Nutrition Challenges for Women with Diabetes

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1 Nutrition Challenges for Women with Diabetes April 25, 2017 Judy Simon MS,RDN, CD, CHES University Washington Medical Center, Roosevelt Clinic and Mind Body Nutrition, PLLC

2 Objectives 1. Identify three unique nutrition challenges for women with diabetes. 2. Describe medical nutrition therapy used in treating women with diabetes throughout the lifecycle. 3. Describe strategies for nutrition and lifestyle treatment for women with diabetes.

3 Disclosures Employee University Washington Medical Center- Dietitian University Washington GCPD Clinical Instructor Mind Body Nutrition PLLC- Owner Speaker expenses and honorarium underwritten WSAND

4 Nutrition Challenges for Women and Diabetes PCOS- Polycystic ovary syndrome- T1Dm and T2 DM Fertility and Pregnancy- Complications with pre-existing diabetes Diabulimia: Restriction or omission of insulin intake to lose weight. It is considered a dual diagnosis disorder: where one has diabetes as well as an eating disorder.

5 What is PCOS? Complex genetic disorder of androgen excess, ovulatory dysfunction and polycystic ovaries Affects 6-10% of women worldwide, most common endcrinopathy in women of reproductive age. Leading cause of menstrual irregularities and infertility.

6 PCOS Hyperandrogenemia: Irregular and/or painful menstrual cycles Infertility Acne Hirsutism Alopecia Elevated Androgen (testosterone, DHEAS) Higher rates of infertility, miscarriage, preterm delivery, gestational diabetes and still births

7 Hyperinsulinemia Weight gain Acanthosis nigricans Skin tags Follicular keratosis

8 PCOS Comorbidities Hypertension Coronary heart disease Diabetes Dyslipidemia (low HDL, high triglycerides) Impaired glucose tolerance Metabolic syndrome Overweight, obesity (central) 38-88% are overweight or obese

9 Ovarian Morphology

10 NIH Evidenced Based Methodology Workshop PCOS Dec 2012 Rotterdam Criteria for Diagnosis Selected Oligo- and/or anovulation Clinical and/or biochemical signs of hyperandrogenism Polycystic ovaries (Two of three needed for diagnosis)

11 Features of PCOS. The diagnostic criteria for PCOS (Table 1) include two or more of these features: hyperandrogenism (blue circle), anovulation (pink circle), and PCO (green circle), resulting in several PCOS phenotypes depending on the diagnostic criteria... Diamanti-Kandarakis E, and Dunaif A Endocrine Reviews 2012;33: by Endocrine Society

12 Fig. 1 PCOS: changing womenʼs health paradigm. Gordon W. Bates, Richard S. Legro Longterm management of Polycystic Ovarian Syndrome (PCOS) Molecular and Cellular Endocrinology Volume 373, Issues

13 Lifestyle Modification Principles Suggested for Obesity management in PCOS and Diabetes Lifestyle modification is the first form of therapy, combining behavioral (reduction of psychosocial stressors), dietary, and exercise management. Reduced-energy diets ( kcal/day reduction) are effective options for weight loss and can reduce body weight by 7% to 10% over a period of 6 to 12 months.

14 Dietary pattern should be nutritionally complete and appropriate for life stage and should aim for <30% of calories from fat, <10% of calories from saturated fat, with increased consumption of fiber, whole-grain breads and cereals, and fruit and vegetables. Alternative dietary options (increasing dietary protein, reducing glycemic index, reducing carbohydrate) may be successful for achieving and sustaining a reduced weight but more research is needed in PCOS.

15 The structure and support within a weight-management program is crucial and may be more important than the dietary composition. Individualization of the program, intensive follow-up and monitoring by a physician, and support from the physician, family, spouse, and peers will improve retention. Structured exercise is an important component of a weight-loss regime; aim for >30 minutes per /day. Moran, Lisa J. et al. Journal of the Academy of Nutrition and Dietetics, 2013; Volume 113, Issue 4,

16 PCOS and Type 1 Diabetes Few studies on prevalence of PCOS in women with T1DM. Studies have found higher rates of PCOS amongst women with T1DM. Treatment of T1D involves exogenous insulin administration- exogenous insulin therapy is absorbed directly into the systemic circulation. Supraphysiological concentrations of insulin in the systemic circulation have direct effects on the peripheral tissues including the ovarian theca cells.

17 PCOS and T1DM 75% of women with T1D on intensive insulin therapy had either PCOS or asymptomatic polycystic ovarian morphology in contrast to 33% of women with T1D on conservative (twice-daily insulin injections). PCOS in adolescents with T1DM is likely to be the increased fat mass, weight gain and insulin resistance during puberty.

18 Case Study 1 Jody- 19 yo T1 DM age just finished freshman year of college High school hockey athlete- prep school and worked out several hours a day Gained weight freshman year college, desperate to lose weight Referred by reproductive endocrinologist who started her on Metformin in addition to her insulin regime

19 Jody HT: 4 11 WT: 140 BMI: 28.3 gained 20 pounds over past year OCP in high school, stopped when a cyst was developed and PCO ovaries diagnosed Insulin 19 units Lantus, CIR: 1:5, 1:10 dinner, correction factor 1 unit for every 40 over 120. Metformin 500 mg Breakfast, 1000 mg dinner

20 LABS: HgA1C 7.8, Vit D 23.3, Chol 250, TG 192, HDL 66, LDL 155 Androgens- wnl Celiac screen negative Liver enzymes- wnl

21 Jody s Diet Very low kcal and very low cho Father was following a very low carb diet with a 30 pound weight loss Working out 5 days a week, twice a week with a trainer, physically active summer job Medical Nutrition Therapy: negotiated kcal with minimum 130 gm CHO- balanced with healthy fats and protein Jody upset she did not lose weight the first week Referred to exercise physiologist for measurement resting metabolic rate and VO2 Max

22 Case 1 MNT Medical Nutrition Therapy: negotiated kcal with minimum 130 gm CHO- balanced with healthy fats and protein Jody upset she did not lose weight the first week Referred to exercise physiologist for measurement resting metabolic rate and VO2 Max

23 Exercise Testing Resting metabolic rate VO2max measurement Exercise metabolic rate, Exercise fuel utilization Aerobic threshold (LT) anaerobic threshold (LAT) HR max, HR recovery, HR zones power zones, training recommendations.

24 Fertility/Pregnancy and Diabetes Incidence T1D and T2D amongst women of reproductive age is increasing worldwide T2DM is more common than T1D in many centers Rising obesity, increased prevalence of GDM (can precede half the pregnancies complicated by T2D). Perinatal mortality in women with T2D is now worse than with T1D.

25 Fertility/Pregnancy and Diabetes Rise in insulin sensitivity in early pregnancy promotes fat storage in the liver and adipose tissue. Greater than 50% rise in insulin resistance in late pregnancy decreases maternal peripheral glucose utilization and increases availability of glucose for uptake by placenta.

26 Pregnancy Complications Increased congenital abnormalities % higher with pre-existing diabetes. For every I unit increase on preconception HgA1C above 5.5 risk for congenital malformation increased by 1.2%. Excessive fetal growth. Pre-pregnancy BMI and excessive gestational weight gain are associated with macrosomia independent of glycemic control Poor glycemic control can contribute to pro-inflammatory intrauterine environment. This may contribute to preeclampsia and fetal growth restriction later in pregnancy.

27 Pre-pregnancy Care in Women with Pre-existing Diabetes Ensure effective contraception until optimization of diabetes care, aim for HgA1C under 6.5. Meet with registered dietitian nutritionist and diabetes educator for optimization healthy diet and diabetes management. Glucose profiling for T1 and T2 patients for tighter control.

28 Pre-pregnancy Care in Women with Pre-existing Diabetes Encourage regular exercise, healthy weight and smoking/etoh cessation. Prenatal supplementation with folic acid, iodone and Vit D (check level). Screen for diabetes complications, hypertension, cardiac disease, autoimmune disease (thyroid function and celiac screen) Discontinue teratogenic medications.

29 Case Study 2 Initially referred for medical nutrition therapy PCOS, fertility and weight loss. 34 yo Susan wanted to get healthier before conception HT: 5 6 WT: 213 BMI: Usual weight: 165 (age 23-29) Dx: Hypothyroid, Anxiety, PCOS, Hyperlipidemia, oligomenorrhea Medications: Levothyroxine, Sertraline (Metformin had been prescribed)

30 Case Study 2 HgA1C 5.9 Fasting insulin 13, FBS 113 Chol 284 TG 670 HDL 42 Vitamin D 13 AMH 11 2 hr GTT Fasting124, 2 hr 93

31 Susan Attends group classes for weight loss for fertility Poor compliance with Metformin Takes prenatal and Vitamin D HgA1C increase 6.1 despite 5 pound weight loss (increases >6.5 later in the year) Vit D increases to 27 Irregular cycles Lipids decrease slightly

32 Pregnant! Unplanned! Over the past two years Susan is inconsistent with diet, medications and prenatal supplements and menses continue to be regular. Not using contraception because of infertility times 7 years Advised to contact clinic for Ultrasound and determined to be 7 weeks pregnant.

33 Starts prenatal supplement, Metformin, Vit D 2000 IU and referred to DM pregnancy clinic. Diabetes clinic initiates 10 U Lantus nightly and weekly logs sent in. Increase 2 units per day until fasting levels under 90. Metformin 1000 mg breakfast, dinner and 500 mg lunch Meets with RDN to develop meal plan for pregnancy and weight goals.

34 Pregnancy Ultrasounds- normal CF DNA 12 weeks normal 18 units Lantus, 3-4 units Novolog if higher carbohydrate dinner, advised to have HS snack carb/protein/fat HgA1C 5.8, 1,5 Anhydroglucitol (Glycomark)9.9 mcg/ml 17 weeks and patient s weight stable at 221. Working on easy, healthy meals while working full time, pregnant and going to school at night.

35 Diabulmia Eating disorder behaviors associated with T1D; patients omit or reduce insulin to lose weight or prevent weight gain. Diabulimia can result in hyperglycemia, glucosuria, ketonuria, rapid weight loss and DKA. Currently not recognized in DSM-V as a diagnosis.

36 Diabulmia Warning signs for diabetes related eating disorders: Poor metabolic control despite reported compliance Weight loss or maintenance despite unchanged or increased food intake Recurrent DKA Symptoms of diabetes: excessive urination, thirst and hunger.

37 Why are women with T1D more at risk for ED? Onset of DM often associated with weight loss she does not want to give up. Insulin can lead to increased hunger and weight gain. Constant focus on weight, diet, and numbers from family and health professionals. Shame about food.

38 Close monitoring of food, glucose, diet, exercise and insulin dosage. Role of parents and others as diabetes police. Need for control. Coping mechanism.

39 Case Study yo female with T1DM since she was 9 yo Elements of bulimia and anorexia (restrictive during the day and bingeing at night) Recently discharged from Residential, partial hospitalization and intensive outpatient eating disorder program (IOP) after 14 months of treatment. Admission: WT: 158.6# Meal plan kcal daily

40 Rapidly lost weight when transitioned to IOP (eating only kcal day) Transitioned from pump to individual injections due to poor management Often refused to take insulin even under parental supervision. Frequently lying and manipulation with insulin. Self harm: cutting and excessive exercise.

41 Kris Moved pack to PHP, better compliance afraid she would be hospitalized. Moved to adult PHP unit. Manipulated pump when it was returned to her. Admitted to IOP at 145, struggled with manipulating insulin. Struggled with constipation and neuropathy.

42 Kris Stepped up to residential at pounds Struggled with overexercise, insulin omission and food restriction. Insulin pump removed. All control over food choices and insulin given to staff, not patient. Restored weight to 145. Recommended focus on intuitive eating rather than just carbs. Home pressures- divorce and alcoholism, no financial or emotional support. College deferred one term and supportive. Support from faith base organization Motivated to try self care so she could attend college.

43 College deferred one term. Support from faith base organization Motivated to try self care so she could attend college. Transitioned to outpatient team: Endocrinologist, ARNP, psychiatrist, therapist and dietitian. Seeing dietitian 1 x week and therapist 2 X per week

44 Medical Nutrition Therapy Continue with meal plan- 3 meals and 3 snacks Patient continued to lose weight since discharge. Omit insulin and one ER admit for hyperglycemia. Skipped many snacks and restricted intake. Occasional night time binges. Used Recovery Record as a tool to record food intake and feelings. Close coordination of outpatient care team. Transitioned to college with RDN on campus.

45 Recovery Record- therapists and dietitians- HIPAA compliant

46 Resources for Diabulimia Help line:

PCOS Awareness Symposium Atlanta September 24 th, Preventing Diabetes & Cardiovascular Disease in PCOS

PCOS Awareness Symposium Atlanta September 24 th, 2016 Preventing Diabetes & Cardiovascular Disease in PCOS Katherine Sherif, MD Professor & Vice Chair, Department of Medicine Director, Jefferson Women