Download Dr Shahjada Selim

© DR. SHAHJADA SELIM
Medical Nutrition
Therapy in Diabetes
Dr Shahjada Selim
Assistant Professor
Department of Endocrinology
Bangabandhu Sheikh Mujib Medical University
Email: [email protected],
[email protected]
© DR. SHAHJADA SELIM
Management of DM
The major components of the treatment of diabetes
are:
A
• Medical Nutrition Therapy
(Diet and Exercise)
B
• Oral Antidiabetic Therapy
C
• Insulin & Incretinomimetic
Therapy
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
MNT in Type 1 Diabetes


Insulin therapy should be integrated
into an individual’s dietary and
physical activity pattern.
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 30; S48-65, 2007
© DR. SHAHJADA SELIM
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.
For planned exercise, insulin doses can
be adjusted. For unplanned exercise,
extra CHO may be needed.
Nutrition recommendations and interventions for diabetes. Diabetes Care 30; S48-65, 2007
© DR. SHAHJADA SELIM
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 30; S48-65, 2007
© DR. SHAHJADA SELIM
MNT Strategies in Type 2
Diabetes

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
© DR. SHAHJADA SELIM
Carbohydrates in Diabetes


Dietary pattern that includes CHO from
fruits,
vegetables,
whole
grains,
legumes, and low fat milk is encouraged
for good health.
Monitoring CHO, whether by CHO
counting, exchange, or estimation
remains a key strategy in achieving
glycemic control.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Glycaemic Index
The area under the curve for the increase in
blood glucose after the injection of 50 gm of
carbohydrate in the food during the 2 hr post
prandial period relative to the same amount of
carbohydrate from a reference food
(i.e.glucose) tested in the same individual
under the same conditions and using the initial
blood glucose concentration as a baseline.
© DR. SHAHJADA SELIM
Glycaemic Index
In simple words, the glycaemic index is a way
Of ranking carbohydrate containing foods
according to the extent to which they raise
blood sugar levels after eating.
Formula –
Incremental area of the test food
GI = --------------------------------------------Incremental area of the glucose
x 100
© DR. SHAHJADA SELIM
Glycemic Index

The blood glucose response of a given
food compared to an equal amount of a
CHO standard (typically glucose or white
bread)
© DR. SHAHJADA SELIM
Glycemic Index
Influenced by various factors
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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
© DR. SHAHJADA SELIM
GI of different foods
Grains, Cereal products
GI
Bread (white)
69
Bread (whole meal)
72
Millet
71
Rice (brown)
66
Rice (white)
72
Sponge cake
46
Breakfast cereals
GI
All bran
51
Cornflakes
80
Root Vegetables
GI
Beetroot
64
carrots
92
Potato
75
Sweet potato
48
© DR. SHAHJADA SELIM
GI of different foods
Dried legumes
GI
Kidney beans
29
Soya beans
15
Chick peas
36
Lentils
29
Fruits
GI
Apples
39
Banana
62
Oranges
40
Orange juice
46
Raisins
64
Sugars
GI
Fructose
20
Maltose
105
Sucrose
59
Glucose
100
© DR. SHAHJADA SELIM
GI of different foods
Dairy products
GI
Ice-cream
36
Milk (skim)
32
Milk (whole)
34
Miscellaneous
GI
Honey
87
Peanuts
13
Potato crisps
51
Tomato soup
38
Sausages
28
Fish fingers
38
© DR. SHAHJADA SELIM
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.
It requires very large amount of fiber (~50
grams) to have a beneficial effect on glycemia,
insulinemia, lipemia
© DR. SHAHJADA SELIM
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).
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Nutritive Sweeteners:
Fructose




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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
© DR. SHAHJADA SELIM
Nutritive Sweeteners:
Sugar Alcohols


Sorbitol, mannitol, xylitol, isomalt,
lactitol,
hydrogenated
starch
hydrolysates
Lower glycemic response, lower calorie
content than sucrose
Nutritive Sweeteners:
Sugar Alcohols
© DR. SHAHJADA SELIM


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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
© DR. SHAHJADA SELIM
Non-Caloric Sweeteners

Saccharin (Sweet’N Low®)

Aspartame (NutraSweet®)

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Acesulfame potassium,
acesulfame-K (Sweet One®)
Sucralose (SPLENDA®)
© DR. SHAHJADA SELIM
Nonnutritive Sweeteners



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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
© DR. SHAHJADA SELIM
Noncaloric Sweeteners:


All FDA-approved nonnutritive sweeteners can be
used by persons with
diabetes
The carbohydrate and calorie
content of sugar blends must
be taken into account
© DR. SHAHJADA SELIM
Recommended Daily Nutrient Sources
Fats
Nutrient
Consensus guidelines
Carbohydrates
50-60 % of total energy
Proteins
15-20 % of total energy
Total fat
< 30 % of total energy
Saturated fatty
acids
< 10 %
Trans fatty acids
<1%
PUFAs
5-8 %
MUFAs
10-15 %
Source : National Consensus Dietary Guidelines For Healthy Living and prevention of obesity, diabetes and related diseases (2009)
Protein and Diabetes
© DR. SHAHJADA SELIM


Insufficient evidence to suggest that usual
protein intake (15-20% of energy) should
be modified
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
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
Protein and Diabetes
© DR. SHAHJADA SELIM


High-protein diets are not recommended as a
method for weight loss at this time. The longterm 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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Dietary Fat

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Saturated Fat: <7% of total calories
Cholesterol: <200 mg/day in people with
diabetes
Minimize intake of trans-fatty acids.
Two or more servings of fish per week
providing n-3 polyunsaturated fatty acids
are recommended.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
MFA vs CHO


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↑ 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
© DR. SHAHJADA SELIM
Optimal Mix of Macronutrients


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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
© DR. SHAHJADA SELIM
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%
© DR. SHAHJADA SELIM
Energy Balance 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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
Energy Balance and Obesity
© DR. SHAHJADA SELIM


For weight loss, either low-carbohydrate
or low-fat calorie-restricted diets may be
effective in the short term (up to 1 year).
For patients on low-carbohydrate diets,
monitor lipid profiles, renal function, and
protein
intake
(in
those
with
nephropathy), and adjust hypoglycemic
therapy
as
needed.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
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.
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.
American Diabetes Association Nutrition Recommendations and interventions for Diabetes, Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Energy Balance 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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Energy Balance and
Obesity
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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
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
Alcohol


Drinks should be limited to 1 drink a day
(women) or 2 (men).
To reduce risk of nocturnal hypoglycemia
in individuals using insulin or insulin
secretagogues, alcohol should be
consumed with food.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
Alcohol
© DR. SHAHJADA SELIM

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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Micronutrients

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
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Micronutrients

Benefit
from
chromium
supplementation in individuals with
diabetes or obesity has not been
clearly demonstrated and therefore
can not be recommended
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
“Diabetes” Supplements
© DR. SHAHJADA SELIM
“Diabetes” Supplements
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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.
© DR. SHAHJADA SELIM
“Diabetes” Supplements
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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
© DR. SHAHJADA SELIM


Vitamin/mineral needs of people with
diabetes who are healthy appear to be
adequately met by the RDAs.
Chromium and magnesium are beneficial
only if the client is deficient.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Micronutrients

Those who may need supplementation
include those on extreme weightreducing diets, strict vegetarians, the
elderly, pregnant or lactating women,
clients with malabsorption disorders,
congestive heart failure (CHF) or
myocardial infarction (MI).
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
Sodium



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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
© DR. SHAHJADA SELIM
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
Estimating Minimum Energy
Requirements for Youth
© DR. SHAHJADA SELIM
Age
1 yr
2-11 yr
Energy Requirements
1000 kcals for first year
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)
© DR. SHAHJADA SELIM
MNT for Type 2 Diabetes
in Youth

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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
© DR. SHAHJADA SELIM
Estimating Energy
Requirements for Adults
Obese and very inactive
persons and chronic
dieters
10-12 kcals/lb or 20
kcals/kg
Persons >55 yr, active
women, sedentary men
13 kcals/lb, 25 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
Source: Franz MJ, Reader D, Monk A. Implementing group and individual medical nutrition therapy for
diabetes. Alexandria, VA, 2002, American Diabetes Association
© DR. SHAHJADA SELIM
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, 2012.
© DR. SHAHJADA SELIM
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, 2012.
Goals of MNT that Apply
to Specific Situations
© DR. SHAHJADA SELIM


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 selfmanagement 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:S61-S78, 2012
© DR. SHAHJADA SELIM
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.
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2012
© DR. SHAHJADA SELIM
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
Diabetes Assessment
Data
© DR. SHAHJADA SELIM




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
© DR. SHAHJADA SELIM
Diabetes Assessment
Data: Diet History

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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
© DR. SHAHJADA SELIM
Diabetes Assessment
Data: Daily Schedule

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Time of waking
Usual meal and eating times
Work schedule or school hours
Type, amount, and timing of
exercise
Usual sleep habits
© DR. SHAHJADA SELIM
Basic Strategies for Type
1 Diabetes


For individuals with type 1 diabetes,
insulin therapy should be integrated into
an individual’s dietary and physical
activity
pattern.
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2012
© DR. SHAHJADA SELIM
Basic Strategies for T1DM


For individuals using fixed daily insulin
doses, carbohydrate intake on a day-today basis should be kept consistent
with respect to time and amount.
For planned exercise, insulin doses can
be adjusted. For unplanned exercise,
extra carbohydrate may be needed.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008
Basic Strategies for T2DM
© DR. SHAHJADA SELIM



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

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.
© DR. SHAHJADA SELIM
Food Guide Pyramid


Use basic guide
Use diabetesspecific guide
National Diabetes Education Program.
http://www.ndep.nih.gov/diabetes/MealPlanner/images/mypyramid.jpg
© DR. SHAHJADA SELIM
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.
© DR. SHAHJADA SELIM
The Diabetes Meal Plan

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?)
© DR. SHAHJADA SELIM
Macronutrients Based On



Patient’s current
eating habits (CHO,
fat, protein)
Lipid levels and
glycemic control
Patient goals.
© DR. SHAHJADA SELIM
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)
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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 intermediateacting insulin (NPH) may require afternoon
snack
Patients on rapid-acting insulin do not need
a snack
Meal Planning:
Carbohydrate Counting
© DR. SHAHJADA SELIM






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
© DR. SHAHJADA SELIM
Hypoglycemia




Low blood glucose
Common side effect of insulin therapy
Sometimes affects patients taking
insulin secretagogues
Can be life-threatening
© DR. SHAHJADA SELIM
Hypoglycemia Symptoms








Shakiness
Sweating
Palpitations
Hunger
Slurred speech
Mental confusion, disorientation
Extreme fatigue, lethargy
Seizures and unconsciousness
© DR. SHAHJADA SELIM
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
Hypoglycemia Treatment
© DR. SHAHJADA SELIM





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/dL, 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:S61-S78, 2008
© DR. SHAHJADA SELIM
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.
Standards of Medical Care for Diabetes Diabetes Care 31:S3-S4, 2012
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
Causes of Hypoglycemia





Delayed meals or snacks
Increased exercise or activity
Unplanned activities
Prolonged duration or increased
intensity of exercise
Alcohol intake without food
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
Diabetic Ketoacidosis





Elevated blood glucose levels (≥250
mg/dL but usually <600 mg/dL)
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)
© DR. SHAHJADA SELIM
DKA Prevented by




SMBG
Testing for ketones
Medical intervention
Appropriate sick day guidelines
© DR. SHAHJADA SELIM
DKA Treatment



Supplemental insulin
Fluid and electrolyte replacement
Medical monitoring
© DR. SHAHJADA SELIM
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.
– 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 31:S61-S78, 2012
© DR. SHAHJADA SELIM
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 1530 minutes. If vomiting continues, health
care team should be notified
© DR. SHAHJADA SELIM
Sick Day Guidelines

The health care team should be called
if illness continues for more than 1
day.
© DR. SHAHJADA SELIM
Causes of Fasting
Hyperglycemia



Waning insulin action
“Dawn” phenomenon
Somogyi Effect (“rebound” hyperglycemia)
© DR. SHAHJADA SELIM
Waning Insulin Action


Inadequate insulin dose overnight
Requires adjustment of insulin
doses
© DR. SHAHJADA SELIM
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)
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
Hyperosmolar
Hyperglycemic State






Extremely high blood glucose level (6002000 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
© DR. SHAHJADA SELIM
Long Term Complications
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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 <2000 mg/day may
reduce symptoms
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
© DR. SHAHJADA SELIM
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.
In most individuals, modest weight
loss beneficially affects blood pressure.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2012
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
Dyslipidemia




Primary therapy (lifestyle interventions)
directed at lowering LDL-C to ≤ 100 mg/dL
Pharmacologic therapy at LDL-C>130 mg/dL
If HDL-C is <40 mg/dL, 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
© DR. SHAHJADA SELIM
Dyslipidemia MNT


Saturated fat should be
limited to 7%
Substitute CHO or MFA
© DR. SHAHJADA SELIM
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 30:S4-S36, 2012
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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)
© DR. SHAHJADA SELIM
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 31:S61-S78, 2008
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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 3575% of men with diabetes
© DR. SHAHJADA SELIM
Gastroparesis



Delayed or irregular contractions of
the stomach
Symptoms include feelings of fullness,
bloating, nausea, vomiting, diarrhea,
constipation
Can affect blood glucose control
© DR. SHAHJADA SELIM
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
Nutrition Intervention
Resources
© DR. SHAHJADA SELIM






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
Metabolic Syndrome
and Diabetes Prevention
© DR. SHAHJADA SELIM
Metabolic Syndrome






Intra-abdominal obesity (waist
circumference>40 inches in men and
>35 inches in women)
Dyslipidemia
Hypertension
Glucose intolerance
Compensatory hyperinsulinemia
↑ macrovascular complications
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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,
sfa<10% energy, fat <30% energy,
fiber >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 344;1390:2001.
© DR. SHAHJADA SELIM
Finnish Diabetes Prevention Study
© DR. SHAHJADA SELIM
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.
© DR. SHAHJADA SELIM
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 142;611-619, 2005
© DR. SHAHJADA SELIM
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
© DR. SHAHJADA SELIM
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2012
Prevention/Delay of Type
2 Diabetes
© DR. SHAHJADA SELIM


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).
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.
Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2012
Prevention/Delay of T2DM
© DR. SHAHJADA SELIM


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.
Monitoring for the development of
diabetes in those with pre-diabetes
should be performed every year.
Standards of Medical Care for Diabetes. Diabetes Care 31:S12-S54, 2012
© DR. SHAHJADA SELIM
THNAKS