Transcript MNT Strategies in Type 2 Diabetes

MNT in Diabetes and
Related Disorders
Expected Outcomes of
MNT in Diabetes
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↓ 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
MNT in Type 1 Diabetes
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Insulin therapy should be integrated
into an individual’s dietary and
physical activity pattern (E)
Individuals using rapid-acting insulin
by injection or an insulin pump should
adjust the meal and snack insulin
doses based on the CHO content of
the meals and snacks (A)
Nutrition recommendations and interventions for diabetes. Diabetes Care
30; S48-65, 2007
MNT in Type 1 Diabetes
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For individuals using fixed daily insulin
doses, CHO intake on a day-to-day
basis should be kept consistent with
respect to time and amount (C)
For planned exercise, insulin doses can
be adjusted. For unplanned exercise,
extra CHO may be needed (E)
Nutrition recommendations and interventions for diabetes. Diabetes Care
30; S48-65, 2007
MNT Strategies in Type 2
Diabetes
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Implement lifestyle changes that reduce
intakes of energy, saturated and trans fatty
acids, cholesterol, and sodium and increase
physical activity in order to improve
glycemia, dyslipidemia, blood pressure (E)
Plasma glucose monitoring can be used to
determine whether adjustments to foods
and meals will be sufficient to achieve blood
glucose goals or if medication(s) needs to
be combined with MNT
Nutrition recommendations and interventions for diabetes. Diabetes
Care 30; S48-65, 2007
Carbohydrates in
Diabetes
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Dietary pattern that includes CHO from
fruits, vegetables, whole grains,
legumes, and low fat milk is
encouraged for good health (B)
Monitoring CHO, whether by CHO
counting, exchange, or estimation
remains a key strategy in achieving
glycemic control (A)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Carbohydrate and
Diabetes
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Sucrose-containing foods can be
substituted for other carbohydrates in
the meal plan or, if added to the meal
plan, covered with insulin or other
glucose-lowering medications. Care
should be taken to avoid excess
energy intake. (A)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Carbohydrate and
Diabetes
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The use of glycemic index and load
may provide a modest additional
benefit over that observed when total
CHO is considered alone (B)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Glycemic Index
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The blood glucose response of a given
food compared to an equal amount of a
CHO standard (typically glucose or white
bread)
Glycemic Index
Influenced by various factors
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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
Glycemic Index and
Glycemic Load of Foods
Food
Glycemic Index Glycemic Load
Carrots
47
3
Potato baked
Sweet corn
Apple
Chocolate cake
85
60
38
38
26
11
6
20
Corn flakes
Oatmeal
Pumpkin
92
42
75
24
9
3
Sucrose
68
7
Krause’s Food & Nutrition Therapy, 12th ed., Appendix 43
Fiber and Diabetes
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As for the general population, people with diabetes
are encouraged to consume a variety of fibercontaining foods. However, evidence is lacking to
recommend a higher fiber intake for people with
diabetes than for the population as a whole. (B)
It requires very large amount of fiber (~50 grams) to
have a beneficial effect on glycemia, insulinemia,
lipemia
Sweeteners and Diabetes
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Sugar alcohols and nonnutritive
sweeteners are safe when consumed
within the daily intake levels
established by the Food and Drug
Administration (FDA) (A)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
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
Nutritive Sweeteners:
Sugar Alcohols
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Sorbitol, mannitol, xylitol, isomalt, lactitol,
hydrogenated starch hydrolysates
Lower glycemic response, lower calorie
content than sucrose
Not water-soluble so often combined with
fats in foods; often deliver as many calories
as sucrose-sweetened foods
Unlikely to have a beneficial effect on blood
sugars
In large quantities, may cause GI distress
and diarrhea
Non-Caloric Sweeteners
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Saccharin (Sweet’N Low®)
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Aspartame (NutraSweet®)
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Acesulfame potassium,
acesulfame-K (Sweet One®)
Sucralose (SPLENDA®)
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
Noncaloric Sweeteners:
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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
Protein and Diabetes
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Insufficient evidence to suggest that
usual protein intake (15-20% of
energy) should be modified (E)
In individuals with Type 2 diabetes,
ingested protein can increase insulin
response without increasing plasma
glucose concentrations. Therefore,
protein should not be used to treat
acute or prevent nighttime
hypoglycemia (A)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Protein and Diabetes
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High-protein diets are not recommended as a
method for weight loss at this time. The long-term
effects of protein intake >20% of calories on
diabetes management and its complications are
unknown.
Although such diets may produce short-term weight
loss and improved glycemia, it has not been
established that these benefits are maintained long
term, and long-term effects on kidney function for
persons with diabetes are unknown. (E)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Dietary Fat
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Saturated Fat: <7% of total calories
(A)
Cholesterol: <200 mg/day in people
with diabetes
Minimize intake of trans-fatty acids (E)
Two or more servings of fish per week
providing n-3 polyunsaturated fatty
acids are recommended (B)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
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
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
Lipid Goals in Diabetes
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LDL cholesterol
HDL cholesterol
Men
Women
Triglycerides
<100 mg/dl
>40 mg/dl
>50 mg/dl
<150 mg/dl
American Diabetes Assoc. Standards of Medical care for Adults with
Diabetes. Diabetes Care 30 (supplement 1) 2007. Accessed 2/13/07
Blood Pressure Goals in
Diabetes
Patients with diabetes should be
treated to a systolic blood
pressure <130 mmHg (C)
 Patients with diabetes should be
treated to a diastolic blood
pressure of <80 mmHg (B)
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American Diabetes Assoc. Standards of Medical Care in Diabetes-2007.
Diabetes Care 30 (supplement 1) 2007. Accessed 2/14/07
Fiber and Phytoesterols
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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%
Energy Balance, Overwt
and Obesity
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In overweight and obese insulin-resistant individuals,
modest weight loss has been shown to improve
insulin resistance. Thus, weight loss is recommended
for all such individuals who have or are at risk for
diabetes. (A)
For weight loss, either low-carbohydrate or low-fat
calorie-restricted diets may be effective in the short
term (up to 1 year). (A)
For patients on low-carbohydrate diets, monitor lipid
profiles, renal function, and protein intake (in those
with nephropathy), and adjust hypoglycemic therapy
as needed. (E)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Energy Balance, Overwt
and Obesity
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Physical activity and behavior modification are
important components of weight loss programs and
are most helpful in maintenance of weight loss. (B)
Weight loss medications may be considered in the
treatment of overweight and obese individuals with
type 2 diabetes and can help achieve a 5–10% weight
loss when combined with lifestyle modification. (B)
American Diabetes Association Nutrition Recommendations and
interventions for Diabetes, Diabetes Care 31:S61-S78, 2008
Energy Balance,
Overweight, and Obesity
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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 (B)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
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
Obesity and Prognosis
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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
Alcohol
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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
Alcohol
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Drinks should be limited to 1 drink a day
(women) or 2 (men) (E)
To reduce risk of nocturnal hypoglycemia in
individuals using insulin or insulin
secretagogues, alcohol should be consumed
with food (E)
In individuals with diabetes, moderate alcohol
consumption (when ingested alone) has no
acute effect on glucose and insulin
concentrations, but carbohydrate coingested
with alcohol (as in a mixed drink) may raise
blood glucose (B)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Alcohol
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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
Alcohol
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For individuals with diabetes, light to
moderate alcohol intake (one to two
drinks per day; 15-30 g alcohol) is
associated with a decreased risk of CVD
Does not appear to be due to an increase
in HDL-C
Micronutrients
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There is no clear evidence of benefit from vitamin
or mineral supplementation in people with diabetes
(compared with the general population) who do not
have underlying deficiencies (A)
Routine supplementation with antioxidants such as
vitamins E and C and carotene is not advised
because of lack of evidence of efficacy and concern
related to long term safety (A)
Benefit from chromium supplementation in
individuals with diabetes or obesity has not been
clearly demonstrated and therefore can not be
recommended (E)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
“Diabetes” Supplements
“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.
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
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Vitamin/mineral needs of people with
diabetes who are healthy appear to be
adequately met by the RDAs.
Those who may need supplementation
include those on extreme weight-reducing
diets, strict vegetarians, the elderly, pregnant
or lactating women, clients with
malabsorption disorders, congestive heart
failure (CHF) or myocardial infarction (MI)
Chromium and magnesium are beneficial
only if the client is deficient.
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
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
Goals of MNT for Diabetes
in Children
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Maintain normal growth and development
– Evaluate using growth charts every 3-6 months
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Base nutrition prescription on the nutrition
assessment
– Re-evaluate every 3-6 months
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Meal planning approach can be based on
CHO counting for increased flexibility or
other systems
Review blood glucose records and revise
medication regimen as necessary
Estimating Minimum Energy
Requirements for Youth
Age
1 yr
Energy Requirements
1000 kcals for first year
2-11 yr
Add 100 kcals/yr to 1000 kcals up to 2000
kcals at age 10
Girls 12-15
>15 years
Boys 12-15
>15 yr
2000 kcals + 50-100 kcals/yr after age 10
Calculate as for an adult
2000 kcals plus 200 kcal/yr after age 10
Sedentary 16 kcals/lb (30-35 kcals/kg)
Moderate activity 18 kcals/lb (40 kcals/kg)
Very physically active: 23 kcals/lb (50
kcals/kg)
MNT for Type 2 Diabetes
in Youth
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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
Estimating Energy
Requirements for Adults
Obese and very inactive
persons and chronic
dieters
Persons >55 yr, active
women, sedentary men
10-12 kcals/lb or 20
kcals/kg
Active men, very active
women
15 kcals/lb, 30 kcals/kg
Thin or very active men
20 kcals/lb or 40 kcals/kg
13 kcals/lb, 25 kcals/kg
Source: Franz MJ, Reader D, Monk A. Implementing group and individual medical nutrition therapy for
diabetes. Alexandria, VA, 2002, American Diabetes Association
Basic MNT Self-Management
Skills for Persons with DM
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Basic food and meal planning guidelines
Physical activity guidelines
Self-monitoring of blood glucose levels
For insulin or insulin secretagogue users,
signs, symptoms, treatment, and prevention
of hypoglycemia
For insulin or insulin secretagogue users
guidelines for managing short-term illness
Plans for follow-up and ongoing education
MNT Essential SelfManagement Skills
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Sources of CHO,
pro, fat
Understanding
nutrition labels
Modification of fat
intake
Alcohol guidelines
Use of BG
monitoring data for
problem solving
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Recipes, menu
ideas, cookbooks
Vitamin, mineral,
botanical
supplements
Behavior
modification
techniques
MNT Essential SelfManagement Skills
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Adjustments of CHO or
insulin for exercise
Grocery shopping
guidelines
Guidelines for eating
out
Snack choices
Mealtime adjustments
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Use of sugarcontaining foods and
non-nutritive
sweeteners
Problem solving tips for
special occasions
Travel schedule
changes
Work shifts if
applicable
Nutrition Self
Management for Diabetes
Goals of MNT for Prevention
and Treatment of Diabetes
Achieve and maintain
 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, 2008.
Goals of MNT for Prevention
and Treatment of Diabetes
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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, 2008.
Goals of MNT that Apply
to Specific Situations
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For youth with type 1 diabetes, youth with
type 2 diabetes, pregnant and lactating
women, and older adults with diabetes, to
meet the nutritional needs of these unique
times in the life cycle
For individuals treated with insulin or insulin
secretagogues, to provide self-management
training for safe conduct of exercise,
including the prevention and treatment of
hypoglycemia and diabetes treatment
during acute illness
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Effectiveness of MNT
Recommendations
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Individuals who have pre-diabetes or
diabetes should receive individualized MNT;
such therapy is best provided by a
registered dietitian familiar with the
components of diabetes MNT (B)
Nutrition counseling should be sensitive to
the personal needs, willingness to change,
and ability to make changes of the
individual with pre-diabetes or diabetes (E)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Diabetes Assessment:
Referral Data
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Age
Diagnosis of
diabetes and other
pertinent medical
history
Medications,
including diabetes
and other pertinent
meds
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Laboratory data
(A1C, cholesterol/
lipid profile,
albumin to
creatinine ratio)
Blood pressure
Clearance for
exercise
Diabetes Assessment
Data
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Diabetes history: previous diabetes
education, use of blood glucose monitoring,
diabetes problems/ concerns
Food/nutrient history: current eating habits
with beginning modifications
Social history: occupation, hours
worked/away from home, living situation,
financial issues
Medications/supplements: medications
taken, vitamin/mineral/supplement use,
herbal supplements
Diabetes Assessment
Data: Diet History
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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
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
Basic Strategies for Type
1 Diabetes
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For individuals with type 1 diabetes, insulin therapy should be
integrated into an individual’s dietary and physical activity
pattern. (E)
Individuals using rapid-acting insulin by injection or an insulin
pump should adjust the meal and snack insulin doses based on
the carbohydrate content of the meals and snacks. (A)
For individuals using fixed daily insulin doses, carbohydrate
intake on a day-to-day basis should be kept consistent with
respect to time and amount. (C)
For planned exercise, insulin doses can be adjusted. For
unplanned exercise, extra carbohydrate may be needed. (E)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
Basic Strategies for Type
2 Diabetes
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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.
Food Guide Pyramid
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Use basic guide
Use diabetesspecific guide
National Diabetes Education Program.
http://www.ndep.nih.gov/diabetes/MealPlanner/images/mypyramid.jpg
Recommendations for
Weight Management
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Make permanent changes in eating
behavior.
Eat regularly.
Slow, gradual weight loss is best.
Choose lower-fat foods.
Incorporate regular physical activity.
The Diabetes Meal Plan
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The meal plan should be based on
– the patient’s current eating habits
– diabetes medications, if any
– current weight status
– collaborative goals (e.g., does the patient
desire to lose weight?)
Macronutrients Based On
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Patient’s current eating
habits (CHO, fat,
protein)
Lipid levels and
glycemic control
Patient goals
Meal Plan
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Estimate current energy, carbohydrate,
protein, and fat intake
Evaluate current meal pattern and schedule
Adjust meal plan to promote treatment
goals (energy, fat, carbohydrate distribution)
Evaluate based on standard meal planning
standards (e.g. Food Guide Pyramid)
Meal Plan: Patient on
MNT Only
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Often start with 3-4 CHO servings per meal
(includes fruits, starches, milk, sweets) for
women and 4-5 for men plus 1-2 for snack
if desired
Evaluate feasibility of meal plan with patient
Trial meal plan and evaluate blood glucose
records
Adjust plan as necessary
Examples of CHO
Servings Mix and Match
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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
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Brownie, 1 small
Yogurt, frozen, ½ c
Cake, frosted, 2
inch square, (2
CHO)
Corn, ½ c
Baked beans 1/3 c
Hummus 1/3 c
Meal Plan: Oral
Medications
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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
Meal Plan: Insulin
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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
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Focuses on CHO as major driver of postprandial blood glucose
Can be used for intensive management or
for basic meal planning
May be most appropriate for Type 1 patients
at desirable weight
Must still address energy needs and
composition of overall diet
Allows increased flexibility
1 carbohydrate serving = 15 grams
Managing Acute
Complications
Hypoglycemia
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Low blood glucose
Common side effect of insulin therapy
Sometimes affects patients taking
insulin secretagogues
Can be life-threatening
Hypoglycemia Symptoms
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Shakiness
Sweating
Palpitations
Hunger
Slurred speech
Mental confusion, disorientation
Extreme fatigue, lethargy
Seizures and unconsciousness
Hypoglycemia Treatment
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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
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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
Hypoglycemia Treatment
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Individuals with hypoglycemia unawareness
or one or more episodes of severe
hypoglycemia should be advised to raise
their glycemic targets to strictly avoid
further hypoglycemia for at least several
weeks in order to partially reverse
hypoglycemia unawareness and reduce risk
of future episodes. (B)
Standards of Medical Care for Diabetes Diabetes Care 31:S3-S4,
2008
Causes of Hypoglycemia
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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
Causes of Hypoglycemia



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
Delayed meals or snacks
Increased exercise or activity
Unplanned activities
Prolonged duration or increased
intensity of exercise
Alcohol intake without food
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
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)
DKA Prevented by

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SMBG
Testing for ketones
Medical intervention
Appropriate sick day guidelines
DKA Treatment

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
Supplemental insulin
Fluid and electrolyte replacement
Medical monitoring
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. (B)
– 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, 2008
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 15-30
minutes. If vomiting continues, health care team
should be notified
Sick Day Guidelines

The health care team should be called if
illness continues for more than 1 day
Causes of Fasting
Hyperglycemia



Waning insulin action
“Dawn” phenomenon
Somogyi Effect (“rebound” hyperglycemia)
Waning Insulin Action

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Inadequate insulin dose overnight
Requires adjustment of insulin doses
Dawn Phenomenon

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
Insulin needs are lower in predawn period
(1-3 a.m.) than at dawn (4-8 a.m.)
Excessive hepatic glucose output overnight
(type 2)
Blood glucose will drop from 1-3 a.m. and
then increase
Treat with metformin (type 2) or taking an
intermediate insulin at bedtime or using a
peakless insulin (glargine)
Somogyi Effect


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Hypoglycemia followed by “rebound”
hyperglycemia as counter-regulatory
hormones are secreted
Hepatic glucose production is stimulated
Usually caused by excessive exogenous
insulin
Decrease bedtime insulin doses, take
intermediate insulin at bedtime, or switch to
a long-acting insulin
Hyperosmolar
Hyperglycemic State
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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
Long Term Complications
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
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
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
Treatment and Mgt of
CVD Risk


In normotensive and hypertensive
individuals, reduced sodium intake
(e.g. 2300 mg/day) with diet high in
fruits, vegetables, and low-fat dairy
products lowers blood pressure (A)
In most individuals, modest weight
loss beneficially affects blood
pressure.(C)
Nutrition recommendations and interventions for diabetes.
Diabetes Care 31:S61-S78, 2008
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
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
Dyslipidemia MNT


Saturated fat should be
limited to 7%
Substitute CHO or MFA
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, 2007
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
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)
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
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
Neuropathy

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Nerve damage; affects 60-70% of patients
with Type 1 and Type 2 diabetes
Peripheral: affects nerves that control
sensation in the feet and hands
Autonomic: affects various organ systems
including GI tract, cardiovascular system
Sexual dysfunction: erectile dysfunction in 3575% of men with diabetes
Gastroparesis



Delayed or irregular contractions of
the stomach
Symptoms include feelings of fullness,
bloating, nausea, vomiting, diarrhea,
constipation
Can affect blood glucose control
Gastroparesis Treatment


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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
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Dietary Guidelines
for Americans
Guide to good
eating
Food Guide
Pyramid
The first step in
diabetes meal
planning
Healthy food
choices
Healthy eating
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Single-topic
diabetes resources
Individualized
menus
Month of meals
Exchange lists for
meal planning
CHO counting
Calorie counting
Fat counting
Metabolic Syndrome
and Diabetes Prevention
Metabolic Syndrome

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Intra-abdominal obesity (waist
circumference>40 inches in men and
>35 inches in women)
Dyslipidemia
Hypertension
Glucose intolerance
Compensatory hyperinsulinemia
↑ macrovascular complications
Metabolic Syndrome MNT

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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
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.
Finnish Diabetes
Prevention Study
Finnish Diabetes
Prevention Study Results
Tuomilehto J et al: Prevention of type 2 diabetes mellitus by changes in lifestyle
among subjects with impaired glucose tolerance. N Engl J Med 344;1390:2001.
Diabetes Prevention
Program (DPP)


Randomized 3234 persons (45%
minority) with IGT to placebo,
metformin, or lifestyle intervention
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
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
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. (A)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Prevention/Delay of Type
2 Diabetes


Individuals at high risk for type 2 diabetes should
be encouraged to achieve the U.S. Department of
Agriculture (USDA) recommendation for dietary
fiber (14 g fiber/1,000 kcal) and foods containing
whole grains (one-half of grain intake). (B)
There is not sufficient, consistent information to
conclude that low–glycemic load diets reduce the
risk for diabetes. Nevertheless, low–glycemic index
foods that are rich in fiber and other important
nutrients are to be encouraged. (E)
Nutrition recommendations and interventions for diabetes. Diabetes
Care 31:S61-S78, 2008
Prevention/Delay of Type
2 Diabetes


In addition to lifestyle counseling, metformin
may be considered in those who are at very
high risk (combined IFG and IGT plus other
risk factors) and who are obese and under
60 years of age. (E)
Monitoring for the development of diabetes
in those with pre-diabetes should be
performed every year. (E)
Standards of Medical Care for Diabetes. Diabetes Care 31:S12-S54,
2008
MNT in Non-Diabetic
Hypoglycemia
Types of Hypoglycemia

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Postprandial hypoglycemia
Alimentary hyperinsulinemia
Idiopathic reactive hypoglycemia
Fasting hypoglycemia
Factitious hypoglycemia
Postprandial (Reactive)
Hypoglycemia


Blood glucose levels fall below normal
2-5 hours after eating
Caused by exaggerated insulin
response due to insulin resistance,
elevated glucagon-like-peptide-1 (GLP1) renal glycosuria, defects in
glucagon response, high insulin
sensitivity
Alimentary Hyperinsulinism
(dumping syndrome)


Most common type of documented
postprandial hypoglycemia
Seen after gastric surgery; due to
rapid delivery of food to the small
intestine → rapid absorption of
glucose → exaggerated insulin
response
Idiopathic Reactive
Hypoglycemia



Normal insulin secretion but increased
insulin sensitivity
Reduced response of glucagon to
acute hypoglycemia
Rare, but often inappropriately
overdiagnosed
Fasting Hypoglycemia



Usually the result of a serious
underlying medical condition
Causes include hormone deficiency
states, certain drugs, insulinoma and
other nonpancreatic tumors
Diagnostic criteria: BG<50 mg/dL,
especially during symptomatic
episodes
Treatment of
Hypoglycemic Symptoms



Eat small meals and snacks (5-6 small
meals)
Spread the intake of CHO through the
day (2-4 CHO servings at a meal, 1-2
at a snack)
Avoid foods that contain large
amounts of CHO (regular soda, syrups,
candy, regular yogurt, pies, cakes)
Treatment of
Hypoglycemic Symptoms



Avoid beverages and foods containing
caffeine
Limit or avoid alcoholic beverages;
interferes with the liver’s ability to
release stored glucose; take ETOH
with food
Decrease fat intake (fat may increase
insulin resistance)