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2/27/2014
Nutrition Therapy Recommendations for the Management of Adults With Diabetes, 2014
Sandy Arner, RD, LDN, Outpatient Dietitian/Nutritionist James H. Quillen VA Medical Center March29,2014
Disclosure Statement
Financial Interest
Unapproved/Investigative Use
I, Sandra Arner, DO NOT have a financial interest/ arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
I, Sandra Arner, DO NOT anticipate discussing the unapproved/investigative use of a commercial product/ device during this activity or presentation.
Learning Objectives
• State three goals of nutrition therapy for diabetes
• Describe two eating patterns suggested for diabetes management
• Identify some priority topic nutrition strategies for all people with diabetes
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Statistics from National Diabetes Fact Sheet of the CDC (Released Jan. 26, 2011)
• 25.8 million people in US have DM (8.3% of US population)
• Diabetes is the leading cause of kidney failure, nontraumatic lower‐limb amputations, and new cases of blindness among adults in the United States
• Diabetes is a major cause of heart disease and stroke
• Diabetes is the seventh leading cause of death in the United States
Tools for Managing Diabetes
• Food/Nutrition
• Exercise/Physical activity
• Medication if prescribed
Evert AB, Bucher JL, et al. (Position Statement) Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013;36:3821‐3842 (Nov. 2013)
American Diabetes Association, Clinical Practice Recommendations 2014, Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Supplement 1):S1‐S155 (Jan. 2014)
Evert AB, Bucher JL, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2014;37(Supplement 1): S120‐S143 (Jan. 2014)
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Goals of Nutrition Therapy That Apply to Adults with Diabetes
• Attain individualized glycemic, blood pressure, & lipid goals
– A1c < 7%
– Blood pressure < 140/80
– Lipids
– LDL‐C < 100
– TG < 150
– HDL > 40 for men, > 50 for women
Goals of Nutrition Therapy (cont’d)
• Achieve and maintain body weight goals
• Prevent or delay complications
• Address individual nutrition needs
• Maintain pleasure of eating
• Provide individual with DM practical tools
Importance of Medical Nutrition Therapy (MNT)
• Institute of Medicine (IOM) report in 1999—evidence demonstrated MNT can
– Improve clinical outcomes
– Possibly decrease cost of managing diabetes for Medicare
Institute of Medicine: The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC, National Academy Press, 2000, p.118–131
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Effectiveness of Nutrition Therapy
Person with Diabetes
Nutrition
Type 1 DM
Intensive flexible insulin therapy education using the carb counting meal planning approach can result
in improved glycemic control
Fixed daily insulin doses
Consistent carb intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia
Type 2 DM
Older adults with Type 2 DM
Simple diabetes meal planning approach often better suited for those with health and numeracy literacy concerns
Academy of Nutrition and Dietetics Evidence‐Based Practice Guidelines (MNT for Those with DM) Franz MJ, Powers MA, et al. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc 2010:110:1852‐1899
• A series of 3‐4 encounters with RD (Registered Dietitian) lasting 45‐90 minutes – Should begin at diagnosis of DM if possible
– Should be completed within 3‐6 months of referral
– RD should determine whether additional MNT encounters are needed
• At least one follow‐up encounter recommended annually to reinforce lifestyle changes and to evaluate and monitor outcomes
– RD should determine whether additional MNT encounters are needed
2008 vs. 2014 Nutrition and DM Recommendations
2008 Nutrition 2014 Nutrition Therapy Recommendations and Recommendations for Interventions for Diabetes Adults With Diabetes
• Dietary prescription
• Diet
• Eating plans, eating patterns
• Patient preference
• Metabolic goals
• Guide for coordinating food with DM medicines
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Energy Balance, For Those Overweight
• Promote weight loss
– Reduce energy intake
– Maintain healthful eating pattern
• Achieve modest weight loss
– Can improve BG, BP, lipids
– Need intensive lifestyle interventions, ongoing support
Optimal Mix of Macronutrients
• No ideal percent of calories from carbohydrate, protein, fat
• Should be based on individual assessment
– Current eating patterns
– Food preferences
– Metabolic goals
Eating Patterns (Dietary Patterns)
• Mediterranean style
• Vegetarian and vegan
• Low fat
• Low carbohydrate
• DASH
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Mediterranean Style
• Abundant plants
• Olive oil principle fat
• Minimally processed
• Low to moderate amount dairy
• Seasonally fresh
• Locally grown
• Up to 4 eggs a week
• Fresh fruits as dessert
• Red meat less often and small portions
• Concentrated sugars and honey on special occasions
• Wine consumption low to moderate amount with meals (as appropriate for individual)
Vegetarian and Vegan
Vegetarian
Vegan
• Devoid of flesh foods
• Devoid of flesh foods
• Can include
• No animal‐derived products
– Egg (ovo)
– Dairy (lacto)
Low Fat
Emphasis
Energy as Fat
• Fruits
• < 30% of total energy intake as all fat • Vegetables
• Grains, starches
• < 10% of total energy intake as saturated fat
• Lean protein
• Low‐fat dairy
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Low Carbohydrate
Emphasis
Avoid/Limit
• Foods higher in protein
• Sugar‐containing foods
• Fats
• Grains
• Low carb vegetables
• Starchy vegetables
• Fruits, generally allowed
DASH (Dietary Approaches to Stop Hypertension)
Emphasize
Reduce
• Fruits
• Saturated fat
• Vegetables
• Red meat
• Low‐fat dairy
• Sweets
• Lean meat
• Sugar‐containing beverages
• Whole grains
• Nuts
• Reduced in sodium (more effective)
Individual Macronutrients—Carbohydrate
Encourage/Include
Limit
• Vegetables
• Carbs with added fats
• Fruits
• Carbs with added sugar
• Whole grains
• Carbs high in sodium
• Legumes
• AVOID/LIMIT—Sugar Sweetened Beverages (SSBs)
• Diary products
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Quality of Carbohydrate—
Glycemic Index and Glycemic Load
• Substituting low glycemic load foods for higher glycemic load foods may modestly improve glycemic control
Glycemic Index and Glycemic Load
Glycemic Index
Glycemic Load
• Ranks carbohydrates according to extent they raise blood sugar after eating
• Measures degree of glycemic response and insulin demand produced by a specific amount of a specific food
Glycemic Index and Glycemic Load
Glycemic Index
Glycemic Load
• Ranks carbohydrates according to extent they raise blood sugar after eating
• Measures degree of glycemic response and insulin demand produced by a specific amount of a specific food
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Dietary Fiber and Whole Grains
• Consume at least amount of fiber and whole grains recommended for general public
– Institute of Medicine 2002
• Age 50 or younger—38 gm/day men, 25 gm/day women
• Age 51 and older— 30 gm/day men, 21 gm/day women
– US Dietary Guidelines 2010
• 14 gm fiber/1000 kcal or 38 gm/day for men, 25 gm/day for women
• Eat half of your grains as whole grains
Sucrose, Fructose, Caloric Sweeteners
Category
Sucrose
Recommendation
Minimize intake when substituting for starch
Avoid displacing nutrient‐dense foods
Fructose (as “free fructose”) Achieve potentially better glycemic (naturally occurring)
control vs. sucrose or starch
Impact on TG unlikely if not excessive (>12% energy intake)
Sugar‐Sweetened Beverages
Limit/avoid (source—sucrose, HFCS)
Reduce risk for weight gain and worsening cardiometabolic profile
Non‐Nutritive & Hypocaloric Substitute for caloric sweeteners may Sweeteners
reduce calorie and carb intake
Individual Macronutrients—Protein Situation of Protein Recommendation
Diabetes
Diabetes without No ideal intake to improve glycemic control diabetic kidney disease or CVD risk
Individualize goals
Diabetes and macro‐
or micro‐albuminuria
Reduction below usual intake not recommended
Type 2 DM
Do not use carb sources high in protein to treat or prevent hypoglycemia
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Individual Macronutrients—Fat Type of Fat
Recommendation
Total Fat
No ideal intake; individualize goals
Fat quality more important than quantity
MUFAs
Mediterranean‐style
MUFA‐rich eating pattern recommended as alternative to low‐fat, hi carb for those w/Type 2 DM
May improve glycemic control, CVD risk factors
PUFAs
Limited evidence on effect in people with Type 2 DM
Dietary Fat
Target Dietary Intake of Fats
Saturated Fat
< 10% of (total) calories
Cholesterol
< 300 mg dietary cholesterol/day
Trans Fat
Limit as much as possible
Guidelines Comparison of Specific Fat Recommendations
Dietary Fat
2010 US Dietary
Guidelines for Americans
2013 ACC/AHA
Guidelines
Total Fat
Not specifically stated
26% to 27% calories
2014 Nutrition
Therapy Recommendations with Diabetes
Not specifically stated
Dietary Cholesterol < 300 mg dietary Not specifically stated < 300 mg dietary cholesterol/day
cholesterol/day
Saturated Fat
< 10% energy
Aim for 5% to 6% calories
< 10% calories
Trans Fat
As low as possible Reduce percent of Limit as much as calories from trans fat possible
Omega‐3 Fatty Acids
• Omega‐3 (EPA, DHA) supplements not recommended to treat or prevent CVD
• Increase intake of foods with EPA, DHA, ALA
– Benefits on lipoproteins, CVD prevention, health outcomes
• Eat fish ≥ twice a week
– Especially fatty fish
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Plant Stanols and Sterols
• Those with DM and dyslipidemia
– May modestly reduce total and LDL cholesterol
– 1.6 to 3 grams per day plant stanols or sterols
• Found in enriched foods
Micronutrients and Herbal Supplements
Nutrient
Antioxidants
(vitamins E, C; carotene)
Recommendation
Not advised due to lack of evidence of efficacy and concern of long‐term safety
Micronutrients
Insufficient evidence to recommend (chromium, magnesium, vitamin D) routine use to improve glycemic control for those with diabetes
Cinnamon
Insufficient evidence to support use Other herbs/supplements
for diabetes treatment
Summary—Micronutrients and Herbal Supplements for Diabetics
• Vitamin or mineral supplementation
– No benefit in those without underlying deficiencies
• Individualized meal planning
– Optimize food choices to meet recommended micronutrient dietary allowance/intake
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Alcohol
• Moderation
– Women: ≤ 1 drink a day
– Men: ≤ 2 drinks a day
– 1 drink = 12 oz. beer, 5 oz. wine, 1.5 oz. distilled spirits
• Alcohol consumption
– May increase risk for delayed hypoglycemia especially if taking insulin, insulin secretagogues
– Need to educate on recognition and management of delayed hypoglycemia
– Consistent excess consumption (≥ 3 drinks/day) may contribute to hyperglycemia
– Abstinence for some should be advised
Sodium
• Reduce to < 2,300 mg/day
– Same as general population
• Those with diabetes and hypertension
– Consider goal < 2,300 mg/day in individual basis
Clinical Priorities for Nutrition Management; Summary of Priority Topics
• Strategies for all people with diabetes
• Priority should be given to coordinating food with type of diabetes medicine
– Insulin secreatagogues
– Biguanides
– Α‐glucosidase inhibitors
– Incretin mimetics (GLP‐1)
– Type I DM and insulin‐requiring Type 2 DM
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Summary of Priority Topics For All People w/DM
• Recommend portion control for weight loss and maintenance
• Know what foods contain carbs
• Choose nutrient‐dense, high fiber foods over processed foods
• Avoid sugar‐sweetened beverages
• Carb counting—usually no need to subtract fiber or sugar alcohols from total
Summary of Priority Topics For All People w/DM (cont’d)
• High trans fat, saturated fat foods—replace with foods high in unsaturated fats
• Choose lean protein and meat alternatives
• Vitamin and mineral supplements, herbal products, cinnamon—not recommended to manage diabetes
• Moderate alcohol consumption
• Limit sodium to 2,300 mg per day
Diabetes Healthy Plate
(from American Diabetes Association; and Michelle May, Megret Fletcher)
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Summary of Priority Topics—Coordinating Food with Type of Diabetes Medicine for Those Individuals on Medicine
Summary of Priority Topics—Coordinating Food with Type of Diabetes Medicine for Those Individuals on Medicine (cont’d)
Case Study, Paul O. What Nutrition Strategies? • 51 year old male
• Diagnosed DM 2009
• Height 67 inches
• Weight 216.8 lb
• BMI 33.52
• BP 120/90
• A1c 7.2%
• FBG 125 mg
• Lipids‐‐
– Total cholesterol 170 mg – TG 182 mg – HDL 41 mg
– LDL‐C 93 mg
• Medicines – glyburide
– HCTZ
– lisinopril
– omeprazole
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Summary—There is No “ADA Diet”
• No standard meal plan or eating plan works universally for all people who have DM
• Nutrition therapy (preferably provided by an RD) should be individualized for each person based on – Individual health goals
– Personal and cultural preferences
– Health literacy and health numeracy
– Access to healthful choices
– Readiness, willingness, and ability to change
Summary (cont’d)
• Nutrition interventions should
– Emphasize variety of minimally processed nutrient‐
dense foods in appropriate portion sizes as part of a healthful eating pattern
– Provide the person with diabetes the practical tools for day‐to‐day food planning and behavior change that can be maintained over the long term
Questions
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