Find Your balance · 1 hour ≥ 180 mg/dL 2 hour ≥ 153 mg/dL GDM diagnosis made when any value...
Transcript of Find Your balance · 1 hour ≥ 180 mg/dL 2 hour ≥ 153 mg/dL GDM diagnosis made when any value...
Diabetes
Mary Ellen Richards, RD, LDN, CDE
Out-Patient Dietitian/Diabetes Educator
PinnacleHealth System
Harrisburg, PA
September 9, 2015
What is Diabetes?
• Diabetes Mellitus consists of a group of metabolic diseases
characterized by hyperglycemia.
• Hyperglycemia results from a defect in insulin secretion, action, or
both.
• The chronic elevated blood glucose is associated with long term
damage & failure of various organs, especially the eyes, kidneys,
nerves, heart & blood vessels.
• Metabolism of carbohydrates, proteins, and fat are affected.
• Prevalence in the United States:
25.8 million people
• Diagnosed – 18.8 million
• Undiagnosed – 7 million
Normal Glucose Homeostasis
Glucose
mg/dL
0
100
200
300
11:00PM 6:00AM
p.3
Normal blood glucose levels will range from 70mg/dl to 140 mg/dl
Both the Pancreas & Liver play roles in
glucose homeostasis
Types of Diabetes
Increased Risk for Diabetes (pre-Diabetes)
Type 1
Type 2
Other specific types due to other causes
Gestational Diabetes
p.5
Increased Risk for Diabetes (Pre-Diabetes)
• New diagnostic term as of 2010
• Definition An intermediate state of altered glucose metabolism with a heightened risk of developing
type 2 diabetes and other associated complications. A state of insulin resistance.
• Incidence Approximate 5 year risk (based upon review of 16 cohort studies)
• A1C between 5.5-6.0% - 9-25% risk of developing diabetes
• A1C between 6.0-6.5 – 25-50% risk of developing diabetes
• Complications Macrovascular disease
Type 1 Diabetes
Definition
– A disease characterized by the autoimmune destruction
of the beta cells of the islets of Langerhans with resulting
absolute insulin deficiency.
Prevalence:
– Accounts for 5% to 10% of all diabetes diagnoses
Complications
– Diabetic Ketoacidosis (DKA)
– Macrovascular (CAD, CVD, PVD)
– Microvascular complications (retinopathy, nephropathy, &
neuropathy)
– Increased risk for other autoimmune diseases: thyroid
disease, B12 deficiency, Celiac Disease
p.7
Type 2 Diabetes
Definition
– Resistance to insulin action &
inadequate compensatory insulin
secretory response & persistent
hepatic glucose production
Prevalence
– Accounts for 90-95% of all
diabetes diagnoses
– 24-25 million people in US
Complications
– Cardiovascular (increased risk
for heart attack, stroke)
– Nephropathy, retinopathy,
neuropathy
– Hyperosmolar Hyperglycemic
State (HHS)
p.8
Definition: Genetic defects in β-cell function (Latent Autoimmune
Diabetes in Adults - LADA), genetic defects in insulin action,
disease of the exocrine pancreas (cystic fibrosis) & drug &
chemical induced (post organ transplant & treatment of HIV/AIDS)
Prevalence: Rare
Complications: same as those found in type 1 or type 2 diabetes
“Other” Due to Other Causes
p.9
Definition
Any degree of glucose intolerance with onset or first
recognition during pregnancy. Incidence
- Occurs in approximately 2-10% of pregnancies
(~ 200,000 cases per year)
Complications – Baby: macrosomia, shoulder dystocia, hypoglycemia,
jaundice, Respiratory Distress Syndrome, stillbirth
– Mother: changing insulin requirements, preeclampsia,
polyhydramnios. Increased risk (40-60%) of type 2
diabetes later.
Gestational Diabetes
p.10
DIAGNOSTIC
CRITERIA
“Pre-Diabetes” Diagnostic Criteria
Any one of the following: • IFG (Impaired Fasting Glucose)
– Fasting plasma glucose of 100-125 mg/dL
• IGT (Impaired Glucose Tolerance) – 2 hour post load 75g OGTT of 140-199 mg/dL
• Hemoglobin A1C – 5.7 – 6.4%
Signs & Symptoms • Insulin resistance signs & symptoms which may include
acanthosis nigricans, dyslipidemia, Metabolic Syndrome, PCOS
Insulin Resistance
• Acanthosis Nigricans
Type 1 & 2 Diabetes: Diagnostic Criteria
Diabetes diagnosis is made (using 2010 criteria) per the following criteria:
Type 1 or type 2 diabetes:
– Glucose ≥ 126 mg/dL after at least an 8-hour fast – Glucose ≥ 200 mg/dL 2 hours after 75g OGTT – Glucose ≥ 200 mg/dL when tested randomly with classic symptoms – A1C ≥ 6.5% – certain anemias can invalidate
Genetic defects are often diagnosed using an anti-antibody testing.
Persons with LADA may test positive for insulin antibodies
(GAD)
a
m
p.14
Gestational Diabetes Diagnostic Criteria
OGTT is performed at 24-28 weeks on all women not previously found to
have overt diabetes or GDM.
“One-step” 2 hour 75g OGTT after an overnight fast ≥8 hours
Fasting ≥ 92 mg/dL
1 hour ≥ 180 mg/dL
2 hour ≥ 153 mg/dL
GDM diagnosis made when any value exceeded.
“Two-step” 1 hour 50g (non-fasting) screen. If plasma glucose
measured at 1 hour is ≥140mg/dL, proceed to 3 hour OGTT.
100g OGTT is performed after a ≥ 8 hour fast.
Fasting ≥ 95 mg/dL
1 hour ≥ 180 mg/dL
2 hour ≥ 155 mg/dL
3 hour ≥ 140 mg/dL
GDM diagnosis made when at least 2 values are met or exceeded.
COMPLICATIONS
Diabetes Complications (Acute)
• Hypoglycemia (seen type 1 and 2)
• Diabetic Ketoacidosis (seen in type 1)
• Hyperglycemic Hyperosmolar State (HHS) (seen in
type 2)
Blood glucose levels that are less than 70 mg/dL
Hypoglycemia
Symptoms
Mild hypoglycemia
Sweating, trembling, difficulty
concentrating, weakness,
lightheadedness, pounding
heart, mood change, lack
of coordination
Severe hypoglycemia
Mental confusion, lethargy,
unconsciousness
Inability to self-treat
Causes
Decrease or delay in food intake
Too much insulin or stacking of
insulin
Increase in exercise/activity
p.18
Blood glucose levels that are less than 70 mg/dL should be treated.
Nutrition Recommendations for
Hypoglycemia
Ingest 15-20 g glucose
containing carbohydrate
Response time is 10-20
minutes
Recheck glucose level in 15
minutes and retreat, if
necessary
Once glucose is normal,
resume routine snack or
meal to prevent recurrence
10g oral glucose raises plasma
glucose levels by ~40 mg/dl over
30 minutes
Adding protein does not affect the
glycemic response & does not
prevent subsequent hypoglycemia
Adding fat may retard & then prolong
the acute glycemic response
Prevention is a critical component of
diabetes management (education)
p.19
Mild Hypoglycemia Treatment Examples
15 grams of a fast-acting carbohydrate includes:
– 3-4 glucose tablets
– 4-6 oz juice
– 8 oz skim milk
– 4-6 oz regular (non-diet) soda
– 8-10 Life Saver® candies
Avoid fat containing carbs
p.20
Diabetic Ketoacidosis (DKA)
DKA is a complication that results from an absolute or relative deficiency in insulin.
Characterized by hyperglycemia, ketosis, dehydration, and electrolyte imbalance. It can be life-threatening.
Causes:
Infection and illness (increased
gluconeogenesis & glycogenolysis)
Initial manifestation of type 1
Omission of insulin, stoppage of insulin
flow (pump)
Psychological problems complicated by
eating disorders
Signs & Symptoms:
Polyuria, polydypsia, blurred vision,
polyphagia & weight loss. GI symptoms
include nausea, vomiting & abdominal
pain. Kussmaul respirations (a type of
hyperventilation) may be present.
Glucose levels >300 mg/dL
If symptomatic, check urine for ketones
Treatment:
Mild: Oral hydration, supplemental
insulin and education
Moderate & Severe: Immediate
emergency treatment including fluid and
electrolyte replacement, insulin
Hyperglycemic Hyperosmolar State (HHS)
• Metabolic crisis usually seen in the
elderly or undiagnosed person with
type 2 diabetes.
• Characterized by severe
hyperglycemia (>600 mg/dL), absence
of ketoacidosis, profound dehydration,
neurologic signs ranging from
decreased mentation to coma.
• Higher mortality rate than DKA.
Causes
• Illness or other stressors (often
unrecognized for weeks)
• Initial presentation of type 2 diabetes
Signs & Symptoms
Similar to those with DKA
Glucose levels > 600 mg/dL
Other: Milder GI symptoms, ketone
bodies not present, Kussmaul’s
respirations seldom observed,
decreased mentation is common
focal neurological signs that mimic
CVA
Treatment
Rehydration, adequate insulin
Prevent complications due to
treatment (fluid overload), treat
underlying medical condition
Education
Diabetes Complications (Chronic)
• Cardiovascular
• Retinopathy
• Nephropathy
• Neuropathy
Cardiovascular Disease
• Includes Peripheral Vascular Disease (PVD), Cerebral Vascular Disease
(CVD), Coronary Artery Disease (CAD)
DM is an independent risk factor for CVD
Cardiovascular events and complications occur with a higher frequency in
individuals with type 2 than in type 1
Persons with type 1 diabetes develop cardiovascular disease at a younger age
than the non diabetes population
Cardiovascular disease mortality is 3-5 times greater in persons with DM
CAD accounts for 50-60% of all deaths in persons with DM
• Cardiovascular Disease Nutrition Related Interventions
Aggressive treatment of hypertension, hyperlipidemia & hyperglycemia
• LDL <100mg (LDL <70 with overt CVD), Total cholesterol <200,
HDL >40 (men) & HDL >50 (women), Triglycerides <150
Retinopathy
• Leading cause of blindness in the United States for persons
between the ages of 20 and 74 (prevalence related to duration of
diabetes)
• 8,000-23,000 new cases of legal blindness annually associated
with diabetes
• Stages of Diabetic Retinopathy Early : Mild NPDR (Non Proliferative Diabetic Retinopathy)
Middle: Moderate, Severe, Very Severe NPDR
Advanced: Proliferative Diabetic Retinopathy
• Nutrition Related Interventions
Optimize blood glucose & blood pressure control
Nephropathy
Spectrum of renal changes that occur in persons with diabetes and cannot be ascribed to other causes.
20-40% of persons with type 1 or type 2 develop evidence of nephropathy
Most common cause of ESRD
Leading cause of death in type 1 diabetes
• Stage 1 (Hyperfiltration & renal hypertrophy)
Often seen at diagnosis, normal or increased GFR
• Stage 2 (Structural changes, glomerular basement membrane thickening)
GFR may be mildly decreased • Onset: 2 to 3 years
• Stage 3 (Incipient nephropathy)
Microalbuminuria; GFR begins to decline • Onset: 7 to 15 years
• Stage 4 (Overt nephropathy)
Proteinuria; Hypertension & nephrotic syndrome usually present, GFR severely decreased • Onset: 10
to 30 years
• Stage 5 (End Stage Renal Disease)
GFR is less than 15 mL/min & uremia is present • Onset: 20-40 years
Nephropathy (continued)
Nutrition Related Interventions
Aimed at different stages of disease progression and includes optimizing glucose control, blood pressure & reducing/controlling dietary protein intake.
Optimize glucose control (kidney does not require insulin for glucose
uptake)
Aggressive control of blood pressure (ACE inhibitor &/or ARB therapy),
DASH Diet, lower sodium intake
HTN > 130/80 accelerates renal disease
Protein Intake:
• Conflicting studies as to the benefit of protein restriction on the progression of renal disease
• Control at 0.8 – 1.0g/kg body weight per day in the earlier stages
• Stage 4: 0.8g/kg body weight per day
Neuropathy
Descriptive term for a large group of sensory and autonomic syndromes with a wide range of manifestations.
Most occur in the peripheral nervous system & are generally gradual and progressive.
Sensory (Most widely known form affecting ¾ of persons with neuropathy)
Sensory loss - mild to severe occurring in a “stocking-glove” pattern
Distal Symmetric Polyneuropathy - very common
Autonomic Gastroparesis, Intestinal (diarrhea), Neurogenic bladder, sexual dysfunction, Orthostatic
hypotension, Cardiac denervation, abnormal cardiovascular response to exercise
Impaired insulin counterregulation
Sudomotor (anhidrosis/gustatory sweating)
Pupillary (decreased/absent response to light)
Focal (Occurs acutely and unpredictably; they are self limiting)
Carpel tunnel syndrome, plexopathy (femoral neuropathy), radiculopathy (intercostal neuropathy), cranial neuropathy, distal symmetrical polyneuropathy
Nutrition Related Interventions
Optimize glucose control
BLOOD SUGAR
GOALS
Blood Sugar Goals for
Increased Risk for Diabetes and Adults
ADA AACE
Recommendations Recommendations
A1C <7% ≤6.5%
Fasting Glucose 80-130 mg/dl <100mg/dl
Level (before meals)
2 hours after meals <180 mg/dl <140 mg/dl
Blood Sugar Goals for Children
Values by age
(years)
Before meals Bedtime/
overnight
A1C Rationale
Toddler &
preschooler
(0-6)
100-180 110-200 <7.5% •Vulnerability to hypoglycemia
•Insulin sensitivity
•Unpredictability in dietary intake &
physical activity
•Lower goal is reasonable if it can be
achieved w/o excessive hypoglycemia
School age
(6-12)
90-180 100-180 <7.5% • Vulnerability to hypoglycemia
• Lower goal is reasonable if it can be
achieved w/o excessive hypoglycemia
Adolescents & young
adults
(13-19)
90-130 90-150 <7.5% • Lower goal is reasonable if it can be
achieved w/o excessive hypoglycemia
Blood Sugar Goals for Gestational
Diabetes
ADA recommendations for women with Gestational Diabetes
Fasting – ≤95 mg/dL
1 hour post prandial - ≤ 140 mg/dL
2 hour post prandial - ≤ 120 mg/dL
ADA recommendations for women with preexisting type 1 or 2 (if they
can be achieved without excessive hypoglycemia)
Fasting & pre-meal – 60-99 mg/dL
Postprandial – 100-129 mg/dL
A1C - <6.0%
Ante-Partum Guidelines
SMBG for 1 week post partum
PRN SMBG until 6-12 week postpartum visit
Non-pregnant OGTT at 6-12 postpartum visit
Routine screening (at least every three years) for type 2 diabetes
Diabetes Management Guidelines
•Four Fold
Monitoring
Medication/Insulin
Exercise/Increased Activity
Diet
6:00
AM
9:00
AM
12:00
PM
Continuous Glucose
Monitoring (CGM)
Blood Glucose Meter
Monitoring Tools
A1C tests
Average Daily
Blood Sugar
135
170
205
240
275
310
345
A1C
Level
6%
7%
8%
9%
10%
11%
12%
p.34
Self Blood Glucose Monitoring (SBGM)
• Involves using a home glucose monitoring device
• Blood glucose levels are checked at varying times and frequencies (FBS,
before meals, 2 hours after meals, before, during or after exercise)
• Allows person with diabetes to be an active participant in care
Self adjustment of food intake, exercise, medication to achieve goals
Identify hypoglycemia
Illness/stress impact on glucose levels
• Studies have shown that people who frequently monitor their glucose
actually have lower A1C percentages
Hemoglobin A1C
Blood test that correlates with a person’s average blood glucose
level over a span of a two to three months.
• Measures how much glucose is attached to the hemoglobin. If
you have a 7% A1C, that means that 7% of you hemoglobin
proteins are glycated.
Normal is <5.7%
• Once glucose sticks to a hemoglobin protein, it stays there for
the lifespan of the hemoglobin protein (about 100 days).
ADA A1C Testing Recommendations
• Two times a year in patients who are meeting treatment goals
• Quarterly in patients whose therapy has changed or who are not
meeting glycemic goals.
Correlation of A1C with Average Glucose
A1C (%) Meal Plasma Glucose
mg/dL mmol/l
6 126 7.0
7 154 8.6
8 183 10.2
9 212 11.8
10 240 13.4
11 269 14.9
12 298 16.5
Continuous Glucose Monitoring
• Measures interstitial glucose (correlates well with plasma glucose)
in real time.
• The concept behind continuous glucose monitoring (CGM) is to
continuously monitor glucose levels around-the-clock to get the full
story of what is happening to glucose levels instead of little
snapshots (SBGM). Alerts one to how food, insulin, and activity are affecting glucose readings all
day and all night.
Alerts one to dangerously high or low glucose levels allowing appropriate action and preventing complications.
Newest devices provide real-time trending information that will allows better understanding of how everyday activities affect glucose levels.
Not intended for use by everyone.
• Still need to SMBG. CGM is an adjunct to self monitoring.
Continuous Glucose Monitoring (CGM)
Schematic representation only.
p.39
Diabetes Medications
Class
Compound
Brand Names
Action(s)
Advantages
Disadvantages
Biguanides Metformin Glucophage
Glucophage XR
Glumetza
Fortamet
↓ Hepatic glucose
production
↑ Peripheral insulin
sensitivity
No weight gain
No hypoglycemia
↓ cardiovascular
events & mortality
•GI side effects (diarrhea,
abdominal cramps)
•Lactic acidosis (rare)
•Vit B-12 deficiency
Contraindications: reduced kidney
function
Sulfonylureas
(2nd generation)
Glyburide
Glipizide
Gliclazide
Glimeperide
Diabeta,
Micronase
Glynase
Glucotrol
Glucotrol XL
Glipizide XL
Amaryl
↑ Insulin secretion Generally well
tolerated
↓cardiovascular
events & mortality
•Relatively glucose-independent
stimulation of insulin secretion:
•Hypoglycemia
•Weight gain
•May blunt myocardial ischemic
preconditioning
Meglitinides Repaglinide
Nateglinide
Prandin
Starlix
↑ Insulin secretion Accentuated effects
with meal ingestion
▪Glucose dependent
•Hypoglycemia, weight gain
•May blunt myocardial ischemic
preconditioning
•Dosing frequency
Thiazolidinediones Pioglitazone
Rosiglitazone
Actos
Avandia
↑ Peripheral insulin
sensitivity
No hypoglycemia
↑ HDL cholesterol
↓ Triglycerides
•Weight gain, edema, heart
failure, bone fractures,
↑ LDL
Rosiglitazone: ↑cardiovascular
events, FDA warnings re:
cardiovascular safety
•Contraindicated in patients with
heart disease
Diabetes Medications (continued)
Class
Compound
Brand Names
Action(s)
Advantages
Disadvantages
Alpha-
Glucosidase
inhibitors
Acarbose
Miglitol
Precose
Glyset
Intestinal carbohydrate
digestion/absorption
slowed
Nonsystemic
medication
↓ Postprandial
glucose
•GI side effects (gas, flatulence,
diarrhea)
GLP-1 Receptor
agonists (incretin
mimetics)
Exenatide
Liraglutide
Exenatide
Albiglutide
Byetta
Victoza
Bydureon
Tanzeum
↑Insulin secretion
(glucose dependent)
↓ Glucagon secretion
(glucose dependent)
Slows gastric
emptying
↑ Satiety
Weight reduction
Potential for
improved β-cell
mass/function
Once weekly
injection
•GI side effects (nausea,
vomiting, diarrhea)
•Cases of acute pancreatitis
observed
•C-cell hyperplasia/ thyroid
tumors in animals (liraglutide)
•Injectable
•Long-term safety unknown
DPP-4 inhibitors
(incretin
enhancers)
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin
Januvia, Januvia
XR
Onglyza
Tradjenta
Nesina
↑Active GLP-1
concentration
↑ Active GIP
concentration
↑ Insulin secretion
↓ Glucagon secretion
No hypoglycemia
Weight “neutrality”
•Occasional report of
urticaria/angioedema
•Cases of pancreatitis observed
•Long term safety unknown
Amylin Pramlintide
Acetate
Symlin® Suppresses glucagon
secretion
Slows gastric
emptying
Improved blood
glucose control
•For use in type 1 or type 2 using
insulin
•Injectable
•Hypoglycemia
•Nausea
•Contraindicated in patients with
gastroparesis, hypoglycemia
unawareness
Class
Compound
Brand Names
Action(s)
Advantages
Disadvantages
SGLT2 inhibitor Canagliflozin
Dapagliflozin
Empagliflozin
Invokana
Farxiga
Jardiance
Reduces renal
glucose
reabsorption &
increases urinary
glucose excretion
No weight gain;
possibly weight
loss
•Female genital mycotic
infections, UTI, ↑urination
•Hypotension
•Hyperkalemia
•Contraindicated in patients
with GFR <30mL/min,
ESRD, dialysis
Glucovance Glyburide + Metformin Janumet Sitagliptin + Metformin
Amaryl M Glimeperide + Metformin Janumet XR Sitagliptin + Metformin
Metaglip Glipizide + Metformin Kazano Alogliptin + Metformin
Avandaryl Glimeperide + Rosiglitazone Kombiglyze Saxagliptin + Metformin
ActoplusMet Pioglitazone + Metformin Jentadueto Linogliptin + Metformin
ActoplusMet XR Pioglitazone + Metformin Osini Alogliptin + Pioglitazone
Avandamet Rosiglitazone + Metformin Invokamet Canagliflozin + Metformin
Duetact Pioglitazone + Glimeperide
Prandimet Rapaglinide + Metformin Juvisync Sitagliptin + Simvastatin
Diabetes Medications (continued)
Combination Diabetes Medications
Type Brand
Name
Generic
Name
Onset of
Effect
Duration of
Effect
Peak
Rapid-Acting Humalog®
Novolog®
Apidra®
Lispro
Aspart
Glulisine
15 minutes 2-4 hours Yes (30-90
minutes)
Short-Acting Humulin®R 30 – 60
minutes
3 -6 hours Yes (2-4 hours)
Intermediate-
Acting
NPH 2- 4 hours 12-18 hours Yes (4-10 hours)
Long-Acting
100u/ml
Lantus®
Levemir®
Glargine
Determir
1-2 hours 20-26 hours Peakless
Long Acting
300u/ml
Toujeo® Glargine 6 hours 24 hours Peakless
Insulins
Exercise
Benefits
• Increased insulin sensitivity
• Post exercise enhanced insulin sensitivity for 24-48 hours
• Reduced hyperinsulinemia (risk factor for
atherosclerosis)
• Decreased risk factors for CAD
↓Cholesterol, LDL, triglycerides
↑HDL
Exercise Recommendations
• 150 minutes per week of moderate intensity aerobic physical
activity, at least 3 days per week with no more than 2 consecutive
days without exercise
• In absence of contraindications, resistance training at least 2x per
week
• Cardiovascular risk factors for CAD should be assessed before
recommending a physical activity program
• Those taking insulin and/or insulin secretagogues may need to
add carbohydrate if pre-exercise glucose levels are <100mg/Dl
Approximate additional15g carbohydrate for every hour of moderate exercise
• Recommend checking blood sugars pre- and post- exercise
MEDICAL NUTRITION THERAPY
• Promote & support healthful eating patterns, emphasizing a variety of nutrient-
dense foods in appropriate portion sizes, in order to improve overall health
• Achieve & maintain
- normal or near normal blood glucose levels as is safely possible
- blood lipid profile that reduces risk for vascular disease
- blood pressure levels in the normal range or as close to normal as is safely
possible
• Achieve & maintain body weight goals
• Prevent, or at least slow, the rate of development of chronic complications by
modifying nutrient intake & lifestyle
• Address individual nutrition needs, taking into account personal & cultural
preference, healthy literacy & willingness to change
• Maintain the pleasure of eating by only limiting food choices as indicated by
scientific evidence.
MNT for Pre-Diabetes
Focus on lifestyle strategies to delay/prevent development of
type 2 diabetes and reduce cardiovascular risk
Calorie restriction, independent of weight loss, is associated
with increased insulin sensitivity
Moderate, sustained weight loss (7% body of weight)
Dietary fiber intake of 14g/1000 kcal with emphasis on whole grains &
other fiber rich foods
Encourage intake of nutrient rich foods
Increase physical activity
Metformin therapy may be considered for those with a BMI >35, age <60
years & women with history of GDM
Emphasis on heart healthy eating
MNT for Diabetes in Adults
For all individuals, provide appropriate nutrition guidelines to prevent & treat
chronic and acute complications associated with diabetes
Emphasis on heart healthy eating
Optimal mix of macronutrients is unlikely to exist
Best mix of carbohydrate, protein & fat appears to vary depending on
individual circumstances. It will depend on glycemic & metabolic status of
the patient (ie, lipid profile).
Triglyceride levels are not increased until carbohydrate intake is >55%
Regardless of macronutrient mix, total caloric intake must be appropriate for
weight management goals
Assess individual needs & evaluate lifestyle
INDIVIDUALIZE
MNT Goals for Specific Situations
Youth
1. Recommend changes in lifestyle to decrease the risks associated with diabetes (acute & chronic).
2. Achieve & maintain a healthy weight through healthy eating habits & exercise.
3. Involve the whole family.
Pregnancy
1. Adequate calories to provide appropriate weight gain and adequate nutrition.
2. Overweight/Obese women may benefit from modest energy reduction (30% less of estimated needs).
3. Ketonemia from ketoacidosis or starvation ketosis should be avoided. Weight loss is not recommended.
MNT for Specific Situations (continued)
Pregnancy (continued)
4. Minimum of 175g carbohydrate/day should be provided.
5. Carbohydrate should be distributed throughout day in 3 small/moderate sized meals and 2-4 snacks. HS snack tends to prevent accelerated overnight ketosis.
6. Carbohydrate is generally less well tolerated at breakfast than other meals.
MNT for Specific Situations (continued)
Lactation
1. Provide adequate calories & nutrients. Monitor appetite & weight.
2. Breastfeeding is recommended. Generally breast-feeding mothers require less insulin. Fluctuations in blood glucose related to nursing session may require a carbohydrate snack before or during breastfeeding.
**Because GDM is a risk factor for subsequent type 2 diabetes after delivery, lifestyle modifications aimed at weight reduction, if needed, & increased physical activity are recommended.
Older Adults
1. For older adults, meet the nutritional & psychosocial needs of aging.
2. Provide appropriate nutrition guidelines to prevent & treat chronic and acute complications associated with diabetes.
Major Nutrient Recommendations
• 45-65% Carbohydrate
• 10-35% Protein
• 20-35% Fat
Carbohydrate Recommendations
Dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes and low-fat milk.
Consistent carbohydrate at meals.
Monitor carbohydrate intake (counting, exchanges or estimation).
Most people will need between 150 & 250g carbohydrate daily (based on 1400-2000 calories daily).
Sucrose containing foods can be substituted for other carbs. Avoid excess energy intake.
Glycemic index & load may provide a modest benefit when coupled with total carbohydrate management.
Dietary Fiber Recommendations
Recommendation: 14g/1000 calories (same as general population)
Intake of dietary fiber is associated with lower all-cause mortality in
people with diabetes.
Keeps foods moving through the digestive tract
• Prevents constipation
• Lowers blood pressure
• Decreases cholesterol & triglyceride levels
• Decreases risks of some type of cancer
• May improve blood glucose control
• Enhances satiety
Protein Recommendations
Usual protein intake of 10-35% of total daily calories.
High protein diets are not recommended as a method for weight loss at this time. Long term effects are unknown.
5-7 ounces lean animal protein daily will meet most individuals needs.
Inclusion of vegetable proteins instead of animal add cardiovascular benefit.
Protein has very little effect on blood glucose levels in well controlled diabetes. Those with poorly controlled diabetes, gluconeogenesis can occur rapidly & adversely affect glycemic control.
Protein ingestion with a carbohydrate has been shown to have no beneficial effect on glucose levels.
Protein at meals can possibly enhance satiety.
Fat Recommendations
Limit saturated fat to <7% of total daily calories.
Intake of trans fat should be minimized.
Limit dietary cholesterol <200mg/day.
Emphasis on monounsaturated fats.
Two or more servings of fish per week (no commercially fried fish filets).
Two grams/day of plant sterol or stanol esters have been shown to lower
plasma total and LDL cholesterol.
All fats have minimal effect on blood glucose levels in small to moderate
amounts.
Sodium Recommendations
• People with type 2 diabetes tend
to be more sodium-sensitive
May contribute to hypertension and
other diabetes complications
• Limit sodium to less then 2300 mg
daily
• Limit high sodium foods
Salt, canned foods, frozen meals,
processed meats, cheese, meals
eaten out
• Stress more fruits, vegetables,
whole grains, fresh meats
Alcohol Recommendations
• Adults who choose to use alcohol, daily intake should be limited to:
One drink per day or less for women or two drinks per day or less for men
• Alcohol does not require insulin to be metabolized as an energy source.
Provides 7 calories/gram
• Moderate alcohol consumption (when ingested alone) has no acute effect on glucose & insulin concentration. Carbohydrate coingested may raise blood glucose.
• Alcohol blocks gluconeogenesis which could result in hypoglycemia when consumed without food.
To reduce risk of hypoglycemia in individuals using insulin or insulin
secretagogues, consume alcohol with food
• Hypoglycemia could be misinterpreted as intoxication. Hypoglycemic effect may persist from 8 to 12 hours after the last drink.
• Light to moderate alcohol intake is associated with a lower CV disease risk.
Nutritive Sweeteners
• Sugar Alcohols (polyols)
Sorbitol, mannitol, xylitol, erythritol, isomalt, lactitol, maltitol, starch
hydrolysates
Provide a lower glucose response than sucrose or glucose and are
lower in calories (2 calories/gram)
Listed on the label under Total Carbohydrate
Found in many commercially prepared sweets or desserts labeled
as “sugar free”
May cause abdominal distress (>10g/day)
No evidence they have advantages or disadvantages in decreasing
carbohydrate or calorie intake
Non-Nutritive Sweeteners
• Sugar Substitutes
4 kinds
• Saccharin* (Sweet ‘n Low, Sugar Twin)
• Aspartame (Nutraweet, Equal)
• Sucralose (Splenda, Nevella)
• Acesulfame K (Sunett, Sweet One)
• Stevia (PurVia, Truvia)
Contain no calories
All have ADI’s published by the FDA
All approved by the FDA as safe for use in people with diabetes *Not approved for use in pregnancy.
Free Foods
• Contain < 20 calories or 5 grams of carbohydrate per serving
• Most non-starchy vegetables……………..
• Condiments, such as, mustard, horseradish, etc.
• Diet soda, calorie free gelatins, coffee or tea without sweetened
flavorings added
• Sugar free beverages containing zero calories
• Herbs, spices
Acute Illness Recommendations
Continue insulin and oral glucose-lowering medications.
Consume adequate fluids.
Continue carbohydrate ingestion in tolerable forms.
•150-200 g carbohydrate daily
•45-50g every 3-4 hours should be sufficient to prevent
starvation ketosis.
Diabetes Nutrition Recommendations
for Use in Healthcare Facilities
1. “ADA” diet is on longer an appropriate prescription since the ADA does
not endorse any single meal plan.
2. Preferred method is to implement a consistent day to day carbohydrate
meal plan.
3. Terms such as “no concentrated sweets”, “no sugar added”, “low sugar”
& “liberal diabetic diets” are no longer appropriate.
4. Patients requiring clear-liquid or full-liquid diets should receive
approximately 150-200g carbohydrate per day spread evenly throughout
the day at meals and snacks.
5. Provide adequate nutrition for residents of long-term care facilities with
fairly consistent day-to-day carbohydrate at meals and snacks.
6. For hospitalized patients with diabetes who require parenteral or enteral
nutrition, treat as you would the patient without diabetes.
Putting It Together
Educating
Your Client
Determining Calorie Needs for Adults
• Miflin St. Jeor Equation
• Benedict Harris Equation
• Approximate Maintenance Calorie Needs/Adults
10 kcal/lb – obese, very inactive
13 kcal/lb - >55, active women and sedentary men
15 kcal/lb – active men or very active women
20 kcal/lb – very active men or athletes
Determining Calorie Requirements for Youth
Method 1
1000 kcal for 1st year
Add 100 kcal/yr up to age 10
Girls 11-15: add 100 kcal or less per year after age 10
Girls > 15: calculate as an adult
Boys 11-15: add 200 kcal,yr after age 10
Boys > 15: 23 kcal/lb very active; 18 kcal/lb usual;
15-16 kcal/lb sedentary
Method 2:
1000 kcal for 1st year
Add 125 kcal x age for boys; 100 kcal x age for girls; add up to 20% more kcal for activity
Toddlers 1-3: 40 kcal per inch length
Calculating Carbohydrate Needs
1500 calories • 40-60% of 1500 calories = 600-900 calories
• 600-900 calories ÷ 4 (4 calories/g) = 150g-225g carbohydrate
• Possible distribution suggestions:
60 -75g carbohydrate at 3 meals
30-40g carbohydrate at 6 meals/snacks
40- 50g carbohydrate at 3 meals, 15-20g carbohydrate at 3 snacks
45-60g carbohydrate at 3 meals, 15-30g carbohydrate at bedtime
2200 calories • 40-60% of 2200 calories = 880-1300 calories
• 880-1320 calories ÷ 4 = 220g-330g carbohydrate
• Possible distribution suggestions:
75 -110g carbohydrate at 3 meals
40-50g carbohydrate at 6 meals/snacks
60-75g carbohydrate at 3 meals, 15-30g carbohydrate at 3 snacks
60-90g carbohydrate at 3 meals, 30g carbohydrate at bedtime
Carbohydrate Management Methods
CONSISTENT CARBOHYDRATE INTAKE
Carbohydrate Gram Counting
– Adds up the exact number of grams of
carbs eaten
– Based on using nutrition labels or other
resources
Carbohydrate Exchanges
– Estimates grams of carbohydrate based
upon a serving of 15g carbohydrate
– Swap one carbohydrate food for another
Carbohydrate Estimation
– Uses hand measurements
p.69
Identify foods containing carbohydrate
Use label or resource material to determine carbohydrate grams
in a serving
Calculate the total grams of carb at that meal
Allows flexibility in food choices including sweets & treats
Counting Carbohydrate Grams
p.70
Fruit and Fruit Juice ½ cup (4 oz) juice
1 cup berries ½ large banana
½ large apple, orange 1 cup melon
Grains ¾ cup dry unsweetened cereal 1 slice bread (white, w. wheat, rye) ¼ bagel (about 1 oz) ½ cup grits/oats (cooked) ⅓ cup pasta or rice 4-6 crackers
Milk and Yogurt 1 cup (8 oz) milk – skim or whole
¾ cup (6 oz) yogurt – plain nonfat
Starchy Vegetables ½ cup mashed potatoes or beans ½ cup corn, peas, lima beans
Sweeteners 1 tablespoon sugar or honey
Vegetables 3 cups raw 1½ cup cooked
Using Exchanges
p.71
Fist = 1 cup
45g of pasta
Palm = 3 oz (85g) A cooked
serving of meat
Thumb = 1 oz (30g) A piece of cheese
Handful = ½ cup 1 oz snack food
(nuts or pretzels)
Thumb Tip = 1 tsp. A serving of low fat
mayonnaise or margarine
Hand Guides
p.72
Nutrition Facts
• Emphasize the Serving Size at
the top
• Always look at “Total
Carbohydrate”
Includes fiber & sugars
8g Fiber or more. Half can be
deducted from Total Carbohydrate
• DO NOT need to look at sugars
• Emphasis is placed on total
amount of carbohydrate rather
than source
• Don’t forget the Fat
p.74
Just a Bowl of Cereal
Nutrition Facts
Serving Size 1 cup (28g)
Amount Per Serving
Calories 101 Calories from Fat 1
% Daily Value*
Total Fat 0.2g 0%
Saturated Fat 0.1g 0%
Trans Fat 0g
Polyunsaturated Fat 0.1g
Monounsaturated Fat 0.0g
Cholesterol 0mg 0%
Sodium 202mg 8%
Total Carbohydrate 24.4g 8%
Dietary Fiber 0.7g 3%
Sugars 2.9g
Protein 1.9g
Nutrition Facts
Serving Size ½ cup (30g)
Amount Per Serving
Calories 100 Calories from Fat 5
% Daily Value*
Total Fat 0.5g 1%
Saturated Fat 0g 0%
Trans Fat 0g
Polyunsaturated Fat 0g
Monounsaturated Fat 0g
Cholesterol 0mg 0%
Sodium 190mg 8%
Total Carbohydrate 23g 8%
Dietary Fiber 3g 10%
Sugars 5g
Protein 2g
1 c of corn flakes
in a small bowl
1 c of corn flakes
in an average size bowl
Serving Size Matters
p.75
Meal Planning Strategies
• No single meal-planning approach works for every patient.
• Pre-printed diet sheets are ineffective & should not be used.
• All foods fit.
• Focus on the concept of heart healthy eating.
My Plate, Pyramid
• Space meals 4 – 6 hours apart; no meal skipping.
• Optional snacks between meals and/or a snack at night.
• Carbohydrate consistency coupled with cardiovascular disease prevention recommendations.
Reduce saturated fat intake
Avoiding high sodium foods
• Portion control.
• Ethnic, cultural, age appropriateness.
Case Study #1
• AJ is a 45 year old single woman who was diagnosed with type 2
diabetes 3 years ago. She recently saw her Dr. after a two year
absence with complaints of chronic fatigue & blurry vision. AJ
states that the Dr had prescribed metformin two years ago but she
decided not to take it. She had also been told to lose weight and
cut out sugar. She states ”everything” has sugar in it!”, and it
became very frustrating for her so she quit looking at labels. She
also cites that she is too tired to exercise. AJ works full time as a
claims adjuster for an insurance company. She does not like to
cook for one. After seeing the Dr. she is willing to take the
metformin and was encouraged by the Dr. to see a dietitian.
Case Study #1 - Data
Ht- 5’6” A1C – 8.3
Wt – 175 lbs (80 kg) Total Cholesterol – 214
BMI – 28.2 LDL – 150
Wt. History - stable HDL – 35
Triglycerides - 275
Case Study #1- Diet Recall
Breakfast Lunch Dinner Snacks
Large Coffee w/
cream & nothing
else
Sandwich (varies)
Fries
Salad w/ Ranch drsg
Lemonade or diet
soda
Salad Bar: various
veggies, “meats”,
mixed salads w/
Ranch dressing
Water
At work:
Nothing or may
grab some candy in
office; an
occasional cake if
birthday in office
Large Coffee w/
cream
Sausage, egg &
cheese biscuit
Roast beef
Mashed potatoes
Gravy
Green beans
Lemonade or diet
soda
Frozen entrée
Water
Or
May skip
(Evening) might
include:
Fruit
Popcorn
Yogurt
Chips/Pretzels
Case Study #1 – Discussion Questions
1. How should you handle AJ’s frustration about diabetes and
meal planning?
2. What are some possible initial education topics for AJ?
3. What are some food/meal planning/lifestyle strategies for AJ?
4. What are AJ’s caloric needs? About 17-1800 calories
5. What calorie level would you recommend for weight loss?
1400-1500 calories + increase in daily activity
A. Carbohydrate needs? 160-180 grams
How would you distribute? 50-60g at each meal
B. Protein needs? 20% of 1500 = 75g/day (5-6 oz meat daily)
C. Fat needs? 30% of 1500 = 50g/day
D. Other nutrient recommendations?
Case Study #2
JD is a 62 year old male with a 20 year history of type 2 diabetes.
He was admitted to the hospital after experiencing chest pain
(possible MI). He reports a history of hypertension and
hyperlipidemia both treated with meds. His diabetes meds include
1000mg metformin with breakfast & dinner, 4 mg glimeperide
before breakfast & dinner and 100 mg Januvia each morning. JD
checks his blood sugars every morning. They are typically in the
140’s. JD does not exercise but is active daily as a school
custodian. He is married with grown children. The Dr. would like
him to start taking insulin. JD and his wife asked to see a dietitian
and would like to review dietary guidelines first. He has not met
with a dietitian since his diagnosis.
Case Study #2 - Data
Ht- 5’10” A1C – 7.9
Wt – 180 lbs (82 kg) Total Cholesterol – 212
BMI – 25.8 LDL – 130
Wt History - stable HDL – 35
Triglycerides - 200
Case Study #2 – Diet Recall
Breakfast Lunch Dinner Snacks
1½ c. Cheerios
w/ 2% milk
1 Toast w/ butter
6-8 oz orange
juice
Black coffee
1-2 Sandwiches-
bologna &
cheese on white
Bag of chips
(med size)
4 sugar free
cookies
Diet soda
Baked or Fried
Chicken Quarter
1 c. Mashed
Potatoes/gravy
Corn on cob
Salad w/ Italian
dressing
Water
At home in
evening:
Cereal w/ milk or
Cheese & Ritz
Crackers or
Fruit
Diet soda
2 eggs
3-4 bacon
6-8 oz orange
juice
Coffee
Same as above 2 c. Spaghetti w/
meatballs
2-3 slices garlic
bread
Water
At work:
Doesn’t usually
snack
Discussion Questions
1. How would you initially assess JD’s interest in dietary changes?
2. What are some possible initial education topics for JD?
3. What are some food/meal planning/lifestyle strategies for JD?
4. What are JD’s caloric needs? 2100 calories
A. Carbohydrate needs? 260 grams daily
Distribution Suggestions? 60g at meals, 15-30g at snacks
B. Protein needs? 20% of 2100 =105 grams (8 oz meat daily)
C. Fat needs? 30% of 2100 = 70g fat daily
D. Other nutrient recommendations?
Everything In Moderation