Diabetes Nutrition Standards of Care Nancy L. Schwartz, RD, LMNT, CDE, CPT 15 April 2016

Transcription

1 Introduction Diabetes Nutrition Standards of Care Nancy L. Schwartz, RD, LMNT, CDE, CPT 15 April 2016 Ongoing patient self-management education and support are critical to preventing acute complications and reducing the risk of long-term complications. Diabetes Care 2016;39(Suppl. 1):S1-S2 2 Medical nutrition therapy (MNT) People want to know what to eat They ask for a specific menu ADA position: there is not a one-size fits all eating pattern for individuals with diabetes Goals of MNT for adults with diabetes To promote and support healthful eating using nutrient-dense foods in appropriate portion sizes in order to improve overall health and: Achieve & maintain body weight goals Attain individualized glycemic, blood pressure and lipid goals Delay or prevent complications of diabetes 3 4 1

2 To address individual nutrition needs based on personal & cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes and barriers to change. To maintain the pleasure of eating by providing non-judgmental messages about food choices. To provide an individual with diabetes with practical tools for developing healthful eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods Metabolic control Achieving A1c goals decreases the risk for microvascular complications and may also be important for cardiovascular disease risk reduction, particularly in newly diagnosed patients. 5 6 RD delivered MNT A1c reductions of 0.3-1% for people with type 1 diabetes A1c reductions of 0.5-2% for people with type 2 diabetes Obesity management can delay progression from pre-diabetes to type 2 diabetes and benefits type 2 diabetes treatment MNT Recommendations An RD provided individualized MNT program for all people with type 1 or type 2 diabetes For those with type 1 and those with type 2 using a flexible insulin therapy program, education on carbohydrate counting and insulin to carb ratio for insulin dosing determination For fixed insulin dosing, having a consistent pattern of carbohydrate intake 7 8 2

3 Type 2 Glycemic & weight management (if not taking insulin) Emphasis on healthy food choices, & portion control Especially for those who have limited health literacy or numeracy And for those who are elderly and prone to hypoglycemia Modest weight loss achievable through lifestyle modification & reduction of energy intake in overweight/obese individuals Interventional programs are recommended Weight management Modest weight loss is defined as sustained reduction of 5% of initial body weight and has been shown to improve glycemic control & reduce need for glucose lowering medications. 5% loss shows benefits but sustained loss of > 7% is optimal Lifestyle programs: reduce calories by /day or provide: For women 1,200-1,500 calories/day, adjusted for baseline weight For men 1,500-1,800 calories/day adjusted for baseline weight The diet choice should be based on health status & preferences Academy of Nutrition & Dietetics (AND) Evidence-based nutrition practice guidelines A series of 3-4 encounters with an RD lasting minutes Encounters should begin at diagnosis or at first referral to an RD for diabetes MNT and should be completed within 3-6 months The RD should determine whether additional MNT encounters are needed At least 1 follow-up encounter is recommended annually to reinforce lifestyle changes and to evaluate & monitor outcomes that indicate the need for changes in MNT or medications; an RD should determine if more MNT is needed Eating patterns & macronutrient distribution No ideal distribution of calories from carbohydrate (CHO), fat and protein Individualize keeping total calorie & metabolic goals in mind CHO: whole grains, vegetables, fruits, legumes and dairy products with emphasis on foods higher in fiber and lower in glycemic load is advised over other sources, especially those containing sugars. People with DM and those at risk should avoid sugar-sweetened beverages to help control weight and reduce risk for CVD & fatty liver. Sucrose-containing foods should be minimized to avoid displacing nutrient-dense choices

4 No Ideal mix A systematic review found that there is no ideal mix that applies broadly and that macronutrient proportions should be individualized. On average, people with diabetes consume: ~45% of their calories from CHO, ~36-40% from fat & ~ 16-18% from protein Regardless of macronutrient mix, total calories should be appropriate for weight management goals Eating patterns Eating (dietary) patterns, is a term used to describe combinations of different foods or food groups that characterize relationships between nutrition & health promotion & disease prevention. People eat combinations of foods, not single nutrients. Reviewed eating patterns: Mediterranean style, Vegetarian & vegan, Low fat, Low CHO and DASH Conclusion: There is no ideal eating pattern that is expected to benefit all individuals with diabetes. Total energy intake (and thus portion size) is an important consideration no matter which eating pattern is chosen Carbohydrate (CHO) Ideal amount of CHO intake is inconclusive. Monitoring glucose response and CHO intake are key for improving post prandial glucose control. The amount of CHO and available insulin may be the most important factor influencing pp BG & should be considered in meal planning. Some studies: lowering glycemic load has resulted in -0.2 to -0.5% A1c The glycemic index measures the blood glucose rise, not the speed. Dietary fiber and whole grains Fiber intakes to improve glycemic control, based on existing research, are unrealistic, requiring intakes of >50 g/day. Fiber s effect on CVD risk factors: total fiber intake, from natural food sources (vs supplements) seems to have beneficial effect on serum cholesterol levels and blood pressure. Recommendations: 25 g/day for women & 38 g/day for men Whole grains (contains the entire grain seed, bran, germ & endosperm) are not associated with improved glycemic control but may reduce systemic inflammation. Consume at least half of all grains as whole grains

5 Resistant starch & fructans Resistant starch is physically enclosed within intact cell structures as in some legumes, raw potato & specially formulated cornstarch. There are no published long-term studies to provide benefits like hypoglycemia prevention and reduction of hyperglycemia using resistant starch. Fructans are an indigestible type of fiber hypothesized to lower glucose. Inulin (chicory root) is added to many foods. Again, there are no published long-term studies showing benefit in people with diabetes. Fructose Fructose in fruit may result in better glycemic control compared with isocaloric intake of sucrose or starch, and free fructose (occurring naturally in foods like fruit) is not likely to have detrimental effects on triglycerides as long as intake is not >12% energy. For 1800 calories = 54 grams of fructose. Some foods marketed to people with diabetes may contain significant fructose (agave nectar); these foods should not be consumed in sizeable portions to avoid excess calories & fructose intake. People with diabetes should limit/avoid intake of sugar sweetened beverages to reduce risk for weight gain and worsening of cardiometabolic risk profile Fructose content of some foods Item Size Grams Fructose Grams CHO Agave nectar 2 Tbsp Item Size Grams Fructose Grams CHO Mango, sliced 1 cup What ose is recommended for Hypoglycemia? Apple, Fugi Med Banana Med Blueberries 1 cup Cherries 1 cup Clementine 1 avg Grapes 1 cup Honey 2 Tbsp Melon, cantaloupe 1 cup Peach, fresh Med Pear, fresh Bartlett Med Pineapple, fresh 1 cup Raisins ¼ cup Raspberries 1 cup Regular cola soda 12 oz Glucose is already glucose (monosaccharide) Sucrose (table sugar) is glucose & fructose (disaccharide) Fructose is fructose (monosaccharide) In comparison study, fructose was least effective, therefore, glucose (tablets, liquid or gel) or sucrose may be preferred over fruit juice. From USDA National Nutrient Database, Release

6 Protein For those without evidence of diabetic kidney disease, there is no ideal amount of protein for optimizing glycemic control or improving one or more CVD risk measures. In type 2: ingested protein increases insulin response without increasing plasma glucose concentrations. Therefore: CHO sources high in protein should NOT be used to treat or prevent hypoglycemia. For those with albuminuria and reduced glomerular filtration rate, dietary protein should be maintained at 0.8g/kg body weight/day. Reducing the amount of dietary protein below the recommended daily allowance is not advocated because it does not alter glycemic measures, cardiovascular risk measures or the rate at which glomerular filtration rate declines. Meals with > 75g protein can raise post prandial glucose at 3-5 hours following consumption. The effect of protein & fat is additive (high fat increases insulin resistance) Red meat consumption recommendations From the American Institute for Cancer Research (AICR) To reduce cancer risk, eat no more than 18 oz. (cooked weight) per week of red meats, like beef, pork and lamb, There is strong evidence of a relationship between more than 18 oz./week and colon cancer risk. There is also convincing evidence that consuming processed meat, such as ham, bacon, salami, pastrami, hot dogs and sausages increases the chances of colorectal cancer. The research on processed meat shows the risk starts to increase with any portion. Dietary fat Data on total fat content for people with diabetes is inconclusive. Diets emphasizing monounsaturated fats may improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in CHO. Eating foods rich in Omega-3 fatty acids (fatty fish, nuts and seeds) is recommended to prevent or treat CVD (not supplements though)

7 The Institute of Medicine (IOM) has defined an acceptable macronutrient distribution range for all adults for total fat at 20-35% of energy with no tolerable upper intake level defined. The type of fatty acids consumed is more important than total amount of fat when looking at metabolic goals and CVD risk. Monounsaturated and polyunsaturated fats are recommended over saturated fat. People with diabetes should be advised to follow the guidelines for the general population with regard to recommended intakes of saturated fat, dietary cholesterol and trans fat. In general, trans fat should be avoided. Dietary fats and diabetes In animal & observational studies, higher intakes of total dietary fat produce greater insulin resistance. In clinical trials saturated & trans fats have been shown to cause insulin resistance whereas mono- & polyunsaturated and omega-3 fatty acids do not have an adverse effect. Polyunsaturated fats are as beneficial as monounsaturated fats Saturated fat Somewhat a controversial situation The American Heart Association recommends saturated fat to make up no more than 5-6% of caloric intake. The 2015 guidelines for Healthy Americans says <10% of calories The newest ADA recommendations say those with diabetes should use the same guidelines as those without diabetes so agree with <10% For 1800 calories: 5-6% = g <10% = < 20 g saturated fat Individuals with diabetes and dyslipidemia may be able to modestly reduce total and LDL cholesterol by consuming g/day of plant stanols or sterols typically found in enriched foods. <300 mg dietary cholesterol/day is recommended

8 Micronutrients & herbal supplements No clear evidence that supplementation with vitamins, minerals, herbs or spices can improve diabetes. There is insufficient evidence to support the routine use of chromium, magnesium and vitamin D to improve glycemic control in people with diabetes There is insufficient evidence to support the use of cinnamon for diabetes treatment May be safety concerns regarding long-term use of antioxidant supplements such as vitamin E, vitamin C and carotene Alcohol Those with diabetes who drink alcohol should do so in moderation: No more than 1 drink per day for women No more than 2 drinks per day for men Drinking alcohol may increase risk of delayed hypoglycemia, especially if using insulin or insulin secretagogues. Warning/education of recognition & management of delayed hypoglycemia is warranted Sodium People with diabetes should limit sodium to <2300 mg/day Further restriction may be indicated for those with DM & hypertension A teaspoon of salt = 2300 mg sodium Sodium intake recommendations should take into account palatability, availability, affordability, and the difficulty of achieving low-sodium recommendations in a nutritionally adequate diet. Coordinating food with insulin secretagogue Moderate amount of CHO at each meal and snacks (when needed) To reduce risk of hypoglycemia: Eat a source of CHO at meals Do not skip meals Physical activity may result in low blood glucose depending on when it is performed. Always carry a source of CHO to reduce risk of hypoglycemia

9 Coordinating food with Metformin: Coordinating food with alpha-glucosidase inhibitors Gradually titrate to minimize GI side effects when initiating use Take medication with food or 15 minutes after if symptoms persist If side effects do not resolve over a few weeks, f/u with MD If taking with insulin or secretagogue, may experience hypoglycemia Gradually titrate to minimize GI side effects when initiating Take at start of meal to have maximal effect If also taking insulin or secretagogue, may experience hypoglycemia If hypoglycemia, use glucose tablets or gel, not polysaccharide Coordinating food with insulin Learn how to count CHO to match insulin to CHO intake If on set doses of insulin, keep CHO consistent If on MDI or a pump: Take mealtime insulin before eating Meals can be consumed at different times If physical activity is performed within 1-2 hours of mealtime insulin, the dose may need to be lowered to reduce risk of hypoglycemia Coordinating food with premixed insulin Insulin doses need to be taken at consistent times every day. Meals need to be consumed at similar times every day. To reduce risk of hypoglycemia, do not skip meals. Physical activity may result in low blood glucose depending on when it is performed. Always carry a source of CHO. Eat similar amounts of CHO each day to match the set doses of insulin

10 Prevention or delay of type 2 diabetes recommendations Target of 7% of body weight loss Increase moderate-intensity physical activity, such as brisk walking, to at least 150 minutes/week. Metformin therapy should be considered in those with BMI > 35, those < 60 years of age and women with history of gestational diabetes. At least annual monitoring for diabetes is suggested. Nutrition for pre-diabetes Unlike past recommendations that focused on simply reducing total dietary fat and cholesterol consumption, more recent evidence argues against the preventative effects of lowering fat and cholesterol intake across the board and supports instead that the quality of fats consumed in the diet is more important than the total quantity of dietary fat. The CDC has updated their handouts to have less emphasis on becoming a fat detective to a healthier food choices approach for intake Nutrition for pre-diabetes Increased consumption of nuts and berries in the context of a diet high in vegetables and fruits has been correlated with reduced diabetes risk. Physical activity (PA) and pre-diabetes Exercise and physical activity have been validated to prevent or delay diabetes as part of lifestyle modification. The studies suggest that while exercise may not reduce body weight, programs of sufficient intensity have been shown to decrease diabetes risk. Inform at risk individuals to move. Data suggest that consumption of a diet enriched in whole grains is helpful in preventing type 2 diabetes. Both resistance training and endurance exercise appear to have beneficial effects on waist circumference, insulin resistance and thus diabetes risk. This extends to prevention of gestational diabetes as well

11 What s the Best nutrition therapy for diabetes? In the words of Marion Franz, MS, RDN, CDE In an ideal world : All people with type 2 would: Lose 5% - 10% baseline weight Eat a nutrient dense diet in appropriate portions Perform 150 min/wk of regular PA All people with type 1 would: Count CHO Use I:C ratio and correction factors In the real world: Facilitate behavior changes that individuals are willing and able to make based on proven lifestyle interventions. A variety of nutrition therapy and PA interventions can be implemented Nutrition therapy for diabetes is effective References Diabetes Care, Volume 39, Supplement 1, January 2016 Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2014; 37 (Suppl. 1):S120-S143. Franz, M, Boucher JL, Evert, AB. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes, Metabolic Syndrome and Obesity: Targets & Therapy 2014: Franz, M. The Key to Diabetes Nutrition Therapy: Individualization, PP presentation American Institute for Cancer Research & American Heart Association 41 42? 43 11