Download Lesson 5 : Medical Nutrition Therapy

Lesson 5 : Medical Nutrition
Therapy
Types of DM




Type 1(5-10%)
Type 2 (90-95%)
Gestational
“Other Specific Types” from







specific genetic syndromes
surgery
drugs
Malnutrition (old term)
infections
other illnesses
Impaired glucose tolerance (pre-diabetes)
Types of DM
Characteristic Type 1 DM
Type 2 DM
Age of Onset
Age 40 or older*
Rapidness of Onset
Childhood or
adolescence
Usually abrupt
Family history
Usually no
Common
Etiology
UnknownHeredity,autoimmune,
viral infections
Usually thin
Very little to none
Common
Polyuria/dipsia/phagia
and weight loss
UnknownHeredity
Body weight
Endogenous Insulin
Ketosis
Symptoms
Usually gradual
Obesity common
Normal, high, or low
Uncommon
Polyuria/dipsia or
none
* growing incidence in adolescents
ADA Terminology Update
Old Term
New Term
IDDM
Type I DM
Type 1 DM
NIDDM
Type II DM
Type 2 DM
Diagnostic Criteria
Test
Stage
FPG
RPG
OGTT
Diabetes
126
200
2hPG
200
plus symptoms
Impaired Glucose
Homeostasis
Normal
Impaired Fasting
Glucose =
FPG 110 and
<126 mg/dl
< 110 mg/dl
FPG = Fasting Plasma Glucose
RPG = Random Plasma Glucose
OGTT = Oral Glucose Tolerance Test
Impaired Glucose
Tolerance =
2hPG140 and
<200 mg/dl
2hPG <140mg/dl
Epidemiology

Epidemic increase in type 2 diabetes


currently 90 % of all forms of diabetes
Predictions


6-8 % of the world population will suffer from
diabetes in the next quarter of a century
300 million people worlwide
Doubling of the prevalence of DM2 to 215
million in the next 15 years
215
250
160
200
Million
people
150
100
100
50
0
1995
2000
2010
DM2
50% not yet diagnosed in Europe & North America!
Diabetes 1994-2010: Global Estimates and Projections
Jiwa F. Statistical Bulletin. Jan-Mar 1997;2-8
Diabetes
60
50
40
US
Europe
China
India
30
20
10
0
1995
2000
2010
Year
2025
Diabetes: A Worldwide Epidemic
The Rise in Diabetes: Why?
•
Increasing longevity.
•
Change in demographics and genetic
predispositions: the greatest growth of patients
will be in Asia, where it is predicted that by
2010, over 60% of the patients suffering from
diabetes will live in this region of the world.
•
Rising urbanization and change in lifestyle.
•
Increase in obesity: over 60% of the adult
population in the United States (and Australia)
are either overweight or obese.
Diabetes: A Worldwide Epidemic
Percent of Individuals Considered Obese
in a Given Country
2%
15%
Japan
Europe
25%
US
50%
70%
Jordan
Samoa
Diabetes, Obesity & Adolescence


In developing nations, more than 70% of the
childhood population presenting with diabetes
suffers from type 2 disease.
In the United States, type 2 diabetes is
preferentially affecting the obese Hispanic and
African-American population.
 In the United States, adolescent clinics
describe 1/3 to 1/2 of their new diabetics as
type 2 patients (Henry Ford Health Clinic,
Detroit).
 The incidence of diabetes in children has
increased 10 fold when compared with a
decade ago.
Mortality in diabetes patients double that compared to
non-diabetics
35
Ratio 2.5
30
Ratio 2.2
26.9
Ratio 2.1
32.0
26.9
25
20
15
Control
Diabetes
15.5
12.5
10.8
10
5
0
10,025
61
6629
279
631
24
(No of patients)
Whitehall
Study
Paris
Prospective Study
Helsinki
Policemen Study
Balkau Lancet 1997; 350:1680
Causes of Death Among People With
Diabetes
Cause
% of Deaths
Ischemic heart disease
40
Other heart disease
15
Diabetes (acute complications)
13
Cancer
13
Cerebrovascular disease
10
Pneumonia/influenza
4
All other causes
5
Geiss LS et al. In: Diabetes in America. 2nd ed. 1995:233-257.
Complications of Diabetes

Macrovascular




coronary artery disease (MI)
cerebrovascular disease (Stroke)
peripheral vascular disease
Microvascular



retinopathy
nephropathy
neuropathy
Diabetes complications








Retinopathy (blindness?)
Nephropathy (kidney problems)
Feet ulceration and/or amputations
Hypertension
Hyperlipidemia (cholesterol?)
Gestational diabetes (during pregnancy)
Diabetes and HIV
Erectile Dysfunction
Diabetes complications
HbA1c – relationship with CV risk
Glycaemia increase
Associated risk increase
1%
21%
14%
43%
increase in
HbA1c
increase in
diabetes-related
deaths
p<0.0001
increase in
myocardial
infarction
p<0.0001
increase in
peripheral
vascular disease
p<0.0001
Stratton IM et al. BMJ 2000; 321: 405–12.
Why Treat Diabetes?

DCCT



Kumamoto Study


Diabetes Control and Complications Trial
10-year study in 1441 patients with Type 1 DM
6-year study in 110 Japanese patients with Type 2 DM
UKPDS


United Kingdom Prospective Diabetes Study
20-year study of 5102 newly diagnosed Type 2 DM
The burden of type 2 diabetes can be reduced
The UKPDS showed that, when glucose levels
are above normal, any reduction in HbA1c is
beneficial
0.9%
reduction in HbA1c
UKPDS 33. Lancet 1998;352:837–853.
=
25%
reduction microvascular
complications
Preventative Measures
DCCT

Intensive control of blood glucose reduced
risk of diabetic complications
76% reduction retinopathy onset
 54% reduction retinopathy progression
 54% reduction nephropathy
 60% reduction neuropathy
2-3x greater incidence of severe hypoglycemia


DCCT Research Group N Engl J Med. 1993;329: 977-986.
UKPDS Key Messages
• To reduce the complications of diabetes, it is necessary
to control:
• blood glucose and HbA1c levels
• blood pressure
• Epidemiologic analyses showed that for every percentage
point reduction in HbA1c, there was a
• 35% reduction in microvascular complications
• 25% reduction in diabetes-related deaths
• 18% reduction in MI
©1998
PPS
American Diabetes Association. Diabetes Care. 1999;22(suppl 1):S27-S31.
UKPDS Group. Lancet. 1998;352:854-865.
UKPDS Group. BMJ. 1998;317:703-713.
Nathan D. Lancet. 1998;352:832-833.
It Works…….at least for some things
DCCT1(1993) Kumamoto2(1995) UKPDS31998)
Retinopathy
Up to 76% less 69% less
21% decrease
Nephropathy
Up to 56% less 70% less
33% decrease
Neuropathy
Up to 60% less
Atherosclerotic 41% fewer
Events
50% fewer
Overall
Microvascular
Complications
Data not
Available
1 The
3
Data not
Available
DCCT Group. N Engl. J Med 1993.
UKPDS Group. Diabetes Care 1998.
2 Ohkubo Y,
ND
25% decrease
etl. al. Diab Res Clin Pract 1995.
Goals of Treatment




Alleviate symptoms
Prevent complications
Prevent progression of current
complications
Improve quality of life
ADA Goals of Treatment (cont.)
Index
Normal
Goal
Action
Preprandial
<110
80-120
<80,>140
1hr Postpran
100-160
100-180
<100,>200
2hr Postpran
80-120
80-150
<80,>150
2-4 AM
70-100
70-120
<70,>120
Bedtime
<120
100-140
<100,>140
A1C
<6
<7
>8
Other Glycemic Measures

A1C



measure of how much hemoglobin has been
glycosylated
represents an “average glucose” over the last 3
months
Fructosamine


measure of proteins that are glycosylated
represents an “average glucose” over 2-4 weeks
Diabetic control


Normal HBA1C 3.5 – 6.5%
Targets
HBA1c
Low
risk
Macrovascular
risk
Microvascular
risk
<6.5
Fasting plasma
glucose
<100
>6.5
>100
>7.5
>110
Collaborative Management





Nutritional Therapy
Activity
Monitoring of Blood Glucose
Medication - Insulin or Oral Agents
Education
Nutritional Therapy





Cornerstone of care for Diabetic
No one “diabetic” or “ADA” diet
Use individualized approach
Consider financial status and cultural and
ethnic influences
Priority placed on amount of CHO, not source
of the CHO
Nutrition


Nutrition Therapy – The Most Fundamental
Component of the Diabetes Treatment Plan
Goals:





Near Normal Glucose Levels
Normal Blood Pressure
Normal Serum Lipid Levels
Reasonable Body Weight
Promotion of Overall Health
Nutrition Therapy
Diet Teaching






Goal - independence; effective selfmanagement.
Include Family.
Follow prescribed plan; accurate portions
Never skip meals
Concern - Alcohol
Concern - Dietetic Foods
Nutrient Components








Protein*
Fat*
CHO*
Sucrose and Fructose
Nutritive Sweeteners
Fat Replacements*
Vitamins and Minerals
Alcohol Intake*
Nutrition Goals for
Type 1 ***
*** Type 2




Increase in energy
intake possible
Diet and Insulin nec. to
control BS
Equal distribution of
CHO through meals for
insulin activity
Consistency in daily
intake - control BS




Reduction of energy
intake for obese
Diet alone may control
blood glucose
Equal distribution of
CHO desirable, not
essential;low fat
desirable
Consistency in daily
intake - control wt.
Nutritional Goals (con’t)
Type I **
**Type 2



Timing of meals crucial
Snacks - frequently
necessary
Additional food for
exercise - CHO 20 g/h
for moderate physical
activity



Timing of meals not
essential
Snacks - not
recommended
Additional food for
exercise if on
sulfonylurea or insulin
Dietary Management
of Diabetes





Maintain as near-normal blood glucose levels as
possible by balancing food, insulin and exercise
Achieve recommended serum blood lipid levels
Provide energy intake to maintain or attain healthy
weight
Prevent and treat acute and long-term diabetes-related
complications
Enhance over all health
Dietary Intake in US
(NHANES III)

Mean daily intake





2095 Total kcal
34% Fat
15% Protein
50% CHO
2% Alcohol
Macronutrient Composition of
Various Diets
100%
3
80%
15
49
40
55
70
60%
55
30
40%
34
30
20%
15
0%
g
Av
15
et
Di
PRO (% kcal)
15
L
ow
30
15
at
F
er
ry
e
V
w
Lo
FAT (% kcal))
t
Fa
Lo
w
30
O
CH
CHO (% kcal)
ry
Ve
w
Lo
O
CH
ETOH (%kcal)
Major Dietary Guidance Tools

Recommended Dietary Allowances


1989 10th Edition currently being revised
Dietary Reference Intakes (DRIs)
 RDAs
,Tolerable Upper Intake Level
(UL), Estimated Average Requirement
(EAR) and Adequate Intake (AI)


The Food Guide Pyramid


Yates et al, Jour Am Diet Assoc. 1998:98:699-706
Human Nutrition Information Service, Home and Garden
Bulletin Number 252, Hyattsville, MD:USDA, 1992
1995 US Dietary Guidelines

USDA and USDHHS, Nutrition and your health: Dietary
guidelines for Americans, 4th edition, 1995; Home and
Garden Bulletin No. 232,Washington, DC:USDA, 1995
Type 1 Diabetes Mellitus
Nutrition Goals for Type 1

Consider intensive insulin therapy to allow flexibility
in meal patterns
Integrate insulin therapy with usual food intake
Develop an eating pattern based on person’s usual
food intake
Monitor blood glucose levels

Ref: Manual of Clinical Nutrition, 2000



Meal Planning


Term “ADA Diet” is obsolete
Avoid the terms



no concentrated sweets
low sugar diet
liberal diabetic diet
Medical Nutrition Therapy

Meal plans should be individualized

based on




nutrition assessment
medical history
psycho-social assessment
treatment goals
Carbohydrate Consistency


CHO intake and distribution should be
comparable from one day to the next.
CHO content of meals within the same day
can vary.
Type of Carbohydrate


The total amount of CHO eaten is more
important than the source or type.
Clinical studies do not justify the longtime
belief that sucrose must be restricted.
Glycemic Index


Compares various CHO foods and ranks
them according to effect on BG.
Limitations:



compared 50 g CHO from each source, actual
portion sizes weren’t necessarily comparable.
looked at BG response when each item was eaten
alone, on an empty stomach. Mixed meals would
produce a different effect.
People may unnecessarily restrict healthful foods.
Sugars and Sweeteners




Sugar, honey, syrup...1 Tbs. =15g CHO
Fructose slightly lower post-prandial
response.
Sugar alcohol is a form of carbohydrate, but
labels can technically state “sugar free”.
FDA approves 4 sugar substitutes which
have no CHO:

aspartame, saccharin, acesulfame-K, sucralose
Macronutrient Composition




No absolute percentages
CHO and MUFA should be 60-70% kcals
SFA < 10% kcals
Protein intakes of 15-20% kcals
Sample energy distribution



50-60 % CHO
15-20 % Protein
20-30 % Fat
Protein Intake






Small to medium portion of protein once daily
12-20% of daily calories
From both animal and vegetable sources
Vegetable source less nephrotoxic than
animal protein
3-5oz (100-150g) of meat, fish or poultry daily
Patient with nephropathy should limit to less
than 12% daily
Fat Intake





<35% of total calories
Saturated fat <10% of total calories
Polyunsaturated fats 10% of total calories
Cholesterol consumption < 300 mg
Moderate increase in monounsaturated fats
such as canola oil and olive oil (up to 20% of
total calories)
CHO Intake




CHO intake determined after protein and fat
intake have been calculated.
Emphasize on whole grains, starches, fruits,
and vegetables
Fiber same as for nondiabetics (20g to 35g)
Rate of digestion related to the presence of
fat, degree of ripeness, cooking method, and
preparation
Carbohydrate Management Tools




Food Pyramid
Food Labels
ADA Exchange Lists
Reference Books
The Food pyramid




Nutrition adivice should be practical and catered for
the needs of the consumer
15 % proteins, 55 % carbohydrates & maximum 30
% fat are scientific but not practical advice
In USA food pyramid introduced in 1992
In Belgium adjusted (1997)
Nutrition Facts
Serving Size 3/4 cup (55g)
Servings Per Container 8
Amount Per Serving
Calories 200
Calories from Fat 10
% Daily Value*
Total Fat 1 g
Saturated Fat 0 g
Cholesterol 0 mg
Sodium 20 mg
Total Carbohydrate 45 g
Dietary Fiber 5 g
Sugars 15 g
Protein 6 g
2%
0%
0%
1%
15%
20%
Vitamin A 0%

Vitamin C 0%
Calcium 0%

Iron 8%
* Percent Daily values are based on a 2,000
calorie diet. Your daily values may be higher
or lower depending on your calorie needs:
Calories
2,000
Total Fat
Less than 65g
Sat Fat
Less than 20g
Cholesterol Less than 300mg
Sodium
Less than 2400mg
Total Carbohydrate
300g
Dietary Fiber
25g
Calories per gram:
Fat 9  Carbohydrates 4
2,500
80g
25g
300mg
2400mg
375g
30g

Protein 4
Exchange Lists
Calories
g CHO
g Pro
g Fat
Starch
80
15
3
0 -1
Fruit
60
15
0
0
Skim Milk
90
12
8
0-3
Low-fat Milk
120
12
8
5
Whole Milk
150
12
8
8
Vegetable
25
5
2
0
Very Lean Meat
35
0
7
0-1
Lean Meat
55
0
7
3
Medium Fat Meat
75
0
7
5
High Fat Meat
100
0
7
8
Fat
45
0
0
5
Starch Group

15 g CHO







1 slice bread (Belgium
30g)
small tortilla
small potato
1/2 cup pasta (60g)
1/2 cup corn (60g)
1/3 cup rice (70g)
3 cups popcorn (180g)
Fruit Group

15 grams CHO







small apple
small orange
17 grapes
1/2 grapefruit
1 cup cantaloupe
3 prunes
4 ounces orange juice (120g)
Milk Group

15 g CHO each



1 cup milk (200ml)
3/4 cup plain yogurt (150g)
1 cup aspartame yogurt (200g)
Vegetable Group

5 grams CHO each



1 cup raw vegis (225g)
1/2 cup cooked vegis (100g)
1/2 cup vegetable juice
(150ml)
Digestion Timing



Peak Post Prandial BG is typically 1-2 hours
after a standard mixed meal.
Liquids (juice/soda) digest quicker.
High fat meals digest slower.
Meal Planning

Set Carbohydrate Intake


specific amount of CHO set to match prescribed
insulin regimen (less flexible)
Adjust Insulin to Desired Carbo Intake

insulin to carbohydrate ratio


1 unit per 10-15 g carbohydrate
1 unit for every 50 mg/dl elevated above target (above
doses may vary)
Insulin Action Times
Type of Insulin
Start
Peak
Duration
Humalog “Lispro”
5-15 min
30-90 min
2-4 hrs
Novolog “Aspart”
5-15 min
30-90 min
2-4 hrs
Regular
30-60 min
2-3 hrs
3-6 hrs
NPH
2-4 hrs
4-10 hrs
10-16 hrs
Lente
3-4 hrs
4-12 hrs
12-18 hrs
Ultralente
6-10 hrs
no peak
18-20 hrs
Glargine
1 hr
no peak
24 hrs
Insulin Delivery



Syringes
Insulin Pens
Insulin Pump



delivers short acting insulin (sub-Q catheter)
adjustable basal rate (usually 0.5-1.0 u/hr)
programmable bolus for food or BG correction
Insulin Pens


Pre-filled with 300 units. Disposable.
Dial dose in 1 unit increments up to 60 unit dose.
Insulin Pump

Programmable insulin pump



holds 300 units
insulin is delivered through sub-Q infusion set/tubing
Remote control

discrete dosing
Exercise



Improves insulin
sensitivity
Lowers Blood Glucose
Uses Glycogen Stores



muscle
liver
Increases release of
FFA from adipose
Exercise Guidelines: Type 1 DM
Metabolic Control



Avoid exercise if BG >250 mg/dl,
ketones present.
Use caution with exercise if BG>300 mg/dl,
without ketones.
Eat CHO if BG < 100 mg/dl
Exercise Guidelines: Type 1 DM
Blood Glucose Monitoring


Monitor BG before and after exercise.
Monitor BG throughout longer duration or
very intense exercise.


identify need to increase food or decrease insulin.
learn how various forms of exercise alter glycemic
response.
Exercise Guidelines: Type 1 DM
Insulin Adjustments



If exercise is planned for just after a meal,
consider reducing the short acting insulin that
covers that meal.
If exercise is planned for 3-4 hours after a
meal, consider reducing the long-acting
insulin.
For unplanned exercise, consider adding
carbohydrate.
Exercise Guidelines: Type 1 DM
Food Intake


Consume CHO before, during, or after
exercise to prevent hypoglycemia.
Always keep CHO foods readily available
during exercise.
Late-onset Hypoglycemia


Related to repletion of glycogen stores.
Can occur up to 24 hrs after exercise.


indicates that insufficient carbohydrate was
available in relation to insulin and exercise.
Depleted glycogen stores are best replaced
when CHO is consumed within 30 min of
exercise completion.
Treating Hypoglycemia


Check BG when s/sx of hypoglycemia
For BG < 70 mg/dl

take 15 grams of CHO





4 oz (120ml) juice
1 Tbs. (15g) sugar, jam, honey
3-4 glucose tabs
recheck BG in 15 minutes, repeat PRN
If unconscious, NPO: administer glucagon or
IV dextrose.
Alcohol Precautions



Alcohol inhibits gluconeogenesis which
impairs the ability to recover from low BG.
Glycogenolysis is not affected by EtOH.
Counter-regulatory response depends on
glycogen stores.
ADA rec’s:

limit to 1-2 drinks, consumed with CHO foods, if
no other contraindications.
Blood Glucose Meters






Plasma referenced
Fingertip vs Offsite
Memory
Downloadable
Some measure ketones
Insurance companies
dictate which meter
they cover.
Continuous Glucose Monitor





Subcutaneous sensor attached to unit worn on belt.
Typically worn for 3 days.
Measures BG continually.
Download graph of BG.
Elucidates potentially unknown BG excursions.
Blood Glucose Targets

Before Meals



< 110
90 - 130
Peak Post Prandial



normal
goal
normal
goal
< 140
< 180
Bedtime


normal
goal
< 120
110 -150
Hemoglobin A1c

Target


ADA < 7
ACE & IDF < 6.5
A1c
4
5
6
7
8
9
10
11
BG
60
90
120
150
180
210
240
270
Type 2 Diabetes Mellitus
Nutrition Goals for Type 2

Weight loss of approximately 10-20 lb (4.59.0 kg)
Space meals throughout day
Avoid excessive CHO intake at one meal
May need consistent mealtime depending on
insulin use or insulin secretagogues
Exercise

Ref: Manual of Clinical Nutrition, 2000




Key Topics






Statistics/Overview
Weight Control
Lipid Control
Blood Pressure Control
Exercise
Other Complications
Diabetes Prevention Program
Research Group
3234 adults with impaired glucose tolerance
 Randomized (3 years)

 standard
lifestyle plus Metformin
 standard lifestyle plus placebo
 intensive lifestyle modification
Lifestyle Modification

Weight loss (decrease weight by 7 %)




individualized counseling
healthy, low calorie, low-fat diet
A 16 lesson curriculum on diet, exercise, behavior
modification
Exercise 150 minutes per week
Results

Intensive lifestyle modification group


reduced incidence of diabetes by 58 %
Metformin

reduced incidence of diabetes by 31 %
Exercise

Potential Benefits





Improved Glucose tolerance
Weight loss or maintenance or desirable weight
Improved cardiovascular risk factors
Improved response to pharmacologic therapy
Improved energy level, muscular strength,
flexibility, quality of life, and sense of well being
Exercise Prescription





Interest
Capacity
Motivation
Physical status
Individualized approach
Types of exercise





Walking
Biking and stationary cycling
Lap swimming and water aerobics
Weight lifting
At least 3-4 times a week, 30-40 minutes per
session, 50 to 70% of maximum oxygen
uptake
Metabolic Staging of
Type 2 Diabetes
Peripheral
insulin
resistance
Hyperinsulinemia
Impaired
glucose
tolerance
Defective glucorecognition
Early diabetes
b-cell failure
Late diabetes
Saltiel AR, Olefsky JM. Diabetes. 1996;45:1661-1669.
“STAGES” OF TYPE 2 DIABETES
LIFESTYLE
100
%
MONOTHERAPY
COMBINATION
THERAPY
b-CELL
FUNCTION
UKPDS: “HOMA”
ANALYSIS
IGT
PP
BS
-10


 
DM
DM
DM
“1”
“3”
“2”
-5
0
5
YEARS FROM DIAGNOSIS
REQUIRE
INSULIN
10
“Pre-diabetes”

HHS and ADA are using this new term to
describe IFG (impaired fasting glucose) and
IGT (impaired glucose tolerance).



16 million people have pre-diabetes.
Most will develop diabetes within 10 years.
Prevention strategies



screen at risk populations ( > 45 yrs, obese)
lose 5-10% of weight
modest exercise 30 min/day
Weight Control
Energy In
=
CHO: 4 kcals/g
Protein:
4 kcals/g
Fat:
9 kcals/g
EtOH: 7 kcals/g
Energy Out
Metabolism
Daily Activities
Exercise
Nutrition Therapy

Provide Follow-up assessment of the meal
plan to



Determine effectiveness in terms of glucose and
lipid control and weight loss
Make necessary changes based on weight loss,
activity level, or changes in medication
Provide ongoing patient education and support
Weight Loss




Improves Glucose Control
Increases Sensitivity to insulin
Lower lipid levels and blood pressure
Corresponding lowering of the dosage of
pharmacologic agents
For a Successful Outcome





Modest Energy Restrictions
Spreading energy intake throughout the day
Increased Physical Activity
Behavior Modification
Psychosocial Support
Energy Intake




Women: 100 # for the first 5 ft of height plus 5 # for
each additional inch over 5 ft.
Men: 106# for the first 5 ft. of height plus 6# for each
additional inch over 5 ft.
Add 10% for larger body build, Subtract 10% for
smaller body builds
Multiply resulting weight by:



Men and Physically Active Women: 15
Most Women, Sedentary Men, and Adults over 55: 13
Sedentary Women, Obese Adults over age 55: 10
Weight Loss
1 pound body fat = 3500 kcals stored energy


Energy deficit of 500 kcals/day to lose 1 lb/wk
Energy deficit of 250 kcals/day to lose 1/2 lb/wk
Create energy deficit by:


Eating less calories
Exercise more
Guidelines for Weight Loss









Limit eating for emotional or situational reasons.
Limit non-nutritious energy sources.
Limit added fats.
Use lean meats.
Use lowfat dairy products.
Use lowfat cooking methods.
Choose low calorie beverages.
Eat a balanced diet and don’t skip meals.
Exercise regularly.
Getting to the Heart of the Matter


The number 1 cause of death for people with
diabetes is heart disease.
Minimize risk factors:
* control BG
* don’t smoke
* control BP
* control lipids
* control weight * exercise regularly
Treatment Goals





Blood Pressure < 130/80
Total Chol
LDL Chol
HDL Chol
Triglycerides
< 200 mg/dl
< 100 mg/dl
> 40 mg/dl
< 150 mg/dl
Heart Healthy Diet





Decrease saturated, hydrogenated, and
trans-fatty acids. (< 7% kcals)
Limit dietary cholesterol. (<200 mg/d)
Increase intake of omega-3 fatty acids.
Increase intake of soluble fiber. (10-25 g/d)
Include plant stanols/sterols. (2 g/d)
Dietary Fats Defined

Saturated Fats



Hydrogenated Fats


solid at room temperature
animal fats
vegetable oils in origin, modified to solidify
Trans Fatty Acids

occur mostly in hydrogenated fats
All of the above fats can raise LDL cholesterol.
Dietary Fats Defined

Polyunsaturated Fats


Monounsaturated Fats


safflower, corn, sunflower, sesame, cottonseed
olive, canola, peanut, avocados
Omega-3 Fatty Acids


fish: salmon, tuna, mackerel, herring, sardines
vegetarian sources: flaxseed, walnut, soybean,
canola, evening primrose.
Dietary Cholesterol


Only found in animal products.
Most concentrated sources:





eggs (212 mg/yolk)
shrimp (194 mg/3.5 oz, 100g)
squid (231 mg/3.5 oz, 100g)
liver
(389 mg beef, 631 mg chicken, 3.5 oz, 100g)
meat (75-95 mg/3.5 oz, 100g beef, chicken, pork)
Soluble Fiber



Binds bile acids in the intestine, so that the
bile acids are not absorbed in the terminal
ileum.
New bile acids are made from circulating
cholesterol, thus lowering serum chol.
Best Sources:



oats, beans/legumes, rice bran, barley
carrots, broccoli, sweet potatoes,
citrus, papaya, apples, strawberries
Homocysteine Alert


Elevated homocysteine levels may increase
the risk of heart disease.
Adequate intake of these vitamins can lower
homocysteine levels:



Folate: fruits, vegetables, legumes, avocado,
yeast, wheat germ, fortified cereals and grains.
Vit B6: whole grains, legumes, fish, chicken...
Vit B12: milk, cheese, meat, fish, chicken, eggs
Blood Pressure Control

Lifestyle Modifications






control weight
exercise regularly
limit sodium
limit alcohol
eat diet rich in potassium
eat adequate amounts of calcium (?)
Reduce Sodium Intake


Limit to 2,400 mg/d
Low Sodium Strategies:




avoid the salt shaker
limit use of processed foods
limit fast food restaurant meals
season with herbs, spices, garlic, ginger, lemon,
onions, flavored vinegar
Potassium

Unless patient is limiting potassium for renal
disease, or hyperkalemia, encourage a diet
rich in potassium. Sources include:




apricots, avocados, bananas, cantaloupe, kiwi,
mangos, oranges, strawberries
artichokes, tomatoes, potatoes, yams, legumes,
parsnips, winter squash
milk, yogurt
lean meat, fish, skinless poultry
Exercise








Improves insulin sensitivity/lowers BG
Helps with weight control
Lowers blood pressure
Lowers LDL and triglycerides
Raises HDL
Improves circulation and strengthens heart
Improves bone density
Relieves stress, improves sleep
Complications = Restricted Diets

Nephropathy



protein restriction 0.8 g/kg/day
potassium, phosphorus, sodium, fluid restrictions.
Gastroparesis



small frequent meals
lowfat, low fiber, puree/liquid consistency
difficulty matching insulin kinetics and digestion
timing.
Dietary Management of Diabetes:
Guidelines
Same as for the general population
Total fat:
30% or less of total energy
 (20% or less in obese)
 If elevated triglycerides, reduce CHO and increase fat to
35-40% of energy
 Saturated fat -- 10% of total energy
Protein:
10 - 20% of total energy intake
CHO:
55% of total energy intake
Dietary Management of Diabetes:
Guidelines
Carbohydrates and Sweeteners
 Emphasis on total CHO rather than simple or complex

Can have sucrose as part of CHO allotment up to a
maximum of 10% of calories

Different foods have different effects on blood sugar
level -- glycemic index
Nutrition Consult – Individualized
Meal Planning



Conduct Initial Assessment of Nutritional Status
Diet History, Lifestyle, Eating Habit
Provide Patient Education Regarding






Basic principles of diet therapy
Meal planning
Problem solving
Developing individualized meal plan
Emphasize one or two priorities
Minimize changes from the patient’s usual diet
Priorities for Meal Planning
If require insulin (two injections of mixed short and
intermediate acting insulin):




Timing of meals and snacks important
Quantity and quality of food important
Watch CHO content
Snacks at time of peak insulin action
With more intensive use of insulin (including regular
insulin before meals)

Have more flexibility in food and timing
Priorities for Meal Planning
Type II diabetes with no insulin:






Gradually reduce total and saturated fat
Spread calories throughout the day
Avoid large amount of food at one time
Space meals at least 4-5 hours apart
Aim for healthy body weight
Promote appropriate exercise
Diabetic Exchange System



Are tools for enabling food choices based on categories
of foods and serving sizes
Patients need to be fairly literate
Canadian and American and European systems differ
Glycemic Index (GI)

An indicator of the impact of foods on the response of
blood glucose

Foods with a low GI are digested and absorbed more
slowly than foods with a high GI

Low GI foods increase amount of CHO entering colon
and increase fermentation

Used for making food choices by diabetics and people
with impaired glucose tolerance
Glycemic Index Value: Examples
Food
bread
cereal
milk
sucrose
orange juice
Glycemic Index
100
72
39
87
74
Artificial Sweeteners

Sugar alcohols (sorbitol, mannitol, xylitol cause less rise
in blood glucose
Non-nutritive Sweeteners
 Aspartame (Equal, Nutrasweet, candarel)
 Saccharin (Sweet’n Low, Sugar Twin)
Alcohol Inake
Alcohol
 Moderate amounts can be consumed when diabetes
is well controlled

No more than two drinks per day

Should always take alcohol with food
Some Special Situations
Delayed meals

Eat a snack if expect meal will be delayed

Carry available source of CHO i.e. Glucose tablets or
hard candy to avoid hypoglycemic reaction
Some Special Situations
Strenuous exercise

Eat extra food before activity and take 15-30 grams of
CHO for every 30 min of strenuous activity (15 g CHO
for each hour of less strenuous exercise)

Eat hearty snack after activity

If activity is pre-planned may reduce insulin dosage
prior to activity
Some Special Situations
Illness





Lack of appetite often with illness
Substitute foods that are well tolerated
Drink sugar containing liquids
For each missed meal give 50 g CHO in small
frequent feedings over 3-4 hours
Type I should not miss insulin as illness often causes
rise in blood glucose
Hypoglycemia: Treatment

Give quickly absorbed CHO immediately (1/3 can coke 33cl, 2
sugar cubes, 15 g glucose tablets)

Repeat treatment every 15-20 minutes if symptoms continue

If unconscious give intravenous glucose or glucagon injection
Diabetes in Children


75% of Type 1 diabetes occurs before 18 years
Peak onset is 6 -11 years

Balance between allowing for normal growth and
development, and need for glycemic control

Need meal plan that fits child’s lifestyle and promotes
optimal compliance
Management Goals in Children




Support normal growth and development
Control blood glucose
Prevent acute and chronic complications
Achieve optimal nutritional status
Gestational Diabetes

Nutrition management similar to Type 1 and Type 2.

Diet tends to be slightly lower in CHO and higher in
protein and fat (30-35%)

Requires individualized approach
Pyramid of Health Action
AHA Dietary Guidelines for Healthy American
Adults and
“Unified” Dietary Guidelines *

Saturated fat < 10% of calories
Total fat < 30% of calories
Polyunsaturated fat <10% of calories
Monounsaturated fat ~ 15% of calories
Cholesterol < 300 mg/d
Carbohydrates > 55% calories
Total calories to achieve and maintain desirable weight
Salt intake limited to < 6 gm/d (2.4 Na)

Alcohol only in moderation (<1-2/d)







*AHA Nutrition Committee, Circ 1996;94:1795-1800
AHA Conf on Prev Nutr. Circ 1999;100:450-456
AHA Discussion of
2000 US Dietary Guidelines?

Eat a nutritionally adequate diet
consisting of a variety of foods



5 servings of fruits/vegetables
6+ servings of whole grains
Limit intake of foods high in saturated
fat, cholesterol and total fat




monounsaturated fat
trans fatty acids
omega 3 fatty acids
cholesterol level
2000 U.S. Dietary Guidelines?
(con’t)

Achieve and maintain an appropriate body
weight




Healthy BMI
Obesity recognized as an independent risk factor
Physical activity
Increase consumption of complex CHO and
fiber

Amount and type
2000 US Dietary Guidelines
(con’t)

Reduce intake of sodium




contribution of ca, mg, K
contribution of obesity
physical activity and alcohol
Consume alcohol in moderation, if at all?

Red wine vs other types of alcohol
2000 US Dietary Guidelines (con’t)

Special Populations:





children
post-menopausal women
elderly
minorities
Populations at increased CVD risk




Elevated LDL-C or pre-existing CVD
Diabetes
Hypertension
Obesity
2000 DGs - Treatment: Obesity and CVD
Diet Composition Recommendations

Total kcal adequate and appropriate






to prevent weight gain
achieve small, incremental weight losses
provide adequate nutrition, flexibility
Low saturated fat (<10% kcal)
Increase MUS to replace SF
Total Fat < 30% kcal