1. Chapter 33
Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

2. Diabetes Mellitus Definition
A group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both

3. Diabetes and Prediabetes Types
Type 1 (formerly IDDM, type I)
Type 2 (formerly NIDDM, type II)
Gestational diabetes mellitus (GDM)
Prediabetes (impaired glucose homeostasis)
Other specific types

4. Diabetes Type 1 Two forms
– Immune mediated—beta cells destroyed by autoimmune process
– Idiopathic—cause of beta cell function loss unknown

5. Diabetes Type 2
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

6. Prediabetes (Impaired Glucose Homeostasis)
Two forms
– Impaired fasting glucose (IFG)— fasting plasma glucose(FPG) above normal
– Impaired glucose tolerance (IGT)— plasma glucose elevated after 75 g glucose load

7. Gestational Diabetes Mellitus (GDM)
Glucose intolerance with onset or first recognition during pregnancy

8. Diabetes—Symptoms General Hyperglycemia Glycosuria Polyuria Polydipsia
Dehydration
Type 1
Ketonuria
Acetone breath
Acidosis
Weight loss
Polyphagia

9. Type 1 Diabetes—Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

10. Type 1 Diabetes—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

11. Type 1 Diabetes—Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Marion J. Franz, 2002.

12. Metabolic Syndrome Characteristics Insulin resistance
Compensatory hyperinsulinemia
Abdominal obesity
Dyslipidemia (elevated TG, low HDL)
Hypertension
Risk factor for cardiovascular disease and glucose intolerance

13. Type 2 Diabetes—Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

14. Type 2 Diabetes—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

15. Type 2 Diabetes—Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, Updated by Marion J. Franz, 2002.

16. Methods of Diagnosis Fasting plasma glucose (FPG)
Casual plasma glucose (any time of day)
Oral glucose tolerance test (OGTT)

17. Criteria for Diagnosis

18. Who Should Be Screened for DM?
Persons >45 years; repeat every 3 years
Younger age; screened more frequently
Overweight (BMI >25)
First-degree relative with diabetes
High-risk ethnic population
Delivered baby >9 lb or diagnosed GDM
Hypertensive
HDL <35 mg/dl or TG >200
Prediabetes
Polycystic ovary syndrome

19. Pathophysiologic Complications of Type 1 Diabetes Mellitus
Ketoacidosis
Macrovascular disease
Microvascular disease
—Retinopathy
—Nephropathy
Neuropathy

20. Pathophysiologic Complications of Type 2 Diabetes Mellitus
Abnormal pattern of insulin secretion and action
Insulin resistance causing decreased cellular uptake of glucose
Increased gluconeogenesis and hepatic glucose release

21. Insulin Counterregulatory Hormones
Glucagon
Epinephrine (adrenaline)
Norepinephrine
Cortisol
Growth hormone

22. Diabetes—Treatment Goals
FPG 90—130 mg/dl
Hemoglobin A1c <7%

23. Oral Glucose-Lowering Medications
Drugs, administered orally, that are used to control or lower blood glucose levels, including first- and second-generation sulfonylureas, nonsulfonylurea secretagogues, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones

24. Oral Glucose-Lowering Medications—cont’d
Sulfonylureas
—Stimulate insulin secretion from beta cells
Meglitinide
—Stimulates insulin secretion from beta cells
Biguanide
—Decreases hepatic glucose production and increases insulin secretion
Thiazolidinediones
—Improve peripheral insulin sensitivity
Alpha glucosidase inhibitor
—Delays carbohydrate absorption

25. Action Times of Human Insulin Regimens
Onset
Peak
Duration
Rapid acting
(Lispro, Aspart)
<15 min
0.5–1.5 hr
2–4 hr
Short acting
(Regular)
0.5–1 hr
2–3 hr
3–6 hr
Intermediate
(NPH)
6–10 hr
10–16 hr
Long acting
(Ultralente)
18–20 hr
Mixtures
Dual

26. Estimating Minimum Energy Requirements for Youth
Base energy requirements on food and nutrition assessment
Validate energy needs
Toddlers

27. Diabetes Prevention Moderate weight loss (5%–7% body weight)
Regular physical activity
Low-fat diet (30% of energy intake)
Structured programs with regular participant contact

28. Types of Hypoglycemia Postprandial hypoglycemia
Alimentary hyperinsulinemia
Idiopathic reactive hypoglycemia
Fasting hypoglycemia
Factitious hypoglycemia

29. Goals of Medical Nutrition Therapy for Diabetes
Maintenance of as near normal BG levels as possible, by balancing food, medication, and physical activity
Achievement of optimal serum lipid levels
Provision of adequate calories for maintaining or attaining reasonable weight in adults, normal growth/development in children and adolescents, increased metabolic needs in pregnancy and lactation, or recovery from catabolic illnesses

30. Goals of Medical Nutrition Therapy for Diabetes—cont’d
Prevention and treatment of the acute or chronic complications of diabetes
Improvement of overall health through optimal nutrition using the Dietary Guidelines for Americans and the Food Guide Pyramid

31. Basic Strategies for Type 1 Diabetes
Meal plan should be based on assessment of patients usual food intake.
Integrate insulin therapy into the usual eating and exercise patterns.
Conventional therapy requires eating at consistent times synchronized with the action of insulin.
Intensified therapy allows more flexibility in timing and amount of food eaten.

32. Basic Strategies for Type 2 Diabetes
Encourage weight loss.
Moderate calorie restriction (250–500 kcal/day less) is associated with improved control independent of weight loss.
Spread nutrient intake, especially carbohydrate (CHO) throughout the day.
Encourage physical activity.
Decrease fat intake.
Monitor BG, and add medications if needed.

33. Food Guide Pyramid
Use basic guide
Use diabetes-specific guide

34. Recommendations for Weight Management
Make permanent changes in eating behavior.
Eat regularly.
Slow, gradual weight loss is best.
Choose lower-fat foods.
Incorporate regular physical activity.

35. Protein Provides 4 kcal/g 10% to 20% of total kcal
0.8 g/kg (note: this is the RDA for the general population) is recommended for clients with microalbuminuria. This is feasible with regular foods.
Once GFR begins to fall, some recommend 0.6 g/kg; this will likely require special low- protein foods and nutrition deficiency is possible.
Animal vs plant

36. Fat
Provides 9 kcal/g
General recommendation of <30% of total kcal and saturated fat <10% of total calories applies to people with DM who have normal lipid levels and a reasonable body weight.
If client is obese or has elevated lipid levels, further reduction combined with physical activity should be considered.
If LDL is primary problem, use the NCEP Step II diet (saturated fat <7% of total calories).

37. Carbohydrate Provides 4 kcal/g
Total carbohydrate consumed is more important than the source of the carbohydrate.
Daily total and distribution should be individualized and based on each client’s habits and blood glucose and lipid goals.

38. Action of Insulin on Carbohydrate, Protein, and Fat Metabolism

39. Sucrose
Numerous studies in which sucrose was substituted for starch found no adverse effect on glycemia.
Sucrose and sucrose-containing foods must be substituted for other carbohydrates and not simply added to the meal plan.
Still important to recommend caution because foods containing sucrose generally contain minor amounts of vitamins and minerals and tend to be higher in fat

40. Nutritive Sweeteners
Include fructose, honey, corn syrup,molasses, fruit juice, dextrose, maltose, mannitol, sorbitol, xylitol, and hydrogenated starch hydrosylates as well as sucrose
Research has shown no significant advantage or disadvantage of any of these over sucrose.
Large amounts of fructose may increase cholesterol levels.
Sugar alcohols in large amounts cause osmotic diarrhea.

41. Nonnutritive Sweeteners
Include aspartame, acesulfame K, sucralose, and saccharin
All can be safely used by people with diabetes mellitus.
Average intake of aspartame is 2 to 4 mg/kg/day, whereas the ADI is 50 mg/kg/day
ADI of acesulfame K is 15 mg/kg, which is the equivalent of a 60 kg person eating 36 teaspoons of sugar daily

42. Fiber
Same recommendation as the general public—20 to 35 g/day. Increase gradually and make sure they have adequate water intake.
Beneficial in maintaining normal GI function and treating or preventing several benign GI disorders and colon cancer
Although selected soluble fibers are capable of delaying glucose absorption, the effect on glycemia is probably insignificant.
Large amounts of soluble fiber may have a beneficial effect on serum lipids
Provide satiety value

43. Sodium
Association between hypertension (HTN) and both types of diabetes mellitus (DM)
Same intake as general population is recommended for otherwise healthy people with DM—less than 3000 mg/day
For people with mild HTN and diabetes— should have less than 2400 mg/day
For people with more serious HTN or edematous clients with nephropathy recommend 2000 mg/day or less

44. Lipid Goals Cholesterol <200 mg/dl LDL cholesterol <100 mg/dl
HDL cholesterol
Men >45 mg/dl
Women >55 mg/dl
Triglycerides <150 mg/dl

45. Blood Pressure Goals
Systolic <130 mm Hg
Diastolic <80 mm Hg

46. Alcohol
In a fasting state ETOH may produce hypoglycemia, and this effect can persist for 8 to 12 hours after the last drink.
Can’t be converted to glucose; inhibits gluconeogenesis

47. Alcohol Guidelines for Insulin Users
Limit to no more than two drinks per day
Drink only with food
Do not cut back on the amount of food eaten..
Abstain if history of ETOH abuse and during pregnancy or lactation or if there are possible interactions with other medications

48. Alcohol Guidelines for Noninsulin Users
Substitute for fat calories
Limit to promote weight loss or maintenance
Limit if triglycerides are elevated
Abstain if history of ETOH abuse and during pregnancy or lactation, or if there are possible interactions with other medications

49. Micronutrients
Vitamin/mineral needs of people with diabetes who are healthy appear to be adequately met by the RDAs.
Those who may need supplementation include those on extreme weight-reducing diets, strict vegetarians, the elderly, pregnant or lactating women, clients with malabsorption disorders, congestive heart failure (CHF) or myocardial infarction (MI)
Chromium and magnesium are beneficial only if the client is deficient.

50. Food Adjustments for Special Situations
Illness
Exercise
Hypoglycemia
Pregnancy
Ethnic or cultural differences

51. Four-Pronged Approach to Diabetes Medical Nutrition Therapy
Comprehensive nutrition assessment
Set goals with the client
Nutrition intervention
Evaluation

52. Nutrition Intervention
Dietary Guidelines for Americans
Guide to good eating
Food Guide Pyramid
The first step in diabetes meal planning
Healthy food choices
Healthy eating
Single-topic diabetes resources
Individualized menus
Month of meals
Exchange lists for meal planning
CHO counting
Calorie counting
Fat counting