommend 2000 mg/day or
  less

41
Goals of MNT for Diabetes in 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

42
Estimating Minimum Energy Requirements for Youth
43
MNT for Type 2 Diabetes in Youth

• Cessation of excessive weight gain
• Promotion of normal growth and development
• Encourage healthy eating habits and increased
  activity for the whole family
• Address other health risk factors
• Add Metformin if lifestyle changes are
  insufficient to achieve goals

44
Estimating Energy Requirements for Adults
Source Franz MJ Reader D Monk A. Implementing
group and individual medical nutrition therapy
for diabetes. Alexandria VA 2002 American
Diabetes Association
45
Basic MNT Self-Management Skills for Persons with
DM

• Basic food and meal planning guidelines
• Physical activity guidelines
• Self-monitoring of blood glucose levels
• For 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

46
MNT Essential Self-Management Skills

• Sources of CHO pro fat
• Understanding nutrition labels
• Modification of fat intake
• Alcohol guidelines
• Use of BG monitoring data for problem solving

• Recipes menu ideas cookbooks
• Vitamin mineral botanical supplements
• Behavior modification techniques

47
MNT Essential Self-Management Skills

• Adjustments of CHO or insulin for exercise
• Grocery shopping guidelines
• Guidelines for eating out
• Snack choices
• Mealtime adjustments

• Use of sugar-containing foods and non-nutritive
  sweeteners
• Problem solving tips for special occasions
• Travel schedule changes
• Work shifts if applicable

48
Nutrition Self Management for Diabetes
49
Goals of MNT for Prevention and 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 possible

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008.
50
Goals of MNT for Prevention and Treatment of
Diabetes

• To 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 31S61-S78 2008.
51
Goals of MNT that Apply to Specific Situations

• For 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

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
52
Effectiveness of MNT Recommendations

• Individuals 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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
53
Diabetes Assessment Referral Data

• Age
• Diagnosis 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 pressure
• Clearance for exercise

54
Diabetes Assessment Data

• 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

55
Diabetes Assessment Data Diet History

• Usual caloric intake
• Quality of the usual diet
• Times sizes and contents of meals and snacks
• Food idiosyncrasies
• Restaurant eating
• Who usually prepares meals
• Eating problems/intolerances
• Alcoholic beverage intake
• Supplements used

56
Diabetes Assessment Data Daily Schedule

• Time of waking
• Usual meal and eating times
• Work schedule or school hours
• Type amount and timing of exercise
• Usual sleep habits

57
Basic Strategies for Type 1 Diabetes

• For individuals with type 1 diabetes insulin
  therapy should be integrated into an individuals
  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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
58
Basic Strategies for Type 2 Diabetes

• Encourage weight loss.
• Moderate calorie restriction (250500 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.

59
Food Guide Pyramid

• Use basic guide
• Use diabetes-specific guide

National Diabetes Education Program.
http//www.ndep.nih.gov/diabetes/MealPlanner/image
s/mypyramid.jpg
60
Recommendations for Weight Management

• Make permanent changes in eating behavior.
• Eat regularly.
• Slow gradual weight loss is best.
• Choose lower-fat foods.
• Incorporate regular physical activity.

61
The Diabetes Meal Plan

• The meal plan should be based on
• the patients current eating habits
• diabetes medications if any
• current weight status
• collaborative goals (e.g. does the patient
  desire to lose weight)

62
Macronutrients Based On

• Patients current eating habits (CHO fat
  protein)
• Lipid levels and glycemic control
• Patient goals

63
Meal Plan

• Estimate current energy carbohydrate protein
  and fat intake
• Evaluate current meal pattern and schedule
• Adjust meal plan to promote treatment goals
  (energy fat carbohydrate distribution)
• Evaluate based on standard meal planning
  standards (e.g. Food Guide Pyramid)

64
Meal Plan Patient on MNT Only

• Often 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

65
Examples of CHO Servings Mix and Match

• Apple 1 small
• Fruit cocktail ½ c
• Nonfat milk 1 c
• Orange juice ½ c
• Bread 1 slice
• Oatmeal ½ c
• Pasta 1/3 c
• Potatoes ½ c

• Brownie 1 small
• Yogurt frozen ½ c
• Cake frosted 2 inch square (2 CHO)
• Corn ½ c
• Baked beans 1/3 c
• Hummus 1/3 c

66
Meal Plan Oral Medications

• May do well with smaller more frequent meals and
  snacks especially if taking an insulin
  secretagogue
• Snack servings should be taken from the meal plan

67
Meal Plan Insulin

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

68
Meal Planning Carbohydrate Counting

• Focuses on CHO as major driver of post-prandial
  blood glucose
• Can 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 flexibility
• 1 carbohydrate serving 15 grams

69
Managing Acute Complications
70
Hypoglycemia

• Low blood glucose
• Common side effect of insulin therapy
• Sometimes affects patients taking insulin
  secretagogues
• Can be life-threatening

71
Hypoglycemia Symptoms

• Shakiness
• Sweating
• Palpitations
• Hunger
• Slurred speech
• Mental confusion disorientation
• Extreme fatigue lethargy
• Seizures and unconsciousness

72
Hypoglycemia 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

73
Hypoglycemia 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 BGanother 15 g CHO
• Repeat until BG is WNL
• If next meal is 1 hour away take additional 15
  g glucose
• Glucagon injection may be prescribed for pts at
  risk for severe hypoglycemia

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
74
Hypoglycemia Treatment

• Individuals 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 31S3-S4 2008
75
Causes of Hypoglycemia

• Medication errors
• Excessive insulin or oral medications
• Improper timing of insulin in relation to food
  intake
• Intensive insulin therapy
• Inadequate food intake
• Omitted or inadequate meals or snacks

76
Causes of Hypoglycemia

• Delayed meals or snacks
• Increased exercise or activity
• Unplanned activities
• Prolonged duration or increased intensity of
  exercise
• Alcohol intake without food

77
Diabetic Ketoacidosis (DKA)

• Caused by hyperglycemia
• Life-threatening but reversible
• Severe disturbances in carbohydrate protein and
  fat metabolism
• Caused by inadequate insulin for glucose
  utilization
• Body uses fat for energy forming ketones
• Acidosis results from production and
  utilization of fatty acid metabolites

78
Diabetic Ketoacidosis

• Elevated blood glucose levels (250 mg/dL but
  usually
• Presence of ketones in blood and urine
• Polyuria polydipsia hyperventilation
  dehydration fruity odor fatigue
• Can lead to coma and death
• Often occurs during acute illness (flu colds
  vomiting and diarrhea)

79
DKA Prevented by

• SMBG
• Testing for ketones
• Medical intervention
• Appropriate sick day guidelines

80
DKA Treatment

• Supplemental insulin
• Fluid and electrolyte replacement
• Medical monitoring

81
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

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
82
Sick Day Guidelines

• If 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 hours
• Ample 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

83
Sick Day Guidelines

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

84
Causes of Fasting Hyperglycemia

• Waning insulin action
• Dawn phenomenon
• Somogyi Effect (rebound hyperglycemia)

85
Waning Insulin Action

• Inadequate insulin dose overnight
• Requires adjustment of insulin doses

86
Dawn Phenomenon

• Insulin 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)

87
Somogyi Effect

• Hypoglycemia 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

88
Hyperosmolar Hyperglycemic State

• Extremely high blood glucose level (600-2000
  mg/dL)
• Absence of or small amounts of ketones
• Profound dehydration
• Pts have sufficient insulin to prevent lipolysis
  and ketosis
• Occurs in older patients with type 2 diabetes
• Treatment hydration and small doses of insulin
  to correct the hyperglycemia

89
Long Term Complications
90
Macrovascular Disease

• Disease of large blood vessels including
  cardiovascular diseases
• Begins with insulin resistance which predates
  diabetes by several years
• Produces metabolic changes called metabolic
  syndrome

91
Macrovascular Disease

• Includes 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

92
Treatment and Mgt of CVD risk

• Target 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

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
93
Treatment and Mgt of CVD Risk

• In 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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
94
Dyslipidemia

• 11-44 of adults with diabetes
• Type 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

95
Dyslipidemia

• Primary therapy (lifestyle interventions)
  directed at lowering LDL-C to 100 mg/dL
• Pharmacologic therapy at LDL-C130 mg/dL
• If HDL-C is
• Aspirin therapy in adult pts with diabetes and
  macrovascular disease or for primary prevention
  in patients 40 years with diabetes and CVD risk
  factors

96
Dyslipidemia MNT

• Saturated fat should be limited to 7
• Substitute CHO or MFA

97
Nephropathy

• In 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
30S4-S36 2007
98
Nephropathy

• First 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

99
Nephropathy Screening

• Perform 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)

100
Nephropathy Treatment

• Glucose and blood pressure control should be
  optimized
• MNT 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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
101
Retinopathy

• Most 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

102
Neuropathy

• 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

103
Gastroparesis

• Delayed or irregular contractions of the stomach
• Symptoms include feelings of fullness bloating
  nausea vomiting diarrhea constipation
• Can affect blood glucose control

104
Gastroparesis Treatment

• Small frequent meals
• Low in fiber and fat
• Liquid meals if necessary
• Adjustments in insulin administration
• May need to take insulin after the meal
• Frequent blood glucose monitoring

105
Nutrition Intervention Resources

• Dietary Guidelines for Americans
• Guide to good eating
• Food Guide Pyramid
• The first step in diabetes meal planning
• Healthy food choices
• Healthy eating

• Single-topic diabetes resources
• Individualized menus
• Month of meals
• Exchange lists for meal planning
• CHO counting
• Calorie counting
• Fat counting

106
Metabolic Syndrome and Diabetes Prevention
107
Metabolic Syndrome

• Intra-abdominal obesity (waist circumference40
  inches in men and 35 inches in women)
• Dyslipidemia
• Hypertension
• Glucose intolerance
• Compensatory hyperinsulinemia
• macrovascular complications

108
Metabolic Syndrome MNT

• Modest weight loss
• Improved glycemic control
• Restricted saturated fats
• Increased physical activity
• If weight is not an issue add MFA
• For triglycerides
• high dose statins or fibric acid
• Fat restriction fish oil supplementation

109
Finnish Diabetes Prevention Study

• 522 middle-aged overweight persons with IGT
• Randomized to brief diet and exercise counseling
  or intensive individualized instruction goal 5
  wt reduction sfafiber 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
34413902001.
110
Finnish Diabetes Prevention Study
111
Finnish Diabetes Prevention Study Results
Tuomilehto J et al Prevention of type 2 diabetes
mellitus by changes in lifestyle among subjects
with impaired glucose tolerance. N Engl J Med
34413902001.
112
Diabetes Prevention Program (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 142611-619 2005
113
Diabetes Prevention Program

• Subjects 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

114
Prevention/Delay of Type 2 Diabetes

• 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)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
115
Prevention/Delay of Type 2 Diabetes

• 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/1000 kcal) and
  foods containing whole grains (one-half of grain
  intake). (B)
• There is not sufficient consistent information
  to conclude that lowglycemic load diets reduce
  the risk for diabetes. Nevertheless lowglycemic
  index foods that are rich in fiber and other
  important nutrients are to be encouraged. (E)

Nutrition recommendations and interventions for
diabetes. Diabetes Care 31S61-S78 2008
116
Prevention/Delay of Type 2 Diabetes

• In 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 31S12-S54 2008
117
MNT in Non-Diabetic Hypoglycemia
118
Types of Hypoglycemia

• Postprandial hypoglycemia
• Alimentary hyperinsulinemia
• Idiopathic reactive hypoglycemia
• Fasting hypoglycemia
• Factitious hypoglycemia

119
Postprandial (Reactive) Hypoglycemia

• Blood glucose levels fall below normal 2-5 hours
  after eating
• Caused by exaggerated insulin response due to
  insulin resistance elevated glucagon-like-peptide
  -1 (GLP-1) renal glycosuria defects in glucagon
  response high insulin sensitivity

120
Alimentary Hyperinsulinism (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

121
Idiopathic Reactive Hypoglycemia

• Normal insulin secretion but increased insulin
  sensitivity
• Reduced response of glucagon to acute
  hypoglycemia
• Rare but often inappropriately overdiagnosed

122
Fasting Hypoglycemia

• Usually the result of a serious underlying
  medical condition
• Causes include hormone deficiency states certain
  drugs insulinoma and other nonpancreatic tumors
• Diagnostic criteria BGduring symptomatic episodes

123
Treatment of Hypoglycemic Symptoms

• Eat 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)

124
Treatment of Hypoglycemic Symptoms

• Avoid beverages and foods containing caffeine
• Limit or avoid alcoholic beverages interferes
  with the livers ability to release stored
  glucose take ETOH with food
• Decrease fat intake (fat may increase insulin
  resistance)