1. Putting Diabetes Nutrition Recommendations into Practice Ann Albright, PhD, RD Director, Division of Diabetes Translation The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

2. Why Eat Well and Be Active? Feel good Have fun Have energy Focus and concentration Healthy Others…..

3. Food is Very Personal Celebrate with food Comfort with food Experience pleasure Combat boredom

4. Lots of Different “Diets”

5. ADA Nutrition Recommendations Goal of the recommendations is to make people with diabetes and health care providers aware of beneficial nutrition interventions Diabetes Care, 29:2140-2157, 2006

6. Key Updates Organizing recommendations by prevention level – primary, secondary, tertiary Increasing emphasis on energy balance and obesity Increasing emphasis on the effectiveness of MNT in preventing and controlling diabetes

7. Key Updates Reducing the recommendation for intake of saturated fatty acids to < 7% and minimizing intake of trans-fatty acids Addressing issues related to the type and amount of carbohydrate in preventing and controlling diabetes

8. Tailoring Implementation The recommendations are flexible with emphasis on achieving desired health and quality of life goals Translating the recommendations into practice involves considering the whole person – life situation, personal preferences and attitudes, and resources

9. Goals of MNT Achieve and maintain –Blood glucose levels in or close to normal range –Lipid profile that reduces risk for CVD –Blood pressure levels in or close to normal range Prevent or slow the development of complications Address individual nutrition needs Maintain the pleasure of eating

10. Overweight and Obesity Primary Prevention In overweight/obese individuals weight loss has been shown to improve insulin resistance – recommended for all such people who have diabetes or at risk for diabetes Structured programs that emphasize lifestyle changes –Reduced energy and fat –Regular physical activity –Regular participant contact

11. Overweight and Obesity Primary Prevention Restriction of CHO or fat calorie intake are equally effective in the short term (up to one year) Must monitor lipids and could worsen kidney function Most important determinant of weight loss is whether nutrition plan can be maintained

12. Overweight and Obesity Primary Prevention PA and behavior modification are important components of weight loss and are most important in maintenance of weight loss Weight loss medications may be considered and can help achieve a 5-10% wt loss combined with lifestyle modification Bariatric surgery may be considered with BMI > 35

13. Carbohydrate (CHO) Secondary Prevention CHO from fruits, vegetables, whole grains, legumes, and low-fat milk encouraged for good health Monitoring CHO, by CHO counting, exchanges, or experienced-based estimation, is a key strategy in glycemic control Glycemic index/load may provide additional modest benefit

14. Carbohydrate (CHO) Secondary Prevention Sucrose-containing foods can be substituted for other CHO in the meal plan or added if mediation adjustment is made Consume a variety of fiber containing foods (14g/1000kcal) Sugar alcohols and nonnutritive sweeteners safe when consumed within levels set by FDA

15. Dietary Fat and Cholesterol Secondary Prevention The CVD risk of those with diabetes is considered to be that of non-diabetic people with pre-existing CVD Limit saturated fat to < 7% of total calories Intake of trans fat should be minimized Limit cholesterol to < 200 mg/day Two or more servings of fish/week

16. Protein (PRO) Secondary Prevention For those with normal renal function, there is insufficient evidence that usual PRO intake (15-20% of energy) be modified PRO should not be used to treat acute or prevent nighttime hypoglycemia Long-term effects of PRO intake > 20% of calories on diabetes management and complications are unknown

17. Optimal Mix of Macronutrients The best mix of CHO, fat, and PRO appears to vary depending on the individual circumstances Dietary Reference Intakes (DRI) may be helpful –45-65% of total energy from CHO –20-35% from fat –10-35% from PRO Total calorie intake must be appropriate for wt management goals

18. Micronutrients No clear evidence of benefits from vitamin or mineral supplements in people with diabetes who do not have underlying deficiencies Routine supplementation with antioxidants (Vitamin C, E) is not advised due to lack of evidence and concern about long-term use Benefit from chromium has not been clearly shown

19. Alcohol If adults with diabetes choose to use alcohol, daily intake should be limited to moderate amount (1 drink or less per day for women and two drinks per day or less for men) To reduce nocturnal hypoglycemia in those on insulin or insulin secretagogues, alcohol should be consumed with food Alcohol alone has no acute effect on glucose

20. Microvascular Complications Tertiary Prevention Reduce PRO intake to 0.8-1.0 g/kg body wt/day in those with diabetes and the earlier stages of CKD and to 0.8 g/kg body wt/day in those with later stages of CKD MNT that favorably affects CVD risk factors may also help with microvascular complications

21. CVD Risk Tertiary Prevention In those with type 1 diabetes a sustained period of improved glycemic control decreased risk of CVD events – target A1C as close to normal without significant hypoglycemia Diets high in fruits, veges, whole grain and nuts For patients with symptomatic heart failure, dietary sodium < 2,000 mg/day

22. CVD Risk Tertiary Prevention In normotensive and hypertensive individuals, reduced sodium intake (<2300 mg/day) with a diet high in fruits, vegetables, and low-fat dairy lowers BP In most individuals, modest weight loss beneficially affects BP

23. Tools Those with prediabets or diabetes should receive an individualized nutrition plan Preferable to have dietitian develop plan with patient, but all members of the team need to know and support the patient in achieving MNT goals

24. Tools Diabetes food pyramid Plate method CHO counting Exchanges Ethnic food preferences Eating out Medicare benefits for diabetes self- management training and MNT See www.diabetes.org and www.ndep.nih.govwww.diabetes.orgwww.ndep.nih.gov

25. Problem Solving Cycle Define problem (prioritize) –What is keeping me from achieving my goals Think about it from different perspectives What do you want to achieve (establish goals) Possible solutions Implementation

26. Coping Skills Managing stress –Identify sources of stress (often not obvious) –How do you currently cope with stress (healthy/unhealthy) –Learn healthy ways to deal with stress How are you doing with managing your stress??