NUTRITIONAL CARE IN DM

Nutrition department Medical school University of Sumatera Utara

Epidemic Type 2 Diabetes and the Hidden IGT Epidemic: 2004

97 million known cases

Epidemic Type 2 Diabetes and the Hidden IGT Epidemic: 2004

97 million known cases 97 million undiagnosed cases

Epidemic Type 2 Diabetes and the Hidden IGT Epidemic: 2004

97 million known cases 97 million undiagnosed cases,

314 million persons with Impaired Glucose Tolerance

Epidemic Type 2 Diabetes and the Hidden IGT Epidemic: 2004

. . . and the cardiovascular disease epidemic to follow through the Metabolic Syndrome. . .

MNT is integral to total diabetes care & management Requires a coordinated team effort MNT requires an individual approach & effective nutrition self-management education

Goals of MNT for DM

Goals of MNT that apply to all persons
with diabetes
1.

Attain & maintain optimal metabolic outcomes including :

- blood glucose levels in the normal range or as close to normal as is safely possible to prevent or reduce risk or complications of diabetes - A lipid & lipoprotein profile that reduces risk for CV disease - Blood pressure levels that reduce the risk for vascular disease

2.

3. 4.

Prevent & treat the chronic complications : Modify nutrient intake as appropriate for the prevention and treatment of obesity, CV disease, hypertension & nephropathy Improve health through healthy food choices & physical activity Address individual nutritional needs, taking into consideration personal & cultural preferences & lifestyle while respecting the individuals needs & willingness to change

Goals of nutrition therapy that apply to specific situations

1.

2.

3.

For youth with type 1 DM, provide adequate energy to ensure normal growth and development; integrate insulin regimen into usual eating & exercise habits For youth with type 2 DM, facilitate changes in eating and exercise habits that reduce insulin resistance and improve metabolic status For pregnant & lactating women, provide adequate energy and nutrients needed for successful outcomes

4.

5.

6.

For older adults, provide for the nutritional needs of an aging individual For individuals treated with insulin or insulin secretagogues, provide information on prevention and treatment of hypoglycemia and exercise-related blood glucose problems and how to manage acute illness For individuals at risk for DM, decreased risk by increasing physical activity and promoting food choices that facilitate moderate weight loss or at least prevent weight gain

Prioritizing nutrition therapy for type 2 DM

To adopt lifestyle strategies that improve the associated metabolic abnormalities of glycemia, dyslipidemia & hypertension Lifestyle strategies independent of weight loss that can improve glycemia include reducing energy intake, monitoring CH servings, limiting consumption of saturated fats and increasing physical activity

carbohydrate

Total amount of carbohydrate is more important than the source (starch or sugar) The 1st priority for food and meal planning is the total amount of carbohydrate

Carbohydrate and Diabetes

Include foods containing carbohydrate from whole grains, fruits, vegetables and low-fat milk

Carbohydrates
Simple Complex

Fiber

Severe restriction of dietary carb is not indicated Within the total caloric recommendation carb should be 45 60% of total energy intake

Carbohydrate and Diabetes

Consistency in carbohydrate intake is important from day to day For people taking a fixed dose of insulin Insulin should be adjusted based on amount of carbohydrate at meals For people on varying doses at meal times

Carbohydrate and Diabetes

Several things affect how much blood glucose increases after eating :

amount of carbohydrate type of sugar or starch cooking and food processing food form other foods in the meal that slow digestion

Carbohydrate and Diabetes

Limited amounts of sugar or foods containing sugar can be used without affecting blood glucose

when substituted for other carbohydrates at the meal

Large amounts of sugar-containing foods are not recommended

Sweeteners and Diabetes

Fructose use should be avoided because of possible adverse effects on blood lipids Naturally occurring fructose in foods such as fruits does not need to be restricted Sugar alcohol (lower glycemic response) not non-caloric All FDA-approved nonnutritive sweeteners are safe for people with diabetes when consumed within recommended levels

Carbohydrate and Diabetes

Fiber: Fiber is encouraged for everyone: 20-35 grams/day Good sources of fiber:

Whole grain cereals Fruits Vegetables Beans and peas

Carbohydrate and Diabetes

Fiber: Only large amounts (50 grams/day) have shown beneficial effect on glycemia, insulinemia and lipemia

Primarily soluble fiber (barley, oatmeal, beans, apples, broccoli) Side effects make this difficult for many people

Soluble fiber effects in diabetes : - inhibiting starch hydrolysis & glucose absorption - delayed gastric emptying - reduced fasting glucose levels by improving insulin sensitivity - promoting satiety

Protein and Diabetes

The recommendation in the absence of renal insufficiency is (0.8g/kg BW/day) 10 20% of total energy intake Intakes >20% higher incidence of albuminuria Protein intake should be reduced in the setting of renal insufficiency

Dietary Fat and Diabetes

Primary goal - Lower LDL cholesterol by: Eating less saturated fat and cholesterol Eating less trans fats

Dietary Fat and Diabetes

Choose monounsaturated fat in place of saturated:

olive oil, canola oil, peanut oil, olives, avocados, nuts

Dietary Fat and Diabetes

Recommendation : 20-35% total calorie Eat less total fat Low-fat diets can help: with weight loss improve cholesterol and other fats

Weight Loss and Diabetes

A small amount of weight loss can: improve insulin resistance lower blood glucose improve blood cholesterol reduce blood pressure

Weight Loss and Diabetes

Successful weight loss usually requires: a structured weight loss program education reduced fat and calories regular physical activity frequent follow-up

Vitamins and Minerals and Diabetes

Vitamins and minerals supplementation is of dubious benefit except in cases of documented deficiency High doses of vitamin and mineral supplements can be toxic Intake of vitamin & minerals should be encourage through natural food sources, most notably vegetables & fruits

Regular meals based on carbohydrate

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Dietary Guidelines

Eat a diet low in saturated and total fat. Eat a diet moderate in sodium and sugar. Eat 5 or more fruits and vegetables a day. Choose a diet rich in whole grains.

Dietary Guidelines

Eat at the same time everyday , at least within 1 hour of regular time. Eat about the same amount of carbohydrate with each meal.

Dietary recommendation
Carbohydrate Dietary fiber Total fat
saturated PUFA (esp. n3) MUFA trans fat

45-60% total energy 14g/1000 kal 20-35% total energy

< 10%total energy 7-10% total energy 15-20% total energy as low as possible

Cholesterol Protein Energy

<300 mg/day 10-20% total energy maintain BMI < 25kg/m2

Essential self-management nutrition education skill

Sources of carb, protein & fat Understanding nutrition labels Modification of fat intake Use of blood glucose monitoring data for problem solving related to food choices and physical activity option Grocery shopping guidelines Guidelines for eating out : restaurant, etc

Essential self-management nutrition education skill

Snack choices Use of sugar-containing foods and nonnutritive sweeteners Behavior modification techniques Vitamin, mineral and botanical supplements

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