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MNT in Diabetes and Related Disorders

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Title: 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/1,000 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)
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