Lesson 5 : Medical Nutrition Therapy

Types of DM

Type 1(5-10%) Type 2 (90-95%) Gestational “Other Specific Types” from

specific genetic syndromes surgery drugs Malnutrition (old term) infections other illnesses

Impaired glucose tolerance (pre-diabetes)

Types of DMCharacteristic Type 1 DM Type 2 DM Age of Onset Childhood or

adolescence Age 40 or older*

Rapidness of Onset Usually abrupt Usually gradual

Family history Usually no Common

Etiology Unknown- Heredity,autoimmune, viral infections

Unknown- Heredity

Body weight Usually thin Obesity common Endogenous Insulin Very little to none Normal, high, or low

Ketosis Common Uncommon Symptoms Polyuria/dipsia/phagia

and weight loss Polyuria/dipsia or none

* growing incidence in adolescents

ADA Terminology Update

Old Term New Term

IDDMType I DM Type 1 DM

NIDDMType II DM Type 2 DM

Diagnostic Criteria

Test

Stage FPG RPG OGTT

Diabetes 126 200 plus symptoms

2hPG 200

Impaired Glucose Homeostasis

Impaired Fasting Glucose = FPG 110 and <126 mg/dl

Impaired Glucose Tolerance = 2hPG140 and <200 mg/dl

Normal < 110 mg/dl 2hPG <140mg/dl

FPG = Fasting Plasma Glucose RPG = Random Plasma Glucose OGTT = Oral Glucose Tolerance Test

Epidemiology

Epidemic increase in type 2 diabetes currently 90 % of all forms of diabetes

Predictions 6-8 % of the world population will suffer from

diabetes in the next quarter of a century 300 million people worlwide

Doubling of the prevalence of DM2 to 215 million in the next 15 years

50% not yet diagnosed in Europe & North America!

Diabetes 1994-2010: Global Estimates and ProjectionsJiwa F. Statistical Bulletin. Jan-Mar 1997;2-8

0

50

100

150

200

250

1995 2000 2010

DM2

Million people

100

160

215

Diabetes

0

10

20

30

40

50

60

1995 2000 2010 2025

USEuropeChinaIndia

Year

Nu

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n M

illi

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s

Diabetes: A Worldwide Epidemic

• Increasing longevity.

• Change in demographics and genetic predispositions: the greatest growth of patients will be in Asia, where it is predicted that by 2010, over 60% of the patients suffering from diabetes will live in this region of the world.

• Rising urbanization and change in lifestyle.

• Increase in obesity: over 60% of the adult population in the United States (and Australia) are either overweight or obese.

The Rise in Diabetes: Why?The Rise in Diabetes: Why?

Diabetes: A Worldwide Epidemic

US

25% 70%

Samoa

Percent of Individuals Considered ObesePercent of Individuals Considered Obese in a Given Countryin a Given Country

15%

Europe Jordan

50%2%

Japan

Diabetes, Obesity & Adolescence In developing nations, more than 70% of the

childhood population presenting with diabetes suffers from type 2 disease.

In the United States, type 2 diabetes is preferentially affecting the obese Hispanic and African-American population. In the United States, adolescent clinics

describe 1/3 to 1/2 of their new diabetics as type 2 patients (Henry Ford Health Clinic, Detroit).

The incidence of diabetes in children has increased 10 fold when compared with a decade ago.

Mortality in diabetes patients double that compared to non-diabetics

Balkau Lancet 1997; 350:1680

WhitehallStudy

0

5

10

15

20

25

30

35

Control

Diabetes

10,025 61 6629 279 631 24(No of patients)

Ratio 2.5 Ratio 2.2 Ratio 2.1

10.8

26.9

12.5

26.9

15.5

32.0

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Paris Prospective Study

Helsinki Policemen Study

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Causes of Death Among People With Causes of Death Among People With DiabetesDiabetes

Ischemic heart diseaseIschemic heart disease

Other heart diseaseOther heart disease

Diabetes (acute complications)Diabetes (acute complications)

CancerCancer

Cerebrovascular diseaseCerebrovascular disease

Pneumonia/influenzaPneumonia/influenza

All other causesAll other causes

CauseCause % of Deaths% of Deaths

Geiss LS et al. In: Geiss LS et al. In: Diabetes in America. Diabetes in America. 2nd ed.2nd ed. 1995:233-257.1995:233-257.

4040

1515

1313

1313

1010

44

55

Complications of Diabetes

Macrovascular coronary artery disease (MI) cerebrovascular disease (Stroke) peripheral vascular disease

Microvascular retinopathy nephropathy neuropathy

Diabetes complications

Retinopathy (blindness?) Nephropathy (kidney problems) Feet ulceration and/or amputations Hypertension Hyperlipidemia (cholesterol?) Gestational diabetes (during pregnancy) Diabetes and HIV Erectile Dysfunction

Diabetes complications

1%increase in

HbA 1c

21%increase in

diabetes-related deaths

p<0.0001

14%increase in myocardial infarctionp<0.0001

43%increase in peripheral vascular disease

p<0.0001

HbA1c – relationship with CV riskGlycaemia increaseGlycaemia increase Associated risk increaseAssociated risk increase

Stratton IM Stratton IM et alet al. BMJ 2000; 321: 405. BMJ 2000; 321: 405––12.12.

Why Treat Diabetes?

DCCT Diabetes Control and Complications Trial 10-year study in 1441 patients with Type 1 DM

Kumamoto Study 6-year study in 110 Japanese patients with Type 2 DM

UKPDS United Kingdom Prospective Diabetes Study 20-year study of 5102 newly diagnosed Type 2 DM

The burden of type 2 diabetes can be reduced

UKPDS 33. Lancet 1998;352:837–853.

The UKPDS showed that, when glucose levels

are above normal, any reduction in HbA1c is

beneficial

=0.9%

reduction in HbA1c

25%reduction microvascular

complications

Preventative MeasuresDCCT

Intensive control of blood glucose reduced risk of diabetic complications 76% reduction retinopathy onset 54% reduction retinopathy progression 54% reduction nephropathy 60% reduction neuropathy

2-3x greater incidence of severe hypoglycemia

DCCT Research Group N Engl J Med. 1993;329: 977-986.

American Diabetes Association. Diabetes Care. 1999;22(suppl 1):S27-S31. UKPDS Group. Lancet. 1998;352:854-865.

UKPDS Group. BMJ. 1998;317:703-713.Nathan D. Lancet. 1998;352:832-833.

UKPDS Key Messages

• To reduce the complications of diabetes, it is necessary to control:• blood glucose and HbA1c levels

• blood pressure

• Epidemiologic analyses showed that for every percentage point reduction in HbA1c, there was a

• 35% reduction in microvascular complications• 25% reduction in diabetes-related deaths• 18% reduction in MI

©1998 PPS

It Works…….at least for some things

DCCT1(1993) Kumamoto2(1995) UKPDS31998)

Retinopathy Up to 76% less 69% less 21% decrease

Nephropathy Up to 56% less 70% less 33% decrease

Neuropathy Up to 60% less

Atherosclerotic Events

41% fewer 50% fewer ND

Overall Microvascular Complications

Data not Available

Data not Available

25% decrease

1 The DCCT Group. N Engl. J Med 1993. 2 Ohkubo Y, etl. al. Diab Res Clin Pract 1995.

3 UKPDS Group. Diabetes Care 1998.

Goals of Treatment

Alleviate symptoms Prevent complications Prevent progression of current

complications Improve quality of life

Alleviate symptoms Prevent complications Prevent progression of current

complications Improve quality of life

ADA Goals of Treatment (cont.)

Index Normal Goal Action

Preprandial <110 80-120 <80,>140

1hr Postpran 100-160 100-180 <100,>200

2hr Postpran 80-120 80-150 <80,>150

2-4 AM 70-100 70-120 <70,>120

Bedtime <120 100-140 <100,>140

A1C <6 <7 >8

Other Glycemic Measures

A1C measure of how much hemoglobin has been

glycosylated represents an “average glucose” over the last 3

months Fructosamine

measure of proteins that are glycosylated represents an “average glucose” over 2-4 weeks

Diabetic control

Normal HBA1C 3.5 – 6.5% Targets

HBA1c Fasting plasma glucose

Low risk

<6.5 <100

Macrovascular risk

>6.5 >100

Microvascular risk

>7.5 >110

Collaborative Management

Nutritional Therapy Activity Monitoring of Blood Glucose Medication - Insulin or Oral Agents Education

Nutritional Therapy

Cornerstone of care for Diabetic No one “diabetic” or “ADA” diet Use individualized approach Consider financial status and cultural and

ethnic influences Priority placed on amount of CHO, not source

of the CHO

Nutrition

Nutrition Therapy – The Most Fundamental Component of the Diabetes Treatment Plan

Goals: Near Normal Glucose Levels Normal Blood Pressure Normal Serum Lipid Levels Reasonable Body Weight Promotion of Overall Health

Nutrition TherapyDiet Teaching Goal - independence; effective self-

management. Include Family. Follow prescribed plan; accurate portions Never skip meals Concern - Alcohol Concern - Dietetic Foods

Nutrient Components

Protein* Fat* CHO* Sucrose and Fructose Nutritive Sweeteners Fat Replacements* Vitamins and Minerals Alcohol Intake*

Nutrition Goals for Type 1 *** *** Type 2 Increase in energy

intake possible Diet and Insulin nec. to

control BS Equal distribution of

CHO through meals for insulin activity

Consistency in daily intake - control BS

Reduction of energy intake for obese

Diet alone may control blood glucose

Equal distribution of CHO desirable, not essential;low fat desirable

Consistency in daily intake - control wt.

Nutritional Goals (con’t) Type I ** **Type 2 Timing of meals -

crucial Snacks - frequently

necessary Additional food for

exercise - CHO 20 g/h for moderate physical activity

Timing of meals not essential

Snacks - not recommended

Additional food for exercise if on sulfonylurea or insulin

Dietary Management of Diabetes Maintain as near-normal blood glucose levels as

possible by balancing food, insulin and exercise Achieve recommended serum blood lipid levels Provide energy intake to maintain or attain healthy

weight Prevent and treat acute and long-term diabetes-related

complications Enhance over all health

Dietary Intake in US (NHANES III)

Mean daily intake 2095 Total kcal 34% Fat 15% Protein 50% CHO 2% Alcohol

Macronutrient Composition of Various Diets

15

34

49

3

15

30

55

15

15

70

30

30

40

30

55

15

0%

20%

40%

60%

80%

100%

Avg

Diet

Lower

Fat

Very

Low Fa

t

Low C

HO

Very

Low C

HO

PRO (% kcal) FAT (% kcal)) CHO (% kcal) ETOH (% kcal)

Major Dietary Guidance Tools Recommended Dietary Allowances

1989 10th Edition currently being revised Dietary Reference Intakes (DRIs)

RDAs ,Tolerable Upper Intake Level (UL), Estimated Average Requirement (EAR) and Adequate Intake (AI)

Yates et al, Jour Am Diet Assoc. 1998:98:699-706

The Food Guide Pyramid Human Nutrition Information Service, Home and Garden

Bulletin Number 252, Hyattsville, MD:USDA, 1992

1995 US Dietary Guidelines USDA and USDHHS, Nutrition and your health: Dietary

guidelines for Americans, 4th edition, 1995; Home and Garden Bulletin No. 232,Washington, DC:USDA, 1995

Type 1 Diabetes Mellitus

Type 1 Diabetes Mellitus

Nutrition Goals for Type 1

Consider intensive insulin therapy to allow flexibility in meal patterns

Integrate insulin therapy with usual food intake Develop an eating pattern based on person’s usual

food intake Monitor blood glucose levels

Ref: Manual of Clinical Nutrition, 2000

Meal PlanningMeal Planning

Term “ADA Diet” is obsolete Avoid the terms

no concentrated sweets low sugar diet liberal diabetic diet

Medical Nutrition TherapyMedical Nutrition Therapy

Meal plans should be individualized based on

nutrition assessment medical history psycho-social assessment treatment goals

Carbohydrate ConsistencyCarbohydrate Consistency

CHO intake and distribution should be comparable from one day to the next.

CHO content of meals within the same day can vary.

Type of Carbohydrate Type of Carbohydrate

The total amount of CHO eaten is more important than the source or type.

Clinical studies do not justify the longtime belief that sucrose must be restricted.

Glycemic IndexGlycemic Index

Compares various CHO foods and ranks them according to effect on BG.

Limitations: compared 50 g CHO from each source, actual

portion sizes weren’t necessarily comparable. looked at BG response when each item was

eaten alone, on an empty stomach. Mixed meals would produce a different effect.

People may unnecessarily restrict healthful foods.

Sugars and SweetenersSugars and Sweeteners

Sugar, honey, syrup...1 Tbs. =15g CHO Fructose slightly lower post-prandial

response. Sugar alcohol is a form of carbohydrate, but

labels can technically state “sugar free”. FDA approves 4 sugar substitutes which

have no CHO: aspartame, saccharin, acesulfame-K, sucralose

Macronutrient CompositionMacronutrient Composition

No absolute percentages CHO and MUFA should be 60-70% kcals SFA < 10% kcals Protein intakes of 15-20% kcals

Sample energy distributionSample energy distribution

50-60 % CHO 15-20 % Protein 20-30 % Fat

Protein Intake

Small to medium portion of protein once daily 12-20% of daily calories From both animal and vegetable sources Vegetable source less nephrotoxic than

animal protein 3-5oz (100-150g) of meat, fish or poultry daily Patient with nephropathy should limit to less

than 12% daily

Fat Intake

<35% of total calories Saturated fat <10% of total calories Polyunsaturated fats 10% of total calories Cholesterol consumption < 300 mg Moderate increase in monounsaturated fats

such as canola oil and olive oil (up to 20% of total calories)

CHO Intake

CHO intake determined after protein and fat intake have been calculated.

Emphasize on whole grains, starches, fruits, and vegetables

Fiber same as for nondiabetics (20g to 35g) Rate of digestion related to the presence of

fat, degree of ripeness, cooking method, and preparation

Carbohydrate Management ToolsCarbohydrate Management Tools Food Pyramid Food Labels ADA Exchange Lists Reference Books

The Food pyramid

Nutrition adivice should be practical and catered for the needs of the consumer

15 % proteins, 55 % carbohydrates & maximum 30 % fat are scientific but not practical advice

In USA food pyramid introduced in 1992 In Belgium adjusted (1997)

Nutrition Facts Serving Size 3/4 cup (55g) Servings Per Container 8 Amount Per Serving Calories 200 Calories from Fat 10 % Daily Value* Total Fat 1 g 2% Saturated Fat 0 g 0% Cholesterol 0 mg 0% Sodium 20 mg 1% Total Carbohydrate 45 g 15% Dietary Fiber 5 g 20% Sugars 15 g Protein 6 g Vitamin A 0% Vitamin C 0%

Calcium 0% Iron 8% * Percent Daily values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs: Calories 2,000 2,500 Total Fat Less than 65g 80g Sat Fat Less than 20g 25g Cholesterol Less than 300mg 300mg Sodium Less than 2400mg 2400mg Total Carbohydrate 300g 375g Dietary Fiber 25g 30g Calories per gram: Fat 9 Carbohydrates 4 Protein 4

Exchange ListsExchange Lists Calories g CHO g Pro g Fat

Starch 80 15 3 0 -1

Fruit 60 15 0 0

Skim Milk 90 12 8 0 - 3

Low-fat Milk 120 12 8 5

Whole Milk 150 12 8 8

Vegetable 25 5 2 0

Very Lean Meat 35 0 7 0 - 1

Lean Meat 55 0 7 3

Medium Fat Meat 75 0 7 5

High Fat Meat 100 0 7 8

Fat 45 0 0 5

Starch GroupStarch Group

15 g CHO 1 slice bread (Belgium

30g) small tortilla small potato 1/2 cup pasta (60g) 1/2 cup corn (60g) 1/3 cup rice (70g) 3 cups popcorn (180g)

Fruit GroupFruit Group

15 grams CHO small apple small orange 17 grapes 1/2 grapefruit 1 cup cantaloupe 3 prunes 4 ounces orange juice (120g)

Milk GroupMilk Group

15 g CHO each 1 cup milk (200ml) 3/4 cup plain yogurt (150g) 1 cup aspartame yogurt (200g)

Vegetable Group Vegetable Group

5 grams CHO each 1 cup raw vegis (225g) 1/2 cup cooked vegis (100g) 1/2 cup vegetable juice

(150ml)

Digestion TimingDigestion Timing

Peak Post Prandial BG is typically 1-2 hours after a standard mixed meal.

Liquids (juice/soda) digest quicker. High fat meals digest slower.

Meal PlanningMeal Planning

Set Carbohydrate Intake specific amount of CHO set to match prescribed

insulin regimen (less flexible) Adjust Insulin to Desired Carbo Intake

insulin to carbohydrate ratio 1 unit per 10-15 g carbohydrate 1 unit for every 50 mg/dl elevated above target (above

doses may vary)

Insulin Action TimesInsulin Action Times

Type of Insulin Start Peak Duration

Humalog “Lispro” 5-15 min 30-90 min 2-4 hrs

Novolog “Aspart” 5-15 min 30-90 min 2-4 hrs

Regular 30-60 min 2-3 hrs 3-6 hrs

NPH 2-4 hrs 4-10 hrs 10-16 hrs

Lente 3-4 hrs 4-12 hrs 12-18 hrs

Ultralente 6-10 hrs no peak 18-20 hrs

Glargine 1 hr no peak 24 hrs

Insulin Delivery Insulin Delivery

Syringes Insulin Pens Insulin Pump

delivers short acting insulin (sub-Q catheter) adjustable basal rate (usually 0.5-1.0 u/hr) programmable bolus for food or BG correction

Insulin PensInsulin Pens

Pre-filled with 300 units. Disposable. Dial dose in 1 unit increments up to 60 unit dose.

Insulin PumpInsulin Pump

Programmable insulin pump holds 300 units insulin is delivered through sub-Q infusion set/tubing

Remote control discrete dosing

ExerciseExercise

Improves insulin sensitivity

Lowers Blood Glucose Uses Glycogen Stores

muscle liver

Increases release of FFA from adipose

Exercise Guidelines: Type 1 DMMetabolic Control

Exercise Guidelines: Type 1 DMMetabolic Control Avoid exercise if BG >250 mg/dl,

ketones present. Use caution with exercise if BG>300 mg/dl,

without ketones. Eat CHO if BG < 100 mg/dl

Exercise Guidelines: Type 1 DMBlood Glucose Monitoring

Exercise Guidelines: Type 1 DMBlood Glucose Monitoring Monitor BG before and after exercise. Monitor BG throughout longer duration or

very intense exercise. identify need to increase food or decrease insulin. learn how various forms of exercise alter glycemic

response.

Exercise Guidelines: Type 1 DMInsulin Adjustments

Exercise Guidelines: Type 1 DMInsulin Adjustments If exercise is planned for just after a meal,

consider reducing the short acting insulin that covers that meal.

If exercise is planned for 3-4 hours after a meal, consider reducing the long-acting insulin.

For unplanned exercise, consider adding carbohydrate.

Exercise Guidelines: Type 1 DMFood Intake

Exercise Guidelines: Type 1 DMFood Intake Consume CHO before, during, or after

exercise to prevent hypoglycemia. Always keep CHO foods readily available

during exercise.

Late-onset HypoglycemiaLate-onset Hypoglycemia

Related to repletion of glycogen stores. Can occur up to 24 hrs after exercise.

indicates that insufficient carbohydrate was available in relation to insulin and exercise.

Depleted glycogen stores are best replaced when CHO is consumed within 30 min of exercise completion.

Treating HypoglycemiaTreating Hypoglycemia

Check BG when s/sx of hypoglycemia For BG < 70 mg/dl

take 15 grams of CHO 4 oz (120ml) juice 1 Tbs. (15g) sugar, jam, honey 3-4 glucose tabs

recheck BG in 15 minutes, repeat PRN If unconscious, NPO: administer glucagon or

IV dextrose.

Alcohol PrecautionsAlcohol Precautions

Alcohol inhibits gluconeogenesis which impairs the ability to recover from low BG.

Glycogenolysis is not affected by EtOH. Counter-regulatory response depends on glycogen stores.

ADA rec’s: limit to 1-2 drinks, consumed with CHO foods, if

no other contraindications.

Blood Glucose MetersBlood Glucose Meters

Plasma referenced Fingertip vs Offsite Memory Downloadable Some measure ketones Insurance companies

dictate which meter they cover.

Continuous Glucose MonitorContinuous Glucose Monitor

Subcutaneous sensor attached to unit worn on belt. Typically worn for 3 days. Measures BG continually. Download graph of BG. Elucidates potentially unknown BG excursions.

Blood Glucose TargetsBlood Glucose Targets

Before Meals normal < 110 goal 90 - 130

Peak Post Prandial normal < 140 goal < 180

Bedtime normal < 120 goal 110 -150

Hemoglobin A1cHemoglobin A1c

Target ADA < 7 ACE & IDF < 6.5

A1c BG

4 60

5 90

6 120

7 150

8 180

9 210

10 240

11 270

Type 2 Diabetes Mellitus

Type 2 Diabetes Mellitus

Nutrition Goals for Type 2

Weight loss of approximately 10-20 lb (4.5-9.0 kg)

Space meals throughout day Avoid excessive CHO intake at one meal May need consistent mealtime depending on

insulin use or insulin secretagogues Exercise

Ref: Manual of Clinical Nutrition, 2000

Key TopicsKey Topics

Statistics/Overview Weight Control Lipid Control Blood Pressure Control Exercise Other Complications

Diabetes Prevention ProgramResearch Group Diabetes Prevention ProgramResearch Group 3234 adults with impaired glucose tolerance3234 adults with impaired glucose tolerance Randomized (3 years)Randomized (3 years)

standard lifestyle plus Metforminstandard lifestyle plus Metformin standard lifestyle plus placebostandard lifestyle plus placebo intensive lifestyle modificationintensive lifestyle modification

Lifestyle ModificationLifestyle Modification

Weight loss (decrease weight by 7 %) individualized counseling healthy, low calorie, low-fat diet A 16 lesson curriculum on diet, exercise, behavior

modification Exercise 150 minutes per week

ResultsResults

Intensive lifestyle modification group reduced incidence of diabetes by 58 %

Metformin reduced incidence of diabetes by 31 %

Exercise

Potential Benefits Improved Glucose tolerance Weight loss or maintenance or desirable weight Improved cardiovascular risk factors Improved response to pharmacologic therapy Improved energy level, muscular strength,

flexibility, quality of life, and sense of well being

Exercise Prescription

Interest Capacity Motivation Physical status Individualized approach

Types of exercise

Walking Biking and stationary cycling Lap swimming and water aerobics Weight lifting At least 3-4 times a week, 30-40 minutes per

session, 50 to 70% of maximum oxygen uptake

PeripheralPeripheralinsulininsulin

resistanceresistance

ImpairedImpairedglucoseglucose

tolerancetolerance

Early diabetesEarly diabetes

Late diabetesLate diabetes

HyperinsulinemiaHyperinsulinemia

Defective glucorecognitionDefective glucorecognition

-cell failure-cell failure

Saltiel AR, Olefsky JM. Saltiel AR, Olefsky JM. Diabetes. Diabetes. 1996;45:1661-1669.1996;45:1661-1669.

Metabolic Staging ofType 2 Diabetes

“STAGES” OF TYPE 2 DIABETES

100%

-CELL

FUNCTION

YEARS FROM DIAGNOSIS-10 -5 0 5 10

IGT PP

BS

DM

“1”

DM

“2”

DM

“3”

MONOTHERAPY

COMBINATIONTHERAPY

REQUIRE INSULIN

LIFESTYLE

UKPDS: “HOMA” ANALYSIS

“Pre-diabetes”“Pre-diabetes”

HHS and ADA are using this new term to describe IFG (impaired fasting glucose) and IGT (impaired glucose tolerance). 16 million people have pre-diabetes. Most will develop diabetes within 10 years.

Prevention strategies screen at risk populations ( > 45 yrs, obese) lose 5-10% of weight modest exercise 30 min/day

Weight ControlWeight Control

Energy In = Energy Out

CHO: 4 kcals/g Metabolism

Protein: 4 kcals/g Daily Activities

Fat: 9 kcals/g Exercise

EtOH: 7 kcals/g

Nutrition Therapy

Provide Follow-up assessment of the meal plan to Determine effectiveness in terms of glucose and

lipid control and weight loss Make necessary changes based on weight loss,

activity level, or changes in medication Provide ongoing patient education and support

Weight Loss

Improves Glucose Control Increases Sensitivity to insulin Lower lipid levels and blood pressure Corresponding lowering of the dosage of

pharmacologic agents

For a Successful Outcome

Modest Energy Restrictions Spreading energy intake throughout the day Increased Physical Activity Behavior Modification Psychosocial Support

Energy Intake

Women: 100 # for the first 5 ft of height plus 5 # for each additional inch over 5 ft.

Men: 106# for the first 5 ft. of height plus 6# for each additional inch over 5 ft.

Add 10% for larger body build, Subtract 10% for smaller body builds

Multiply resulting weight by: Men and Physically Active Women: 15 Most Women, Sedentary Men, and Adults over 55: 13 Sedentary Women, Obese Adults over age 55: 10

Weight LossWeight Loss

1 pound body fat = 3500 kcals stored energy Energy deficit of 500 kcals/day to lose 1 lb/wk Energy deficit of 250 kcals/day to lose 1/2 lb/wk

Create energy deficit by: Eating less calories Exercise more

Guidelines for Weight LossGuidelines for Weight Loss

Limit eating for emotional or situational reasons. Limit non-nutritious energy sources. Limit added fats. Use lean meats. Use lowfat dairy products. Use lowfat cooking methods. Choose low calorie beverages. Eat a balanced diet and don’t skip meals. Exercise regularly.

Getting to the Heart of the MatterGetting to the Heart of the Matter The number 1 cause of death for people with

diabetes is heart disease. Minimize risk factors:

* control BG * don’t smoke

* control BP * control lipids

* control weight * exercise regularly

Treatment Goals Treatment Goals

Blood Pressure < 130/80

Total Chol < 200 mg/dl LDL Chol < 100 mg/dl HDL Chol > 40 mg/dl Triglycerides < 150 mg/dl

Heart Healthy Diet Heart Healthy Diet

Decrease saturated, hydrogenated, and trans-fatty acids. (< 7% kcals)

Limit dietary cholesterol. (<200 mg/d)

Increase intake of omega-3 fatty acids. Increase intake of soluble fiber. (10-25 g/d)

Include plant stanols/sterols. (2 g/d)

Dietary Fats DefinedDietary Fats Defined

Saturated Fats solid at room temperature animal fats

Hydrogenated Fats vegetable oils in origin, modified to solidify

Trans Fatty Acids occur mostly in hydrogenated fats

All of the above fats can raise LDL cholesterol.

Dietary Fats DefinedDietary Fats Defined

Polyunsaturated Fats safflower, corn, sunflower, sesame, cottonseed

Monounsaturated Fats olive, canola, peanut, avocados

Omega-3 Fatty Acids fish: salmon, tuna, mackerel, herring, sardines vegetarian sources: flaxseed, walnut, soybean,

canola, evening primrose.

Dietary CholesterolDietary Cholesterol

Only found in animal products. Most concentrated sources:

eggs (212 mg/yolk) shrimp (194 mg/3.5 oz, 100g) squid (231 mg/3.5 oz, 100g) liver (389 mg beef, 631 mg chicken, 3.5 oz, 100g) meat (75-95 mg/3.5 oz, 100g beef, chicken, pork)

Soluble FiberSoluble Fiber

Binds bile acids in the intestine, so that the bile acids are not absorbed in the terminal ileum.

New bile acids are made from circulating cholesterol, thus lowering serum chol.

Best Sources: oats, beans/legumes, rice bran, barley carrots, broccoli, sweet potatoes, citrus, papaya, apples, strawberries

Homocysteine AlertHomocysteine Alert

Elevated homocysteine levels may increase the risk of heart disease.

Adequate intake of these vitamins can lower homocysteine levels: Folate: fruits, vegetables, legumes, avocado,

yeast, wheat germ, fortified cereals and grains. Vit B6: whole grains, legumes, fish, chicken... Vit B12: milk, cheese, meat, fish, chicken, eggs

Blood Pressure ControlBlood Pressure Control

Lifestyle Modifications control weight exercise regularly limit sodium limit alcohol eat diet rich in potassium eat adequate amounts of calcium (?)

Reduce Sodium IntakeReduce Sodium Intake

Limit to 2,400 mg/d Low Sodium Strategies:

avoid the salt shaker limit use of processed foods limit fast food restaurant meals season with herbs, spices, garlic, ginger, lemon,

onions, flavored vinegar

PotassiumPotassium

Unless patient is limiting potassium for renal disease, or hyperkalemia, encourage a diet rich in potassium. Sources include: apricots, avocados, bananas, cantaloupe, kiwi,

mangos, oranges, strawberries artichokes, tomatoes, potatoes, yams, legumes,

parsnips, winter squash milk, yogurt lean meat, fish, skinless poultry

ExerciseExercise

Improves insulin sensitivity/lowers BG Helps with weight control Lowers blood pressure Lowers LDL and triglycerides Raises HDL Improves circulation and strengthens heart Improves bone density Relieves stress, improves sleep

Complications = Restricted DietsComplications = Restricted Diets Nephropathy

protein restriction 0.8 g/kg/day potassium, phosphorus, sodium, fluid restrictions.

Gastroparesis small frequent meals lowfat, low fiber, puree/liquid consistency difficulty matching insulin kinetics and digestion

timing.

Dietary Management of Diabetes: Guidelines

Same as for the general population

Total fat: 30% or less of total energy (20% or less in obese) If elevated triglycerides, reduce CHO and increase fat to 35-

40% of energy Saturated fat -- 10% of total energy

Protein: 10 - 20% of total energy intake

CHO: 55% of total energy intake

Dietary Management of Diabetes: GuidelinesCarbohydrates and Sweeteners Emphasis on total CHO rather than simple or complex

Can have sucrose as part of CHO allotment up to a maximum of 10% of calories

Different foods have different effects on blood sugar level -- glycemic index

Nutrition Consult – Individualized Meal Planning Conduct Initial Assessment of Nutritional Status Diet History, Lifestyle, Eating Habit Provide Patient Education Regarding

Basic principles of diet therapy Meal planning Problem solving Developing individualized meal plan Emphasize one or two priorities Minimize changes from the patient’s usual diet

Priorities for Meal Planning

If require insulin (two injections of mixed short and intermediate acting insulin):

Timing of meals and snacks important Quantity and quality of food important Watch CHO content Snacks at time of peak insulin action

With more intensive use of insulin (including regular insulin before meals)

Have more flexibility in food and timing

Priorities for Meal Planning

Type II diabetes with no insulin:

Gradually reduce total and saturated fat Spread calories throughout the day Avoid large amount of food at one time Space meals at least 4-5 hours apart Aim for healthy body weight Promote appropriate exercise

Diabetic Exchange System

Are tools for enabling food choices based on categories of foods and serving sizes

Patients need to be fairly literate Canadian and American and European systems differ

Glycemic Index (GI)

An indicator of the impact of foods on the response of blood glucose

Foods with a low GI are digested and absorbed more slowly than foods with a high GI

Low GI foods increase amount of CHO entering colon and increase fermentation

Used for making food choices by diabetics and people with impaired glucose tolerance

Glycemic Index Value: ExamplesFood

bread

cereal

milk

sucrose

orange juice

Glycemic Index

100

72

39

87

74

Artificial Sweeteners

Sugar alcohols (sorbitol, mannitol, xylitol cause less rise in blood glucose

Non-nutritive Sweeteners Aspartame (Equal, Nutrasweet, candarel) Saccharin (Sweet’n Low, Sugar Twin)

Alcohol Inake

Alcohol Moderate amounts can be consumed when diabetes

is well controlled

No more than two drinks per day

Should always take alcohol with food

Some Special Situations

Delayed meals Eat a snack if expect meal will be delayed

Carry available source of CHO i.e. Glucose tablets or

hard candy to avoid hypoglycemic reaction

Some Special Situations

Strenuous exercise Eat extra food before activity and take 15-30 grams of

CHO for every 30 min of strenuous activity (15 g CHO for each hour of less strenuous exercise)

Eat hearty snack after activity

If activity is pre-planned may reduce insulin dosage prior to activity

Some Special Situations

Illness Lack of appetite often with illness Substitute foods that are well tolerated Drink sugar containing liquids For each missed meal give 50 g CHO in small

frequent feedings over 3-4 hours Type I should not miss insulin as illness often causes

rise in blood glucose

Hypoglycemia: Treatment

Give quickly absorbed CHO immediately (1/3 can coke 33cl, 2 sugar cubes, 15 g glucose tablets)

Repeat treatment every 15-20 minutes if symptoms continue

If unconscious give intravenous glucose or glucagon injection

Diabetes in Children

75% of Type 1 diabetes occurs before 18 years Peak onset is 6 -11 years

Balance between allowing for normal growth and development, and need for glycemic control

Need meal plan that fits child’s lifestyle and promotes optimal compliance

Management Goals in Children Support normal growth and development Control blood glucose Prevent acute and chronic complications Achieve optimal nutritional status

Gestational Diabetes

Nutrition management similar to Type 1 and Type 2.

Diet tends to be slightly lower in CHO and higher in protein and fat (30-35%)

Requires individualized approach

Pyramid of Health Action

AHA Dietary Guidelines for Healthy American Adults and “Unified” Dietary Guidelines * Saturated fat < 10% of calories

Total fat < 30% of calories Polyunsaturated fat <10% of calories Monounsaturated fat ~ 15% of calories Cholesterol < 300 mg/d Carbohydrates > 55% calories Total calories to achieve and maintain desirable weight Salt intake limited to < 6 gm/d (2.4 Na) Alcohol only in moderation (<1-2/d)

*AHA Nutrition Committee, Circ 1996;94:1795-1800 AHA Conf on Prev Nutr. Circ 1999;100:450-456

AHA Discussion of2000 US Dietary Guidelines? Eat a nutritionally adequate diet

consisting of a variety of foods 5 servings of fruits/vegetables 6+ servings of whole grains

Limit intake of foods high in saturated fat, cholesterol and total fat monounsaturated fat trans fatty acids omega 3 fatty acids cholesterol level

2000 U.S. Dietary Guidelines?(con’t) Achieve and maintain an appropriate body

weight Healthy BMI Obesity recognized as an independent risk factor Physical activity

Increase consumption of complex CHO and fiber Amount and type

2000 US Dietary Guidelines(con’t) Reduce intake of sodium

contribution of ca, mg, K contribution of obesity physical activity and alcohol

Consume alcohol in moderation, if at all? Red wine vs other types of alcohol

2000 US Dietary Guidelines (con’t) Special Populations:

children post-menopausal women elderly minorities

Populations at increased CVD risk Elevated LDL-C or pre-existing CVD Diabetes Hypertension Obesity

2000 DGs - Treatment: Obesity and CVD Diet Composition Recommendations

Total kcal adequate and appropriate to prevent weight gain achieve small, incremental weight losses provide adequate nutrition, flexibility

Low saturated fat (<10% kcal) Increase MUS to replace SF Total Fat < 30% kcal