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