Medical Nutrition Therapy for Diabetes Mellitus Raziyeh Shenavar MSc. of Nutrition
Diabetes Mellitus A group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both.
Types of Diabetes Type 1 (IDDM) Type 2 (NIDDM) Gestational diabetes mellitus (GDM) Prediabetes (impaired glucose homeostasis)
Diagnostic Criteria Diagnosis Diabetes Pre-diabetes Impaired fasting glucose Impaired glucose tolerance Normal Criteria FBS >126 mg/dl CPG >200 mg/dl 2hPG >200 mg/dl FBS 100-125 mg/dl 2hPG 140-199 mg/dl FBS <100 mg/dl 2hPG <140 mg/dl
Prediabetes (Impaired Glucose Homeostasis) Two forms; may have either or both Impaired fasting glucose (IFG): fasting plasma glucose(fpg) above normal Impaired glucose tolerance (IGT): plasma glucose elevated after 75 g glucose load
Type 1 Diabetes Two forms Immune mediated: beta cells destroyed by autoimmune process Idiopathic: cause of beta cell function loss unknown Symptoms: hyperglycemia, polyuria, polydipsia, weight loss, dehydration, electrolyte disturbance, and ketoacidosis
Type 2 Diabetes Most common form of diabetes accounting for 90% to 95% of diagnosed cases Combination of insulin resistance and beta cell failure (insulin deficiency) Progressive disease: hyperglycemia develops gradually and may not cause the classic symptoms of type 1 diabetes
Gestational Diabetes Mellitus (GDM) Glucose intolerance with onset or first recognition during pregnancy Occurs in about 7% of pregnancies
Risk Factors for Type 2 Diabetes BMI >25 Physical inactivity High-risk ethnic groups Previous delivery of baby >9 lbs or GDM Hypertension HDL <35 mg/dl or triglycerides >250 mg/dl IGT or IFG History of vascular disease
Complications of Diabetes Macrovascular coronary artery disease (MI) cerebrovascular disease (Stroke) peripheral vascular disease Microvascular retinopathy nephropathy neuropathy
Management of Pre-Diabetes Lifestyle change Increase physical activity Moderate weight loss Education Reduced fat and energy intake Regular participant follow-up Whole grains and dietary fiber
Carbohydrate Low-carbohydrate diets are not recommended Sugars do not increase glycemia more than isocaloric amounts of starch Factors influencing glycemic response to foods: glycemic index (GI) and glycemic load (GL) Carbohydrate counting; portions of food containing 15 g carbohydrate Exchange lists
What is the Glycemic Index? All carbs (except fiber) convert to blood glucose eventually GI Reflects the magnitude of blood glucose rise in the first 2 hours Ranks foods by how much they raise blood glucose levels compared to glucose or white bread. In general, the lower the rating, the better the quality of carbohydrate. o Usually low in calories and fat, while also being high in fiber, nutrients and antioxidants.
What Is Glycemic Load? Glycemic load = glycemic index x actual amount of available carbohydrates consumed Reminder that serving size is still important! Low G.I. but a very large serving = high glycemic load Total carb intake is a primary factor in glycemic response of a meal
Glycemic Index ranking of selected starchy foods Higher (GI>90) Intermediate (GI: 70-90) Lower (GI<70) Most dry cereals Most breads Most crackers White rice, boiled Most cakes Most potatoes Pancakes and waffles Oat bran Whole-wheat bread Most muffins Long-grain rice Most cookies New potatoes Sweet corn All bran cereals Oatmeal, muesli, pumpernickel bread Most pasta Barley Yams Most dry beans and lentils
Fiber Recommend same as general public: variety of fiber-containing foods such as legumes, fiber-rich cereals (>5 g/serving), fruits, vegetables, and whole grains
Sweeteners Sucrose in food plan should be substituted for other carbohydrate sources or covered with insulin or glucose-lowering medications Sugar alcohols (sorbitol, mannitol, xylitol) cause less rise in blood glucose >10g/day may cause GI upset Non-nutritive Sweeteners Aspartame Sucralose Acesulfame Potassium Saccharin (Sweet n Low, Sugar Twin) Cylamates Both of these not recommended during pregnancy
Protein Does not affect blood glucose levels in well-controlled diabetes 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
Dietary Fat Saturated Fat: <7% of total calories Cholesterol: <200 mg/day in people with diabetes Minimize intake of trans-fatty acids Two or more servings of fish per week providing n-3 polyunsaturated fatty acids are recommended
Micronutrients Vitamins+Minerals: Routine supplementation is not necessary
Exercise Improves insulin sensitivity Lowers Blood Glucose Uses Glycogen Stores muscle liver Increases release of FFA from adipose
Insulin Insulin formulations classified according to their duration of action as well as time of onset & peak activity. Types of Insulin Preparations: Long acting insulin best used as background (basal) insulin NPH, Lente, Ultralente Short acting insulin Regular, Toronto quickly absorbed and best used at mealtime Rapid acting insulin Novorapid, lispro (Humalog) rapidly absorbed and best used at mealtime
Action Times of Human Insulin Preparations Insulin Type Onset Peak Effect Duration Rapid-acting 10-15 min 60-90 min 3-5 hrs Short-acting 30-min 2-3 hrs 6.5 hrs Intermediate & Longacting NPH Lente Ultralente 1-3 hrs 1-2 hrs 4-8 hrs 5-8 hrs 6-12 hrs 2-12 hrs 10-18 hrs 10-18 hrs 18-24 hrs
Nutrition Therapy for Type 2 Diabetes Lose weight if you are overweight Lose weight slowly and safely, 1-2 pounds weekly Enjoy foods from all food groups. Avoid fad diets that eliminate any specific foods or groups of foods. Eat smaller portions and exercise more Exercise to promote or maintain weight loss (consult with your doctor before beginning) 30 minutes most days of the week is recommended Include aerobic exercise and resistance training for the best results Start slowly and increase the duration and intensity of exercise if you are new to exercise.
Nutrition Therapy for Type 2 Diabetes Obtain carbohydrates mainly from fruits, vegetables, whole grains, legumes, and low-fat or skim milk. These foods are the best carbohydrate sources o They are usually high in fiber and high in nutrients your body needs Consume at least 130 grams of carbohydrate each day Low-carbohydrate diets are not recommended for diabetes management Carbohydrates contain important nutrients Choose most of your carbohydrates from fruits, vegetables, and whole grains Use sugar substitutes if desired Use only sugar substitutes that are approved by the FDA Sugar substitutes can help you enjoy sweet treats more often Sugar substitutes don t appear to cause weight loss or control blood sugars
Nutrition Therapy for Type 2 Diabetes Limit saturated fats, trans fat, and dietary cholesterol These types of dietary fats and cholesterol can contribute to heart disease, which is related to diabetes When you use fats, use liquid oils instead of solid fats when possible. Trans fat are produced by the food industry by taking liquid oils and changing them into solid fats. This process improves the shelf life and stability of flavors of processed foods
Nutrition Therapy for Gestational Diabetes Mellitus GDM occurs in ~3.7 % of all pregnancies (8-18% in aboriginal populations) Justifies screening for all pregnant women Increased risk of later diabetes in mother Carbohydrate-controlled meal plan, adequate energy, normoglycemia, and absence of ketosis. Adequate in energy to promote normal weight gain and prevent ketonuria Individualize and adjust meal plan throughout pregnancy Use of insulin Carbohydrate distribution Exercise
Food Exchange List in Diabetes Carbohydrate (grams) Protein (grams) Fat (grams) Calories Carbohydrates Starch: breads, cereals and grains. Starchy vegetables, and beans, peas, and lentils 15 0-3 0-1 80 Fruits 15 - - 60 Milk Fat-free, low-fat, 1% 12 8 0-3 100 Reduced fat, 2% 12 8 5 120 Whole 12 8 8 160 Sweets, desserts, and other carbohydrates 15 Varies Varies Varies Nonstarchy Vegetables 5 2-25
Food Exchange List in Diabetes-cont d Carbohydrate (grams) Protein (grams) Fat (grams) Calories Meat and Meat Substitutes Lean - 7 0-3 45 Medium-fat - 7 4-8 75 High-fat - 7 8+ 100 Plant-based proteins Varies 7 Varies Varies Fats - - 5 45
Food Bread White whole-grain Beans, Peas, and lentils Beans, cooked (black, garbanzo, kidney, lima, navy, pinto, white) Peas, cooked (black-eyed, split) Starchy Vegetables Corn Peas, green Parsnips Potato Baked with skin Boiled, all kinds Fruits fresh fruit canned or fresh fruit or unsweetened fruit juice Milk Food Exchange List in Diabetes-cont d Serving Size 1 slice (30 grams) 1 slice (30 grams) ½ cup ½ cup ½ cup ½ cup ½ cup ¼ large (3 oz) ½ cup or ½ medium (3 oz) 1 small ½ cup 1 cup
The End Any Question???