DIABETES MEDICAL NUTRITION THERAPY: CORE CONCEPTS

Anne Daly, MS, RDN, BC-ADM, CDESouthern Illinois Univ School of MedicineCenter for Family & Community Medicine

OBJECTIVES OF TALK

To review the goals of medical nutrition therapy (MNT), evidence for effectiveness & key MNT messages for PWD

To describe commonly used nutrition interventions & discuss challenges PWD face in the real world to implement healthy lifestyles

ABC’s of Diabetes Management

ABC’s Significance

A-A1C Average blood sugar level over the past three monthsKeeping A1C closer to normal reduces the risk for long term complicationsPerformed 2-4 times per year

B-Blood Pressure Controlling BP decreases risk for strokes, heart attacks, eye and kidney damagePerformed q visit

C-Cholesterol High cholesterol adds to the risk of heart diseasePerformed at least once per year

MEETING DIABETES CARE GOALS IN U.S.

30-50% not meet goals A1c, BP, lipids

40-50% receive no DSME, vaccinations or dental exams

20% continue smoking

Centers for Disease Control 2012Diabetes Care 2013 NEJM 2013; 368:1613-1624

HUGE GAP BETWEEN PROMISE OF QUALITY CARE VS. REALITY OF DB CARE

HCP feel: Frustrated by pts

inability to change behavior and follow prescribed diabetes care plans

Patients feel: Overwhelmed Guilty Frustrated

Diabetes Education Underutilized

Few people with diabetes receive diabetes education…

People with Diabetes

•Don’t follow through on referral•Are emotional / shocked at diagnosis•End up relying on family / friends•Believe they know enough / can handle it on their own

Providers•Know importance of DE, but don’t necessarily prescribe – or don’t prescribe definitively enough•Sometimes forget to follow up with patients to encourage attendance

THE RESEARCH SHOWS:

DIABETES NUTRITION THERAPY

What to eat = most challenging part DB treatment plans

“One size fits all” approaches do not work Individualized medical nutrition therapy (MNT)

provided by RDN familiar with DB MNT recommended all persons with T1, T2, pre-DB All team members, including MDs, PAs, NPs,

PharmD, behavioralists, need be knowledgeable about MNT, so can support its role, and ensure pt has adequate access to therapy support

GOALS OF MEDICAL NUTRITION THERAPY

Healthful eating with variety nutrient dense foods in appropriate portions to attain target metabolic goals

Achieve and maintain body weight goals Delay & prevent DB complications Address individual nutr needs based on

personal & cultural preferences, health literacy & numeracy, access to healthful foods, willingness & ability to make behavioral changes, barriers to change

GOALS OF MNT CONTINUED

Maintain pleasure of eating, promote positive messages re: food choices, limiting food choices only when based on evidence

Provide practical tools for day-to-day meal planning, rather than focusing on individual macronutrients, micronutrients or single foods

Diabetes Care 2014; 37 (Supp 1)S120-S143

EVIDENCE OF EFFECTIVENESS OF MNT

Glycemic Control ~ 1% decrease A1c newly diagnosed T1D ~ 2% decrease A1c newly diagnosed T2D ~1% decrease A1c w average 4 yr duration T2D 50-100 mg/dl decrease FBG Outcomes known by 6 wks-3months

American Diabetes Association. Therapy for Diabetes Mellitus (6th ed) 2014

EVIDENCE OF EFFECTIVENESS MNT CONT

Lipids Decrease TC 24-32 mg/dl Decrease LDL 15-25 mg/dl Decrease TG 15-35 mg/dl Wo PA, HDL-C decreases; w PA, no

decreaseHypertension 5 mmHG decrease systolic BP, 2 mm

HG decrease (in pts with HTN)

Nutrition therapy changes as type 2 diabetes progresses

Nutrition Therapy Pre-diabetes Early Type 2 Diabetes Later Type 2 Diabetes

Nutrition (food) focus

Healthy eating guidelines

-- My Plate / DASH Diet/ Mediterranean Diet

Consistent carbohydrate intake*

-- Carb distributed throughout the day

-- 3 meals and 0-2 snacks/day Per meal: 2-4 carb choices (30-60 gm carb)

Daily; at least 9 carb choices (130 gm carb)

Insulin-to-carbohydrate ratios

-- Initially a consistent carb intake with consistent insulin

-- To maximize therapy, when patient is ready, advance from carb counting to insulin-to-carb ratio

Physical activity Regular activity Regular activity Regular activity (30 minutes moderate activity; minimum 5 days a week)

Weight management

Weight loss

(5-7% body weight)

Weight management

(Prevent weight gain or aim for weight loss of 5-7% body weight)

Weight management

(Prevent weight gain or aim for weight loss of 5-7% body weight)

Insulin Resistance

Insulin Deficiency

-10 -5 0 5 10 15 20 25 30-15

Pre-diabetes

Years

Normalinsulin level

Later type 2 diabetesEarly type 2 diabetes

* Carbohydrate is in a wide variety of foods including grains, beans, starchy vegetables, fruits, juices, milk, yogurt, snacks and desserts

KEY MESSAGES FOR ALL PEOPLE W DB

Manage portion sizes to help meet carb prescription, weight loss, and maintenance

Carbohydrate-containing foods/beverages and endogenous insulin production=greatest determinant pp BG; need know which foods contain carbs—whole grains, starchy veg, non-starchy veg, fruits, milk & milk products, sweets/desserts

Choose nutrient dense, high fiber foods when possible vs processed foods without added sodium, fat and sugars

KEY MESSAGES ALL PEOPLE WITH DB CONT

Avoid sugar sweetened beverages, ie soda pop, sweet tea, juices, punches

Select leaner protein sources and meat alternatives

Limit alcohol to one drink/day for women, two drinks or less for adult men

Add 30 minutes of physical activity each day

NUTRITION THERAPY PRINCIPLESFOR T1D AND INSULIN-REQUIRING T2D

Learn how to count carbohydrates to be able to “match” mealtime insulin to carbohydrate consumed

If on multiple daily injections (MDI) or pump: Take mealtime insulin before eating Meals can be consumed +/- 1 hour usual

eating time If do PA within 1-2 hrs of mealtime insulin

injection, dose may be decreased to decrease risk hypo

NUTRITION THERAPY PRINCIPLES FOR T1D AND INSULIN-REQUIRING T2 D CONT

If on a premixed insulin plan: Insulin needs be taken before eating Meals need be eaten at similar times each day Do not skip meals to reduce risk of

hypoglycemia Physical activity may result in hypo, depending

on when performed; always carry quick-acting carbohydrate to reduce risk of hypoglycemia

If on a fixed insulin plan: Eat similar amounts of carbohydrate each day

to match set insulin doses

NUTRITION THERAPY PRINCIPLES FOR T2D

Avoid excess intake of carbs at any one time; aim for consistent intake of carbs at similar times each day; use SBGM to evaluate distribution carbs

Limit saturated fat and trans fatty acids, cholesterol.

Avoid excess intake of sodium If overweight or obese, modify calorie intake, using

portion control & other strategies Increase physical activity to reach 30 min 5 days/wk Monitor BG to determine whether food adjustments

sufficient, or if medications need be added Add and advanced diabetes medications, as needed

Healthy Eating

http://www.ndep.nih.gov/diabetes/MealPlanner/pyramid.htm

Manage Glucose

Timing of meals 1. Eat at least 3 times daily 2. Be consistent 3. Do not skip meals 4. Eat breakfastHow much food 1. Smaller portions 2. Small plate 3. One serving 4. Eat slowly 5. Bad foods out of site 6. Gradually cut down sizeWhat type of food 1. Reduce amount of carbs 2. Increase fiber

Carb (CHO) Counting: ~15 g carb = 1 Carb choice

For detailed list of “carb” exchanges, see

Now published as: Choose Your Foods: Exchange Lists for Diabetes Published by the Academy of Nutritionand Dietetics and theAmerican Diabetes Association

DIABETES MEAL PLANNING TOPICS

What is healthy eating—how to create the plate Food groups--# servings recommended/day Reading nutrition facts label—focus on serving size Estimating/checking portion sizes Carbohydrate consistency/carbohydrate counting Calorie counting/weight loss strategies Understanding dietary fats Eating away from home Recipe modifications Sick days Special occasions/holidays

MNT AND MEDICATIONS MUST BE WELL MATCHED TO PHYSIOLOGY OF DB

PWD can eat their way thru any pills/meds we give them

Medication adherence overestimated; barriers include side effects, lack perceived effectiveness, cost, misunderstanding how take correctly

Use BG monitoring to see effects food and activity/sitting

SUMMARY

Diabetes care in U.S. remains challenge

Referring PWD for both DSMT and MNT first step

Using multidisciplinary team approach recommended

PWD need ongoing support to manage daily self-care behaviors