MNT in Diabetes and Related Disorders Expected Outcomes

MNT in Diabetes and Related Disorders

Expected Outcomes of MNT in Diabetes ↓ of 1% of A 1 C in patients with newly diagnosed Type 1 diabetes n ↓ of about 2% of A 1 C in persons with newly diagnosed Type 2 diabetes n ↓ of about 1% of A 1 C in persons with Type 2 diabetes of 4 -year duration n ↓ LDL-C by 15 -25 mg/d. L in 3 -6 months n Nutrition recommendations and interventions for diabetes. Diabetes Care 2007; 30; S 48 -S 65

MNT in Type 1 Diabetes Insulin therapy should be integrated into an individual’s dietary and physical activity pattern (E) n 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) n Nutrition recommendations and interventions for diabetes. Diabetes Care 30; S 48 -65, 2007

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) n For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra CHO may be needed (E) n Nutrition recommendations and interventions for diabetes. Diabetes Care 30; S 48 -65, 2007

MNT Strategies in Type 2 Diabetes n n 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; S 48 -65, 2007

Carbohydrates in Diabetes Dietary pattern that includes CHO from fruits, vegetables, whole grains, legumes, and low fat milk is encouraged for good health (B) n Monitoring CHO, whether by CHO counting, exchange, or estimation remains a key strategy in achieving glycemic control (A) n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

Carbohydrate and Diabetes n 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: S 61 -S 78, 2008

Carbohydrate and Diabetes n 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: S 61 -S 78, 2008

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

Glycemic Index Influenced by various factors n n n n 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

Glycemic Index and Glycemic Load of Foods Food Glycemic Index Glycemic Load Carrots 47 3 Potato baked Sweet corn 85 60 26 11 Apple Chocolate cake Corn flakes Oatmeal Pumpkin Sucrose 38 38 92 42 75 68 6 20 24 9 3 7 Krause’s Food & Nutrition Therapy, 12 th ed. , Appendix 43

Fiber and Diabetes n As for the general population, people with diabetes are encouraged to consume a variety of fibercontaining foods. However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. (B) n It requires very large amount of fiber (~50 grams) to have a beneficial effect on glycemia, insulinemia, lipemia

Sweeteners and Diabetes n 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: S 61 -S 78, 2008

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

Nutritive Sweeteners: Sugar Alcohols n n n 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

Non-Caloric Sweeteners n Saccharin (Sweet’N Low®) n Aspartame (Nutra. Sweet®) n Acesulfame potassium, acesulfame-K (Sweet One®) n Sucralose (SPLENDA®)

Nonnutritive Sweeteners n n 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

Noncaloric Sweeteners: All FDA-approved nonnutritive sweeteners can be used by persons with diabetes n The carbohydrate and calorie content of sugar blends must be taken into account n

Protein and Diabetes Insufficient evidence to suggest that usual protein intake (15 -20% of energy) should be modified (E) n 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) n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

Protein and Diabetes n n 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: S 61 -S 78, 2008

Dietary Fat Saturated Fat: <7% of total calories (A) n Cholesterol: <200 mg/day in people with diabetes n Minimize intake of trans-fatty acids (E) n Two or more servings of fish per week providing n-3 polyunsaturated fatty acids are recommended (B) n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

MFA vs CHO ↑ CHO diet (>55% ) may ↑ triglycerides and postprandial glucose compared with ↑ MFA diet n However, ↑ CHO ↓ fat diet can produce modest weight loss n Metabolic profile and need for weight loss will determine balance between CHO and MFA n

Optimal Mix of Macronutrients The best mix of protein, CHO and fat varies depending on individual circumstances n The DRIs recommend that healthy adults should consume 45 -65% of energy from CHO, 20 -35% from fat, and 10 -35% from protein n Total caloric intake must be appropriate for weight management n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

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

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

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

Energy Balance, Overwt and Obesity n n n 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: S 61 -S 78, 2008

Energy Balance, Overwt and Obesity n n 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: S 61 -S 78, 2008

Energy Balance, Overweight, and Obesity Bariatric surgery may be considered for individuals with type 2 diabetes and BMI>35 kg/m 2 and can result in marked improvements in glycemia n Long term benefits and risks of bariatric surgery in individuals with pre -diabetes or diabetes continue to be studied (B) n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

Energy Balance and Obesity n n 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

Obesity and Prognosis Obesity in diabetic persons is not associated with mortality or microvascular, macrovascular complications n Short term weight loss in subjects with Type 2 diabetes is associated with improvement in insulin resistance, glycemia, serum lipids, and blood pressure n

Alcohol In the fasting state, alcohol may cause hypoglycemia in persons using exogenous insulin or insulin secretagogues n Alcohol is a source of energy, but not converted to glucose; interferes with gluconeogensis n

Alcohol n n n 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: S 61 -S 78, 2008

Alcohol Occasional use of alcoholic beverages should be considered an addition to the regular meal plan, and no food should be omitted n Excessive amounts of alcohol (three or more drinks per day) on a consistent basis, contributes to hyperglycemia n

Alcohol n n 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

Micronutrients n n n 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: S 61 -S 78, 2008

“Diabetes” Supplements

“Diabetes” Supplements n n n n n 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

Micronutrients n n n 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: S 61 -S 78, 2008

Sodium n n 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

Goals of MNT for Diabetes in Children n Maintain normal growth and development – Evaluate using growth charts every 3 -6 months n Base nutrition prescription on the nutrition assessment – Re-evaluate every 3 -6 months n n 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

Estimating Minimum Energy Requirements for Youth Age Energy Requirements 1 yr 1000 kcals for first year 2 -11 yr Add 100 kcals/yr to 1000 kcals up to 2000 kcals at age 10 Girls 12 -15 2000 kcals + 50 -100 kcals/yr after age 10 >15 years Calculate as for an adult Boys 12 -15 2000 kcals plus 200 kcal/yr after age 10 >15 yr Sedentary 16 kcals/lb (30 -35 kcals/kg) Moderate activity 18 kcals/lb (40 kcals/kg) Very physically active: 23 kcals/lb (50 kcals/kg)

MNT for Type 2 Diabetes in Youth n n n 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

Estimating Energy Requirements for Adults Obese and very inactive persons and chronic dieters Persons >55 yr, active women, sedentary men 10 -12 kcals/lb or 20 kcals/kg Active men, very active women 15 kcals/lb, 30 kcals/kg Thin or very active men 20 kcals/lb or 40 kcals/kg 13 kcals/lb, 25 kcals/kg Source: Franz MJ, Reader D, Monk A. Implementing group and individual medical nutrition therapy for diabetes. Alexandria, VA, 2002, American Diabetes Association

Basic MNT Self-Management Skills for Persons with DM n n n Basic food and meal planning guidelines Physical activity guidelines Self-monitoring of blood glucose levels For insulin secretagogue users, signs, symptoms, treatment, and prevention of hypoglycemia For insulin secretagogue users guidelines for managing short-term illness Plans for follow-up and ongoing education

MNT Essential Self. Management Skills n n n Sources of CHO, pro, fat Understanding nutrition labels Modification of fat intake Alcohol guidelines Use of BG monitoring data for problem solving n n n Recipes, menu ideas, cookbooks Vitamin, mineral, botanical supplements Behavior modification techniques

MNT Essential Self. Management Skills n n n Adjustments of CHO or insulin for exercise Grocery shopping guidelines Guidelines for eating out Snack choices Mealtime adjustments n n Use of sugar-containing foods and non-nutritive sweeteners Problem solving tips for special occasions Travel schedule changes Work shifts if applicable

Nutrition Self Management for Diabetes

Goals of MNT for Prevention and Treatment of Diabetes Achieve and maintain n Blood glucose levels in the normal range, or as close to normal as is safely possible n A lipid and lipoprotein profile that reduces the risk for vascular disease n 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: S 61 -S 78, 2008.

Goals of MNT for Prevention and Treatment of Diabetes n n n 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: S 61 -S 78, 2008.

Goals of MNT that Apply to Specific Situations n n 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 31: S 61 -S 78, 2008

Effectiveness of MNT Recommendations n n 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 31: S 61 -S 78, 2008

Diabetes Assessment: Referral Data n n n Age Diagnosis of diabetes and other pertinent medical history Medications, including diabetes and other pertinent meds n n n Laboratory data (A 1 C, cholesterol/ lipid profile, albumin to creatinine ratio) Blood pressure Clearance for exercise

Diabetes Assessment Data n n 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

Diabetes Assessment Data: Diet History n n n n n 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

Diabetes Assessment Data: Daily Schedule n n n Time of waking Usual meal and eating times Work schedule or school hours Type, amount, and timing of exercise Usual sleep habits

Basic Strategies for Type 1 Diabetes n For individuals with type 1 diabetes, insulin therapy should be integrated into an individual’s dietary and physical activity pattern. (E) n 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) n 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) n 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 31: S 61 -S 78, 2008

Basic Strategies for Type 2 Diabetes n n n Encourage weight loss. Moderate calorie restriction (250– 500 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.

Food Guide Pyramid Use basic guide n Use diabetesspecific guide n National Diabetes Education Program. http: //www. ndep. nih. gov/diabetes/Meal. Planner/images/mypyramid. jpg

Recommendations for Weight Management n n n Make permanent changes in eating behavior. Eat regularly. Slow, gradual weight loss is best. Choose lower-fat foods. Incorporate regular physical activity.

The Diabetes Meal Plan n The meal plan should be based on – the patient’s current eating habits – diabetes medications, if any – current weight status – collaborative goals (e. g. , does the patient desire to lose weight? )

Macronutrients Based On n Patient’s current eating habits (CHO, fat, protein) Lipid levels and glycemic control Patient goals

Meal Plan n n 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)

Meal Plan: Patient on MNT Only n n 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

Examples of CHO Servings Mix and Match n n n n 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 n n n 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

Meal Plan: Oral Medications May do well with smaller, more frequent meals and snacks, especially if taking an insulin secretagogue n Snack servings should be taken from the meal plan n

Meal Plan: Insulin n n 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 intermediateacting insulin (NPH) may require afternoon snack Patients on rapid-acting insulin do not need a snack

Meal Planning: Carbohydrate Counting n n n Focuses on CHO as major driver of postprandial 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

Managing Acute Complications

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

Hypoglycemia Symptoms n n n n Shakiness Sweating Palpitations Hunger Slurred speech Mental confusion, disorientation Extreme fatigue, lethargy Seizures and unconsciousness

Hypoglycemia Treatment n n Glucose of 70 mg/d. L or lower should be treated immediately A level of 60 to 80 mg/d. L 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

Hypoglycemia Treatment n n n 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 BG<70 mg/d. L, take another 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 31: S 61 -S 78, 2008

Hypoglycemia Treatment n 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 Care 31: S 3 -S 4, 2008

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

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

Diabetic Ketoacidosis (DKA) n n n 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

Diabetic Ketoacidosis Elevated blood glucose levels (≥ 250 mg/d. L but usually <600 mg/d. L) n Presence of ketones in blood and urine n Polyuria, polydipsia, hyperventilation, dehydration, fruity odor, fatigue n Can lead to coma and death n Often occurs during acute illness (flu, colds, vomiting and diarrhea) n

DKA Prevented by SMBG n Testing for ketones n Medical intervention n Appropriate sick day guidelines n

DKA Treatment n n n Supplemental insulin Fluid and electrolyte replacement Medical monitoring

Sick Day Guidelines n 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 4 x daily – Levels exceeding 240 mg/d. L and ketones are signals that additional insulin is needed Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

Sick Day Guidelines n 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 n 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

Sick Day Guidelines n The health care team should be called if illness continues for more than 1 day

Causes of Fasting Hyperglycemia n n n Waning insulin action “Dawn” phenomenon Somogyi Effect (“rebound” hyperglycemia)

Waning Insulin Action n n Inadequate insulin dose overnight Requires adjustment of insulin doses

Dawn Phenomenon n n 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)

Somogyi Effect n n 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

Hyperosmolar Hyperglycemic State n n n Extremely high blood glucose level (6002000 mg/d. L) 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

Long Term Complications

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

Macrovascular Disease Includes coronary heart disease, peripheral vascular disease, and cerebrovascular disease n More common, occurs at an earlier age, more extensive and severe in people with diabetes n Women in particular are at risk n

Treatment and Mgt of CVD risk Target A 1 C as close to normal as possible without significant hypoglycemia (B) n Diets high in fruits, vegetables, and whole grains may reduce risk (C) n For pts with heart failure, dietary sodium intake of <2000 mg/day may reduce symptoms n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

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) n In most individuals, modest weight loss beneficially affects blood pressure. (C) n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

Dyslipidemia 11 -44% of adults with diabetes n Type 2: hypercholesterolemia prevalence is 28 -34%; 5 -14% have high TG; low HDL-C is common n Patients with Type 2 diabetes have smaller, denser LDL particles, increasing atherogenicity n

Dyslipidemia n n Primary therapy (lifestyle interventions) directed at lowering LDL-C to ≤ 100 mg/d. L Pharmacologic therapy at LDL-C>130 mg/d. L If HDL-C is <40 mg/d. L, fibric acid treatment Aspirin therapy in adult pts with diabetes and macrovascular disease or for primary prevention in patients >40 years with diabetes and CVD risk factors

Dyslipidemia MNT n n Saturated fat should be limited to 7% Substitute CHO or MFA

Nephropathy n 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 30: S 4 -S 36, 2007

Nephropathy First symptom is microalbuminuria (>30 mg daily or 20 mcg/minute) n Progresses to clinical albuminuria (≥ 300 mg/day), hypertension, ↓ in glomerular filtration rate n Albuminuria is a marker for increased CVD risk also n

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

Nephropathy Treatment Glucose and blood pressure control should be optimized n 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) n Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

Retinopathy Most frequent cause of new cases of blindness among adults 20 -74 years n After 20 years of DM, nearly all pts with Type 1 and >60% of Type 2 have some retinopathy n Laser photocoagulation surgery can reduce risk of further vision loss but not correct previous losses n

Neuropathy n n 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 3575% of men with diabetes

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

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

Nutrition Intervention Resources n n n Dietary Guidelines for Americans Guide to good eating Food Guide Pyramid The first step in diabetes meal planning Healthy food choices Healthy eating n n n n Single-topic diabetes resources Individualized menus Month of meals Exchange lists for meal planning CHO counting Calorie counting Fat counting

Metabolic Syndrome and Diabetes Prevention

Metabolic Syndrome Intra-abdominal obesity (waist circumference>40 inches in men and >35 inches in women) n Dyslipidemia n Hypertension n Glucose intolerance n Compensatory hyperinsulinemia n ↑ macrovascular complications n

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

Finnish Diabetes Prevention Study 522 middle-aged, overweight persons with IGT n Randomized to brief diet and exercise counseling or intensive individualized instruction: goal 5% wt reduction, sfa<10% energy, fat <30% energy, fiber >15 grams/1000 kcals; physical activity (>150 minutes weekly) n Tuomilehto J et al: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344; 1390: 2001.

Finnish Diabetes Prevention Study

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 344; 1390: 2001.

Diabetes Prevention Program (DPP) Randomized 3234 persons (45% minority) with IGT to placebo, metformin, or lifestyle intervention n Subjects in metformin and placebo groups received standard lifestyle recommendations including written information and an annual 20 -30 minute individual session n Orchard TJ et al. Ann Int Med 142; 611 -619, 2005

Diabetes Prevention Program n n n 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

Prevention/Delay of Type 2 Diabetes n 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 31: S 61 -S 78, 2008

Prevention/Delay of Type 2 Diabetes n 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) n There is not sufficient, consistent information to conclude that low–glycemic load diets reduce the risk for diabetes. Nevertheless, low–glycemic index foods that are rich in fiber and other important nutrients are to be encouraged. (E) Nutrition recommendations and interventions for diabetes. Diabetes Care 31: S 61 -S 78, 2008

Prevention/Delay of Type 2 Diabetes n 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) n Monitoring for the development of diabetes in those with pre-diabetes should be performed every year. (E) Standards of Medical Care for Diabetes Care 31: S 12 -S 54, 2008

MNT in Non-Diabetic Hypoglycemia

Types of Hypoglycemia n n n Postprandial hypoglycemia Alimentary hyperinsulinemia Idiopathic reactive hypoglycemia Fasting hypoglycemia Factitious hypoglycemia

Postprandial (Reactive) Hypoglycemia Blood glucose levels fall below normal 2 -5 hours after eating n 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 n

Alimentary Hyperinsulinism (dumping syndrome) Most common type of documented postprandial hypoglycemia n Seen after gastric surgery; due to rapid delivery of food to the small intestine → rapid absorption of glucose → exaggerated insulin response n

Idiopathic Reactive Hypoglycemia Normal insulin secretion but increased insulin sensitivity n Reduced response of glucagon to acute hypoglycemia n Rare, but often inappropriately overdiagnosed n

Fasting Hypoglycemia Usually the result of a serious underlying medical condition n Causes include hormone deficiency states, certain drugs, insulinoma and other nonpancreatic tumors n Diagnostic criteria: BG<50 mg/d. L, especially during symptomatic episodes n

Treatment of Hypoglycemic Symptoms Eat small meals and snacks (5 -6 small meals) n Spread the intake of CHO through the day (2 -4 CHO servings at a meal, 1 -2 at a snack) n Avoid foods that contain large amounts of CHO (regular soda, syrups, candy, regular yogurt, pies, cakes) n

Treatment of Hypoglycemic Symptoms Avoid beverages and foods containing caffeine n Limit or avoid alcoholic beverages; interferes with the liver’s ability to release stored glucose; take ETOH with food n Decrease fat intake (fat may increase insulin resistance) n