MNT Strategies in Type 2 Diabetes

MNT in Diabetes and Related Disorders

1MNT in Type 1 DiabetesInsulin therapy should be integrated into an individuals 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, 20072MNT in Type 1 DiabetesFor 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, 20073MNT Strategies in Type 2 DiabetesImplement 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, 20074Carbohydrates in DiabetesDietary 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

5Carbohydrate and DiabetesSucrose-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

6Carbohydrate and DiabetesThe 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

7Glycemic IndexThe blood glucose response of a given food compared to an equal amount of a CHO standard (typically glucose or white bread)

8Glycemic IndexInfluenced by various factorsStarch structureFiber contentCooking methodsDegree of processingWhether it is eaten in the context of a mealPresence or absence of fatA given food can elicit highly variable responses

9Glycemic Index and Glycemic Load of FoodsFoodGlycemic Index Glycemic LoadCarrots473Potato baked8526Sweet corn6011Apple386Chocolate cake3820Corn flakes9224Oatmeal429Pumpkin753Sucrose687Krauses Food & Nutrition Therapy, 12th ed., Appendix 4310Fiber and DiabetesAs for the general population, people with diabetes are encouraged to consume a variety of fiber-containing 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

11Sweeteners and DiabetesSugar 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

12Nutritive Sweeteners: FructoseDelivers 4 kcals/gramHas lower glycemic index than sucrose or starchLarge amounts may negatively affect lipidsNo advantage to substituting it for sucroseFound naturally in foods such as fruits and vegetables

13Nutritive Sweeteners: Sugar AlcoholsSorbitol, mannitol, xylitol, isomalt, lactitol, hydrogenated starch hydrolysatesLower glycemic response, lower calorie content than sucroseNot water-soluble so often combined with fats in foods; often deliver as many calories as sucrose-sweetened foodsUnlikely to have a beneficial effect on blood sugarsIn large quantities, may cause GI distress and diarrhea14Non-Caloric SweetenersSaccharin (SweetN Low)

Aspartame (NutraSweet)

Acesulfame potassium, acesulfame-K (Sweet One)

Sucralose (SPLENDA)

15Nonnutritive SweetenersInclude aspartame, acesulfame K, sucralose, and saccharinFDA has established an acceptable daily intake (ADI) for food additivesAverage intake of aspartame is 2 to 4 mg/kg/day, whereas the ADI is 50 mg/kg/dayADI of acesulfame K is 15 mg/kg, which is the equivalent of a 60 kg person eating 36 teaspoons of sugar daily16Noncaloric Sweeteners: All FDA-approved non-nutritive sweeteners can be used by persons with diabetesThe carbohydrate and calorie content of sugar blends must be taken into account

17Protein and DiabetesInsufficient 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

18Protein and DiabetesHigh-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 FatSaturated Fat: 50 mg/dlTriglycerides15 yr2000 kcals plus 200 kcal/yr after age 10Sedentary 16 kcals/lb (30-35 kcals/kg)Moderate activity 18 kcals/lb (40 kcals/kg)Very physically active: 23 kcals/lb (50 kcals/kg)41MNT for Type 2 Diabetes in YouthCessation of excessive weight gainPromotion of normal growth and development Encourage healthy eating habits and increased activity for the whole familyAddress other health risk factorsAdd Metformin if lifestyle changes are insufficient to achieve goals

42Estimating Energy Requirements for AdultsObese and very inactive persons and chronic dieters10-12 kcals/lb or 20 kcals/kgPersons >55 yr, active women, sedentary men13 kcals/lb, 25 kcals/kgActive men, very active women15 kcals/lb, 30 kcals/kgThin or very active men20 kcals/lb or 40 kcals/kgSource: Franz MJ, Reader D, Monk A. Implementing group and individual medical nutrition therapy for diabetes. Alexandria, VA, 2002, American Diabetes Association43Basic MNT Self-Management Skills for Persons with DMBasic food and meal planning guidelinesPhysical activity guidelinesSelf-monitoring of blood glucose levelsFor insulin or insulin secretagogue users, signs, symptoms, treatment, and prevention of hypoglycemiaFor insulin or insulin secretagogue users guidelines for managing short-term illnessPlans for follow-up and ongoing education44MNT Essential Self-Management SkillsSources of CHO, pro, fatUnderstanding nutrition labelsModification of fat intakeAlcohol guidelinesUse of BG monitoring data for problem solvingRecipes, menu ideas, cookbooksVitamin, mineral, botanical supplementsBehavior modification techniques

45MNT Essential Self-Management SkillsAdjustments of CHO or insulin for exerciseGrocery shopping guidelinesGuidelines for eating outSnack choicesMealtime adjustments

Use of sugar-containing foods and non-nutritive sweetenersProblem solving tips for special occasionsTravel schedule changesWork shifts if applicable46Nutrition Self Management for Diabetes

47Goals of MNT for Prevention and Treatment of DiabetesAchieve and maintain Blood glucose levels in the normal range, or as close to normal as is safely possibleA lipid and lipoprotein profile that reduces the risk for vascular diseaseBlood 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, 2008.48Goals of MNT for Prevention and Treatment of DiabetesTo prevent or at least slow the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyleTo address individual nutrition needs, taking into account personal and cultural preferences and willingness to changeTo 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.

49Goals of MNT that Apply to Specific SituationsFor 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 cycleFor 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, 200850Effectiveness of MNT RecommendationsIndividuals 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, 200851Diabetes Assessment: Referral DataAgeDiagnosis of diabetes and other pertinent medical historyMedications, including diabetes and other pertinent medsLaboratory data (A1C, cholesterol/ lipid profile, albumin to creatinine ratio) Blood pressureClearance for exercise52Diabetes Assessment DataDiabetes history: previous diabetes education, use of blood glucose monitoring, diabetes problems/ concernsFood/nutrient history: current eating habits with beginning modificationsSocial history: occupation, hours worked/away from home, living situation, financial issuesMedications/supplements: medications taken, vitamin/mineral/supplement use, herbal supplements53Diabetes Assessment Data: Diet HistoryUsual caloric intakeQuality of the usual dietTimes, sizes, and contents of meals and snacksFood idiosyncrasiesRestaurant eatingWho usually prepares mealsEating problems/intolerancesAlcoholic beverage intakeSupplements used54Diabetes Assessment Data: Daily ScheduleTime of wakingUsual meal and eating timesWork schedule or school hoursType, amount, and timing of exerciseUsual sleep habits

55Basic Strategies for Type 1 DiabetesFor individuals with type 1 diabetes, insulin therapy should be integrated into an individuals 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

56Basic Strategies for Type 2 DiabetesEncourage weight loss.Moderate calorie restriction (250500 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.57Food Guide PyramidUse basic guideUse diabetes-specific guideNational Diabetes Education Program. http://www.ndep.nih.gov/diabetes/MealPlanner/images/mypyramid.jpg

58Recommendations for Weight ManagementMake permanent changes in eating behavior.Eat regularly.Slow, gradual weight loss is best.Choose lower-fat foods.Incorporate regular physical activity.

59The Diabetes Meal PlanThe meal plan should be based on the patients current eating habits diabetes medications, if any current weight statuscollaborative goals (e.g., does the patient desire to lose weight?)60Macronutrients Based OnPatients current eating habits (CHO, fat, protein)Lipid levels and glycemic controlPatient goals

61Meal PlanEstimate current energy, carbohydrate, protein, and fat intakeEvaluate current meal pattern and scheduleAdjust meal plan to promote treatment goals (energy, fat, carbohydrate distribution)Evaluate based on standard meal planning standards (e.g. Food Guide Pyramid)

62Meal Plan: Patient on MNT OnlyOften 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 desiredEvaluate feasibility of meal plan with patientTrial meal plan and evaluate blood glucose recordsAdjust plan as necessary

63Examples of CHO Servings Mix and MatchApple, 1 smallFruit cocktail, cNonfat milk, 1 cOrange juice, cBread, 1 sliceOatmeal, cPasta, 1/3 cPotatoes, cBrownie, 1 smallYogurt, frozen, cCake, frosted, 2 inch square, (2 CHO)Corn, cBaked beans 1/3 cHummus 1/3 c64Meal Plan: Oral MedicationsMay do well with smaller, more frequent meals and snacks, especially if taking an insulin secretagogueSnack servings should be taken from the meal plan65Meal Plan: InsulinCan start with the meal plan and devise an insulin regimen to fitMany patients require a bedtime snack to prevent night-time hypoglycemiaPatients who use morning intermediate-acting insulin (NPH) may require afternoon snackPatients on rapid-acting insulin do not need a snack66Meal Planning: Carbohydrate CountingFocuses on CHO as major driver of post-prandial blood glucoseCan be used for intensive management or for basic meal planningMay be most appropriate for Type 1 patients at desirable weightMust still address energy needs and composition of overall dietAllows increased flexibility1 carbohydrate serving = 15 grams

67Managing Acute Complications

68HypoglycemiaLow blood glucoseCommon side effect of insulin therapySometimes affects patients taking insulin secretagoguesCan be life-threatening69Hypoglycemia SymptomsShakinessSweatingPalpitationsHungerSlurred speechMental confusion, disorientationExtreme fatigue, lethargySeizures and unconsciousness

70Hypoglycemia TreatmentGlucose of 70 mg/dL or lower should be treated immediatelyA level of 60 to 80 mg/dL may require carbohydrate ingestion, deferral of exercise, change in insulin dosageTreatment involves ingestion of glucose or carbohydrate-containing food (glucose preferred)Protein does not help with treatment or prevent recurrence of hypoglycemia71Hypoglycemia TreatmentIngestion of 15-20 grams of glucose (3 glucose tablets, cup fruit juice or regular soft drink, 6 saltine crackers, 1 tbsp honey or sugar)Wait 15 minutes and retest; if BG1 hour away, take additional 15 g glucoseGlucagon injection may be prescribed for pts at risk for severe hypoglycemia

Nutrition recommendations and interventions for diabetes. Diabetes Care 31:S61-S78, 2008

72Hypoglycemia TreatmentIndividuals 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 HypoglycemiaMedication errorsExcessive insulin or oral medicationsImproper timing of insulin in relation to food intakeIntensive insulin therapyInadequate food intakeOmitted or inadequate meals or snacks74Causes of HypoglycemiaDelayed meals or snacksIncreased exercise or activityUnplanned activitiesProlonged duration or increased intensity of exerciseAlcohol intake without food75Diabetic Ketoacidosis (DKA)Caused by hyperglycemiaLife-threatening but reversibleSevere disturbances in carbohydrate, protein, and fat metabolismCaused by inadequate insulin for glucose utilizationBody uses fat for energy, forming ketonesAcidosis results from production and utilization of fatty acid metabolites76Diabetic KetoacidosisElevated blood glucose levels (250 mg/dL but usually 30 mg daily or 20 mcg/minute)Progresses to clinical albuminuria (300 mg/day), hypertension, in glomerular filtration rateAlbuminuria is a marker for increased CVD risk also96Nephropathy ScreeningPerform 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)97Nephropathy TreatmentGlucose and blood pressure control should be optimizedMNT: 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

98RetinopathyMost 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 retinopathyLaser photocoagulation surgery can reduce risk of further vision loss but not correct previous losses99NeuropathyNerve damage; affects 60-70% of patients with Type 1 and Type 2 diabetesPeripheral: affects nerves that control sensation in the feet and handsAutonomic: affects various organ systems including GI tract, cardiovascular systemSexual dysfunction: erectile dysfunction in 35-75% of men with diabetes100GastroparesisDelayed or irregular contractions of the stomachSymptoms include feelings of fullness, bloating, nausea, vomiting, diarrhea, constipationCan affect blood glucose control

101Gastroparesis TreatmentSmall, frequent mealsLow in fiber and fatLiquid meals if necessaryAdjustments in insulin administrationMay need to take insulin after the mealFrequent blood glucose monitoring

102Nutrition Intervention ResourcesDietary Guidelines for AmericansGuide to good eatingFood Guide PyramidThe first step in diabetes meal planningHealthy food choicesHealthy eatingSingle-topic diabetes resourcesIndividualized menusMonth of mealsExchange lists for meal planningCHO countingCalorie countingFat counting103Metabolic Syndrome and Diabetes Prevention104Metabolic SyndromeIntra-abdominal obesity (waist circumference>40 inches in men and >35 inches in women)DyslipidemiaHypertensionGlucose intoleranceCompensatory hyperinsulinemia macrovascular complications105Metabolic Syndrome MNTModest weight lossImproved glycemic controlRestricted saturated fatsIncreased physical activityIf weight is not an issue, add MFAFor triglycerides high dose statins or fibric acidFat restriction, fish oil supplementation106Finnish Diabetes Prevention Study522 middle-aged, overweight persons with IGTRandomized to brief diet and exercise counseling or intensive individualized instruction: goal 5% wt reduction, sfa150 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.

107Finnish Diabetes Prevention Study

108Finnish Diabetes Prevention Study ResultsTuomilehto 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.

109Diabetes Prevention Program (DPP)Randomized 3234 persons (45% minority) with IGT to placebo, metformin, or lifestyle interventionSubjects in metformin and placebo groups received standard lifestyle recommendations including written information and an annual 20-30 minute individual sessionOrchard TJ et al. Ann Int Med 142;611-619, 2005110Diabetes Prevention ProgramSubjects in lifestyle arm expected to achieve weight loss of at least 7% and to perform 150 minutes of physical activity/weekSubjects seen weekly for first 24 weeks, then monthlyAfter 2.8 years, 58% reduction in diabetes progression in lifestyle group vs 31% in metformin group111Prevention/Delay of Type 2 DiabetesAmong 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, 2008112Prevention/Delay of Type 2 DiabetesIndividuals 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 lowglycemic load diets reduce the risk for diabetes. Nevertheless, lowglycemic 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, 2008Prevention/Delay of Type 2 DiabetesIn 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

114MNT in Non-Diabetic Hypoglycemia115Types of HypoglycemiaPostprandial hypoglycemiaAlimentary hyperinsulinemiaIdiopathic reactive hypoglycemiaFasting hypoglycemiaFactitious hypoglycemia116Postprandial (Reactive) HypoglycemiaBlood glucose levels fall below normal 2-5 hours after eatingCaused by exaggerated insulin response due to insulin resistance, elevated glucagon-like-peptide-1 (GLP-1) renal glycosuria, defects in glucagon response, high insulin sensitivity117Alimentary Hyperinsulinism (dumping syndrome)Most common type of documented postprandial hypoglycemiaSeen after gastric surgery; due to rapid delivery of food to the small intestine rapid absorption of glucose exaggerated insulin response118Idiopathic Reactive HypoglycemiaNormal insulin secretion but increased insulin sensitivityReduced response of glucagon to acute hypoglycemiaRare, but often inappropriately overdiagnosed119Fasting HypoglycemiaUsually the result of a serious underlying medical conditionCauses include hormone deficiency states, certain drugs, insulinoma and other nonpancreatic tumorsDiagnostic criteria: BG