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MNT in Diabetes and Related Disorders

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  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 2007;30;S48-S65

  3. MNT in Type 1 Diabetes • Insulin therapy should be integrated into an individual’s dietary and physical activity pattern (E) • Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin doses based on the 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 31:S61-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 31:S61-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 31:S61-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 Krause’s 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 31:S61-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  (Sweet’N 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 31:S61-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 31:S61-S78, 2008

  21. Dietary Fat • Saturated Fat: <7% of total calories (A) • Cholesterol: <200 mg/day in people with diabetes • 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 31:S61-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 31:S61-S78, 2008

  24. Lipid Goals in Diabetes • LDL cholesterol <100 mg/dl • HDL cholesterol Men >40 mg/dl Women >50 mg/dl • Triglycerides <150 mg/dl American Diabetes Assoc. Standards of Medical care for Adults with Diabetes. Diabetes Care 30 (supplement 1) 2007. Accessed 2/13/07

  25. Blood Pressure Goals in Diabetes • Patients with diabetes should be treated to a systolic blood pressure <130 mmHg (C) • Patients with diabetes should be treated to a diastolic blood pressure of <80 mmHg (B) American Diabetes Assoc. Standards of Medical Care in Diabetes-2007. Diabetes Care 30 (supplement 1) 2007. Accessed 2/14/07

  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 31:S61-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 5–10% weight loss when combined with lifestyle modification. (B) American Diabetes Association Nutrition Recommendations and interventions for Diabetes, Diabetes Care 31:S61-S78, 2008

  29. Energy Balance, Overweight, and Obesity • Bariatric surgery may be considered for individuals with type 2 diabetes and BMI>35 kg/m2 and can result in marked improvements in glycemia • Long term benefits and risks of bariatric surgery in individuals with pre-diabetes or diabetes continue to be studied (B) Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-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 31:S61-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 31:S61-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 31:S61-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 DM—less than 3000 mg/day • For people with mild HTN and diabetes—should have less than 2400 mg/day • For people with more serious HTN or edematous clients with nephropathy recommend 2000 mg/day or less

  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. 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 MNT Essential Self-Management Skills

  47. 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 MNT Essential Self-Management Skills

  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 31:S61-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 31:S61-S78, 2008.