Medical Nutrition Therapy for Diabetes Does a perfect eating plan exist?

1. Medical Nutrition Therapy for DiabetesDoes a perfect eating plan exist? Jennifer Regester, RD, CDN, CDE

4. Type of diabetes, any complications Blood sugar control Past medical history Anthropometrics- height, weight, BMI, body composition Biochemical- labs Medications, including supplements Dietary 24 hour recall (meals, snacks, and beverages) Favorite foods Food allergies Eating patterns and habits Physical activity Readiness to change Attitude Nutrition Assessment

5. Most Common Diabetes Overweight/Obesity Hypertension High Cholesterol Renal Disease HIV/AIDS Pregnancy Emotional eating Least Common Underweight Gastrointestinal issues Celiac disease Food allergies Eating disorders Sports nutrition Vegetarianism Bariatric surgery Nutrition Assessment

6. MNT Goals for Diabetes • Achieve and maintain: • Blood glucose levels in the normal range • Lipid profile that reduces risk for cardiovascular disease • Blood pressure levels in the normal range 2. To prevent (or slow) the rate of development of chronic complications by modifying nutrient intake and lifestyle

7. MNT Goals for Diabetes • To address individual nutrition needs, taking into consideration personal and cultural preferences and willingness to change 4. To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence

8. MNT Recommendations • Monitor carbohydrate intake for glycemic control • Include a variety of carbohydrates from fruit, vegetables, whole grains, legumes, and fat-free/low-fat dairy products • The use the glycemic index may provide a modest benefit • Avoid excess energy intake

9. Special Considerations Overweight/Obese Type 1 Diabetes Type 2 Diabetes Gestational Diabetes

10. Special Considerations • Weight loss • Weight loss has been shown to improve insulin resistance • Encourage dietary changes, increased physical activity, and behavior modification • Weight loss medications may be considered and can help with an additional 5-10% weight loss with lifestyle modifications • Bariatric surgery

11. Special Considerations • Type 1 Diabetes • Insulin therapy may be integrated into an individual’s dietary and physical activity pattern • Adjust rapid-acting insulin doses based on carbohydrate content in meals and snacks • When on fixed daily insulin doses keep carbohydrate content consistent with respect to time and amount • Adjust insulin for planned exercise. For unplanned exercise, extra carbohydrate may be needed

12. Special Considerations • Type 2 Diabetes • Encourage lifestyle modifications to improve glycemia, dyslipidemia, and blood pressure • Reduce caloric intake, saturated and trans fats, cholesterol, and sodium • Increase fiber, nutrient-rich foods • Increase energy expenditure

13. Special Considerations • Pregnancy • Adequate caloric intake and nutrients needed to provide appropriate weight gain for mother and fetus • Focus on food choices for a healthy and steady weight gain, glycemic control, and absence of ketones • Aim to develop healthy habits and lifestyle modifications (diet and exercise) for after delivery

14. Timing of meals Healthy choices and balanced meals Variety including nutrient-rich foods and high-fiber foods Moderation using portion control Limit refined sugars Carbohydrate counting Prescribed meal plan Exchange system Carbohydrate servings Label reading Glycemic index Insulin to carbohydrate ratio + correction factor (if applicable) Meal Planning Strategies

15. Total carbohydrate: 45-65% of total calories Total Protein: 10-35% of total calories Total fat: 20-35% of total calories Breakdown of Macronutrients

16. Patient’s lifestyle Work schedule Family life Support system Education level Knowledge about diabetes and nutrition Record keeping abilities Attitude Ability to adapt to change Reaction to advice Goal setting Nutrition Counseling

17. “So what do I eat?” How to be a “Nutritionist” when you do not have an RD

18. Doctor’s Advice • “Nutrition is an important part of taking care of your diabetes” • Avoid telling patients to diet and lose weight without resources • Do not recommend fad diets, try to encourage healthy lifestyle changes instead • Be specific- “try to be active at least 30 minutes most days of the week” • Keep it positive

19. Basic Nutrition Advice • Timing of meals and snacks (no more than 4 hours without eating) • Get a variety of healthy, high-fiber foods • Limiting refined carbs and added sugars • Watch portion sizes and read labels • Keep a food journal • Learn to make lifestyle changes and not diet for a short period of time

20. How to Read a Nutrition Label http://www.dtc.ucsf.edu/images/charts/nutrition_facts1.gif

21. MyPyramid http://www.mypyramid.gov

22. Portion Control http://www.ncescatalog.com

23. Portion Control http://www.snacksense.com/files/u1/portions_v4.jpg

24. The Plate Method http://www.tops.org/images/plate.gif

25. Follow-up Resources • www.diabetes.org • www.dlife.com • www.diabeticlivingonline.com • www.calorieking.com • www.sparkpeople.com www.friedmandiabetesinstitute.com Refer patients to RDs

26. Does a perfect eating plan exist?

27. References • Franz, Marion J., MS, RD, LD, CDE. “Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin”. Krause’s Food, Nutrition, and Diet Therapy. Saunders: Philadelphia. 2004: p. 792-837. • “Nutrition Recommendations and Interventions for Diabetes”. American Diabetes Association. Diabetes Care. 2008;31(suppl 21):S61-S78. • Carey, Rita E., Ms, RD, CDE. “Wanted: The Best Diabetes Diet for Optimal Outcomes”. Today’s Dietitian. 2009;11(No. 8): p. 24-30. • Escott-Stump, Sylvia. “Type 1 Diabetes Mellitus”. Nutrition Diagnosis-Related Care. Philadelphia: Lippincott Williams & Wilkins, 2002. p. 379-385. • Escott-Stump, Sylvia. “Type 2 Diabetes Mellitus”. Nutrition Diagnosis-Related Care. Philadelphia: Lippincott Williams & Wilkins, 2002. p. 388-393. • Escott-Stump, Sylvia. “Gestational Diabetes”. Nutrition Diagnosis-Related Care. Philadelphia: Lippincott Williams & Wilkins, 2002. p. 394-396.