Download Within Trial Cost-Effectiveness of the Diabetes Prevention

Putting Diabetes Nutrition
Recommendations into Practice
Ann Albright, PhD, RD
Director, Division of Diabetes Translation
The findings and conclusions in this presentation are those of the author and do not necessarily represent the
views of the Centers for Disease Control and Prevention.
Why Eat Well and Be Active?
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Feel good
Have fun
Have energy
Focus and concentration
Healthy
Others…..
Food is Very Personal
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Celebrate with food
Comfort with food
Experience pleasure
Combat boredom
Lots of Different “Diets”
ADA Nutrition Recommendations
Goal of the recommendations is to
make people with diabetes and
health care providers aware of
beneficial nutrition interventions
Diabetes Care, 29:2140-2157, 2006
Key Updates
• Organizing recommendations by prevention
level – primary, secondary, tertiary
• Increasing emphasis on energy balance and
obesity
• Increasing emphasis on the effectiveness of
MNT in preventing and controlling diabetes
Key Updates
• Reducing the recommendation for intake of
saturated fatty acids to < 7% and minimizing
intake of trans-fatty acids
• Addressing issues related to the type and
amount of carbohydrate in preventing and
controlling diabetes
Tailoring Implementation
• The recommendations are flexible with
emphasis on achieving desired health and
quality of life goals
• Translating the recommendations into
practice involves considering the whole
person – life situation, personal preferences
and attitudes, and resources
Goals of MNT
• Achieve and maintain
– Blood glucose levels in or close to normal range
– Lipid profile that reduces risk for CVD
– Blood pressure levels in or close to normal range
• Prevent or slow the development of
complications
• Address individual nutrition needs
• Maintain the pleasure of eating
Overweight and Obesity
Primary Prevention
• In overweight/obese individuals weight loss has
been shown to improve insulin resistance –
recommended for all such people who have
diabetes or at risk for diabetes
• Structured programs that emphasize lifestyle
changes
– Reduced energy and fat
– Regular physical activity
– Regular participant contact
Overweight and Obesity
Primary Prevention
• Restriction of CHO or fat calorie intake are
equally effective in the short term (up to one
year)
• Must monitor lipids and could worsen kidney
function
• Most important determinant of weight loss is
whether nutrition plan can be maintained
Overweight and Obesity
Primary Prevention
• PA and behavior modification are important
components of weight loss and are most
important in maintenance of weight loss
• Weight loss medications may be considered
and can help achieve a 5-10% wt loss
combined with lifestyle modification
• Bariatric surgery may be considered with BMI
> 35
Carbohydrate (CHO)
Secondary Prevention
• CHO from fruits, vegetables, whole grains,
legumes, and low-fat milk encouraged for
good health
• Monitoring CHO, by CHO counting,
exchanges, or experienced-based estimation,
is a key strategy in glycemic control
• Glycemic index/load may provide additional
modest benefit
Carbohydrate (CHO)
Secondary Prevention
• Sucrose-containing foods can be substituted
for other CHO in the meal plan or added if
mediation adjustment is made
• Consume a variety of fiber containing foods
(14g/1000kcal)
• Sugar alcohols and nonnutritive sweeteners
safe when consumed within levels set by
FDA
Dietary Fat and Cholesterol
Secondary Prevention
• The CVD risk of those with diabetes is
considered to be that of non-diabetic people
with pre-existing CVD
• Limit saturated fat to < 7% of total calories
• Intake of trans fat should be minimized
• Limit cholesterol to < 200 mg/day
• Two or more servings of fish/week
Protein (PRO)
Secondary Prevention
• For those with normal renal function, there is
insufficient evidence that usual PRO intake
(15-20% of energy) be modified
• PRO should not be used to treat acute or
prevent nighttime hypoglycemia
• Long-term effects of PRO intake > 20% of
calories on diabetes management and
complications are unknown
Optimal Mix of Macronutrients
• The best mix of CHO, fat, and PRO appears to vary
depending on the individual circumstances
• Dietary Reference Intakes (DRI) may be helpful
– 45-65% of total energy from CHO
– 20-35% from fat
– 10-35% from PRO
• Total calorie intake must be appropriate for wt
management goals
Micronutrients
• No clear evidence of benefits from vitamin or
mineral supplements in people with diabetes
who do not have underlying deficiencies
• Routine supplementation with antioxidants
(Vitamin C, E) is not advised due to lack of
evidence and concern about long-term use
• Benefit from chromium has not been clearly
shown
Alcohol
• If adults with diabetes choose to use alcohol,
daily intake should be limited to moderate
amount (1 drink or less per day for women
and two drinks per day or less for men)
• To reduce nocturnal hypoglycemia in those
on insulin or insulin secretagogues, alcohol
should be consumed with food
• Alcohol alone has no acute effect on glucose
Microvascular Complications
Tertiary Prevention
• Reduce PRO intake to 0.8-1.0 g/kg body
wt/day in those with diabetes and the earlier
stages of CKD and to 0.8 g/kg body wt/day in
those with later stages of CKD
• MNT that favorably affects CVD risk factors
may also help with microvascular
complications
CVD Risk
Tertiary Prevention
• In those with type 1 diabetes a sustained period of
improved glycemic control decreased risk of CVD
events – target A1C as close to normal without
significant hypoglycemia
• Diets high in fruits, veges, whole grain and nuts
• For patients with symptomatic heart failure, dietary
sodium < 2,000 mg/day
CVD Risk
Tertiary Prevention
• In normotensive and hypertensive individuals,
reduced sodium intake (<2300 mg/day) with
a diet high in fruits, vegetables, and low-fat
dairy lowers BP
• In most individuals, modest weight loss
beneficially affects BP
Tools
• Those with prediabets or diabetes should
receive an individualized nutrition plan
• Preferable to have dietitian develop plan with
patient, but all members of the team need to
know and support the patient in achieving
MNT goals
Tools
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Diabetes food pyramid
Plate method
CHO counting
Exchanges
Ethnic food preferences
Eating out
Medicare benefits for diabetes selfmanagement training and MNT
See www.diabetes.org and www.ndep.nih.gov
Problem Solving Cycle
• Define problem (prioritize)
– What is keeping me from achieving my goals
• Think about it from different perspectives
• What do you want to achieve (establish
goals)
• Possible solutions
• Implementation
Coping Skills
• Managing stress
– Identify sources of stress (often not obvious)
– How do you currently cope with stress
(healthy/unhealthy)
– Learn healthy ways to deal with stress
• How are you doing with managing your stress??