MNT for Diabetes PDF

MNT for Diabetes FNES 366 MNT for Diabetes Krause’s Food and the Nutrition Care Process American Diabetes Association (ADA) https://professional.diabetes.org/meetings/journals Allison Charny, MSEd, RD, CDCES, CDN Overview ◼ Background ◼ Definitions, Pathophysiology, Medical Diagn...

MNT for Diabetes FNES 366 MNT for Diabetes Krause’s Food and the Nutrition Care Process American Diabetes Association (ADA) https://professional.diabetes.org/meetings/journals Allison Charny, MSEd, RD, CDCES, CDN Overview ◼ Background ◼ Definitions, Pathophysiology, Medical Diagnosis ◼ Complications ◼ Acute, Chronic ◼ Management ◼ Nutrition, Medications, Exercise, Monitoring, Education ◼ Nutrition Care Process Background ◼ Definition ◼ Prevalence ◼ Basic Pathophysiology ◼ Categories of DM ◼ Screening ◼ Medical Diagnosis ◼ Metabolic Syndrome What is Diabetes? ◼ Metabolic disease ◼ group of diseases characterized by high blood glucose (BG) concentrations ◼ many forms of damage to body organs ◼ eyes, kidneys, nerves, heart and blood vessels Incidence and Prevalence USA 2020 ◼ Public health nightmare ◼ 34 million diabetes / 10% population ◼ 88 million prediabetes / 35% population ◼ Increased morbidity and mortality ◼ Direct and indirect costs $327 billion in 2017* https://www.cdc.gov/diabetes/data/statistics/statistics-report.html *https://www.ncbi.nlm.nih.gov/pubmed/29567642  Age-Adjusted Prevalence of Diagnosed Diabetes Among US Adults 2015 Missing data 45 years; repeat every 3 yrs ◼ Younger age and more frequently if: ◼ Overweight (BMI >25) ◼ Decreased exercise ◼ First-degree relative with diabetes ◼ High-risk ethnic population ◼ Delivered baby >9 lb or diagnosed GDM ◼ Hypertensive ◼ HDL 250 ◼ Prediabetes ◼ PCOS or acanthosis nigricans Diagnosis of DM Two of the following confirm DM dx: 1. Symptoms + casual glucose > 200 mg/dl 2. FPG > 126 mg/dl 3. 2 hr PG > 200mg/dl after a 75g glu load (OGTT) 4. A1C > 6.5% Apply your knowledge A person with type ___ DM is over- producing insulin in attempt to counter insulin resistance. Upon review of the functions of insulin this person’s fat stores will likely: Increase, decrease remain the same? GDM ◼ Glu intolerance DURING pregnancy ◼ 7% of all pregnant women ◼ Occurs in 2nd and 3rd trimester ◼ After delivery: ◼ 90% glu normalizes ◼ 5-10% have type 2 ◼ ~35-60% develop type 2 in 5-10 years ◼ All women screened between 24th and 28th weeks ◼ High risk women screened for DM in 1st visit Dx of GDM ◼ Non-fasting screen: if 50 g glu 1 hr > 140 then 3 hr 100 g OGTT. Dx if 2 hr > 140 ◼ OGTT. Take fasting level, then give 75 g glu load. Dx of GDM if any values > ◼ Fasting 92 ◼ 1hr 180 ◼ 2hr 153  Apply your knowledge 5-10% of women diagnosed with GDM actually have T2DM - - they had T2DM prior to becoming pregnant but did not know of their DM What are the implications of this to the developing fetus? What can we do as healthcare practitioners to address this problem? Prediabetes ◼ IFG: FPG 100 mg/dl – 125 mg/dl ◼ IGT: 2 hr plasma glu 140 mg/dl to 199 mg/dl ◼ A1C: 5.7%-6.4% ◼ If IFG or IGT then prediabetes, risk factor for future diabetes and CVD  Apply your knowledge A client contacts you for help with diet and exercise ◼ He is a 47 yo M, no hx of DM, BMI of 32, with increased appetite and weight gain ◼ He states his “sugar was high” during a visit to his MD this AM (non-fasting casual glucose 224 mg/dl) Might he have prediabetes? DM? GDM? Will you treat him? Metabolic Syndrome From ATP III: ◼ Grouping of risk factors associated with insulin resistance and then greater risk for CVD ◼ 3 of 5 needed to diagnose Metabolic Syndrome: ◼ 1. abdominal obesity (waist circumf) >40”M; >35”F ◼ 2. Trig > 150 mg/dl or on drug treatment ◼ 3. HDL < 40 mg/dl M; < 50 F or on drug treatment ◼ 4. BP > 130/85 or on drug treatment ◼ 5. Fasting glucose > 100 mg/dl or on drug treatment Complications ◼ Acute ◼ Chronic  Complications: Acute Hyperglycemia: BG > 250 ◼ Diabetic ketoacidosis (DKA) ◼ Lack of insulin, fat used for energy, ketones produced resulting in acidosis ◼ Glu > 250 and urine glucose and ketones, dehydration, acetone breath, kussmaul breathing ◼ Hyperglycemic Hyperosmolar State (HHS) ◼ Glu > 400-2800 mg/dl, ↑↑dehydration, NO ketones ◼ Typically in elderly with type 2 DM ◼ Somogyi Effect: “rebound” hyperglycemia due to ↑ insulin ◼ Dawn Phenomenon: hyperglycemia between 4-8 AM due to effect of growth hormone Complications: Acute Hypoglycemia: BG < 70 ◼ Causes: (Krause Box 29-5) ◼ Symptoms: ◼ Initial: anxiety, sweating, palpitations, shakiness, hunger ◼ Later: fatigue, confusion, unconsciousness ◼ Treatment: “rule of 15’s” (Box 29-6) ◼ 15 g fast-acting CHO ◼ glucose, sucrose ◼ Low fiber ◼ Low fat ◼ Wait ~15 min, test ◼ Repeat as needed ◼ Meal Apply your knowledge ◼ Your client (on insulin) is exercising; near the end of the session he states he “doesn’t feel well” (nauseous, shaky) ◼ What would you do / recommend? Complications: Acute Sick Day Management ◼ fever, vomiting, diarrhea ◼ 1. Continue medications ◼ 2. SMBG and urine ketones 4x/day ◼ 3. Fluids 1-2 Tbsp/15-30 minutes ◼ 4. Liquids, soft CHO, 10-15g/1-2hr ◼ 5. Danger: BG > 250 and ketones Apply your knowledge ◼ You are teaching your patient nutrition management of DM ◼ She tells you she had a “bad stomach virus”, fever, vomiting, could not eat ◼ Afraid of low glucose she stopped her diabetes medication ◼ Was this the best thing do?  Complications: Chronic ◼ Neuropathy ◼ Peripheral: nerves of hands, feet affected ◼ Autonomic: nerve functions of various organs affected ◼ ie: silent ischemia, impotence, gastroparesis ◼ Microvascular ◼ Nephropathy ◼ Retinopathy ◼ Nonprolifererative, preproliferative, proliferative ◼ Macrovascular ◼ CHD, Cerebrovascular Disease, PVD  Treatment Goals ◼ Hemoglobin A1C5 g/serving)  Sweeteners ◼ Sucrose in food plan should be substituted for other carbohydrate sources or covered with insulin or glucose-lowering medications ◼ Reduces intake of healthy foods or increases calorie intake ◼ Fructose has no benefit over sucrose ◼ Reduced calorie sweeteners: sugar alcohols (may cause diarrhea) and tagatose ◼ Nonnutritive sweeteners: saccharin, aspartame, neotame, acesulfame potassium, and sucralose ◼ ADI, GRAS Protein ◼ Does not affect blood glucose levels in well-controlled diabetes ◼ Does not slow absorption of carbohydrate ◼ Recommend usual protein intake (15% to 20% of kcals)  Dietary Fat ◼ People with diabetes have similar risk to those with past history of CVD ◼ Recommend (same as for general population (TLC): ◼ Total fat ~25% to 35% of total kcals ◼ Saturated fatty acids reduced (substitute with PUFA and MUFA) ◼ Minimize/eliminate trans fat ◼ Include polyunsaturated fatty acids, esp omega-3 ◼ Plant sterol and stanols? Inhibit dietary cholesterol Alcohol ◼ Abstain if history of abuse, pregnancy, medical problems ◼ Moderate1 alcohol intake with food has minimal effect on glucose and insulin ◼ Excessive alcohol (3+ drinks/day) contributes to hyperglycemia ◼ Can cause hypoglycemia with insulin and insulin secretagogues 1F:1 drink/day; M:2 drinks/day; 1 drink = 1 oz liquor, 5 oz wine, 12 oz beer Micronutrients ◼ No clear evidence of benefits of supplements ◼ High-risk groups ◼ Chromium possibly beneficial ◼ Cinnamon, ALA, berberine promising; consider other interactions with other meds Tools for Nutrition Intervention ◼ Plate Method ◼ http://www.uwhealth.org/files/uwhealth/docs/pdf/diabetes_platemetho d_withpics.pdf ◼ Exchange Lists for Meal Planning ◼ CHO Counting ◼ http://www.diabetes.org/food-and-fitness/food/planning-meals/carb- counting/ ◼ http://tracker.diabetes.org/ ADA/AND Exchange Lists Appendix 18 ◼ System of guidance and management of nutrient intake ◼ AKA Choose Your Foods: Food Lists for Diabetes ◼ Based on division of foods into lists according to nutrient content of the food ◼ Foods on each list have the same calories, CHO, pro, fat as other foods on the list ◼ Portion may vary; each portion is an exchange Exchange Lists ◼ Assists with variety, flexibility, portion control, timing of meals ◼ Weighing and measuring of food is important at least initially ◼ Provided considering a person’s lifestyle ADA Exchange Lists ◼ Carbohydrate ◼ Fat ◼ Starch ◼ Polyunsaturated ◼ Milk ◼ Monounsaturated ◼ Fruit ◼ Saturated ◼ Other ◼ Veg ◼ Free foods ◼ Meat ◼ Foods for moderate ◼ Lean intake, daily ◼ Medium fat ◼ High fat ◼ Combination foods ◼ Plant protein  ADA Exchange Values Know this table! (T 30-8) Group CHO Pro Fat Cal Carbohydrate Starch 15 0-3 0-1 80 Fruit 15 - - 60 Milk Skim, 1% 12 8 0-3 100 2% 12 8 5 120 Whole 12 8 8 150 Other CHO 15 varies varies varies Vegetables 5 2 - 25 Meat Lean - 7 0-1 45 Medium fat - 7 3 75 High fat - 7 5 100 Plant pro varies 7 varies varies Fat - - 5 45 ADA Exchanges Meal Plan Form ◼ EXCHANGE LISTS FOR MEAL PLANNING _______ Calories ◼ %CHO %Pro %Fat ◼ cal cal cal ◼ g g g Total Kcal______ ◼ EXCHANGES Menu CHOg PROg FATg kcal ◼ MORNING MEAL ◼ ____ CHO group ◼ ____ Starch ______________________________________________________ ◼ ____ Fruit ______________________________________________________ ◼ ____ Milk_____ ______________________________________________________ ◼ ____ Meat group__ ______________________________________________________ ◼ ____ Fat group ___ ______________________________________________________ ◼ MORNING SNACK ◼ NOON MEAL ◼ ____ CHO group ◼ ____ Starch ______________________________________________________ ◼ ____ Fruit ______________________________________________________ ◼ ____ Milk_____ ______________________________________________________ ◼ ____ Veg ______________________________________________________ ◼ ____ Meat group__ ______________________________________________________ ◼ ____ Fat group ___ ______________________________________________________ ◼ AFTERNOON SNACK ◼ EVENING MEAL ◼ ____ CHO group ◼ ____ Starch ______________________________________________________ ◼ ____ Fruit ______________________________________________________ ◼ ____ Milk ______ ______________________________________________________ ◼ ____ Veg ______________________________________________________ ◼ ____ Meat group__ ______________________________________________________ ◼ ____ Fat group ___ ______________________________________________________ ◼ BEDTIME SNACK Meal Planning 1. Calculate kcal needs 2. Distribute kcal and grams based on individualized macronutrient percent 3. Create meal plan based on guidelines for healthy eating using Exchanges or other methods 4. Provide sample meal plan using chosen method Meal Planning: Example ◼ 45 yo F, 5’9”, 145#, 30 kcal/kg = 2000 kcal/day ◼ 50% CHO / 20% pro / 30% fat ◼ See 1900-2000 kcal sample meal plan Krause Fig 29-5  ADA Exchange Lists Example ◼ EXCHANGE LISTS FOR MEAL PLANNING ◼ 2400 Calories 50% CHO 25% Pro 25% Fat ◼ 1200 cal 600 cal 600 cal 2400 cal total ◼ 300 g 150 g 67 g ◼ EXCHANGES Menu CHOg PROg FATg CALORIES ◼ MORNING MEAL ◼ __2__ CHO group ◼ _1__ Starch 1 Slice WW Bread 15 3 1 80 ◼ ____ Fruit ◼ _1__ Milk 1 cup skim milk 12 8 1-2 90 ◼ _1__ Meat group 1 egg 75 75 ◼ _1__ Fat group 1 tsp non-trans fat spread 5 45 ◼ MORNING SNACK ◼ NOON MEAL ◼ ____ CHO group ◼ ____ Starch ◼ ____ Fruit ◼ ____ Milk ◼ ____ Veg ◼ ____ Meat group ◼ ____ Fat group ◼ AFTERNOON SNACK ◼ EVENING MEAL ◼ ____ CHO group ◼ ____ Starch ◼ ____ Fruit ◼ ____ Milk ◼ ____ Veg ◼ ____ Meat group ◼ ____ Fat group ◼ BEDTIME SNACK CHO Counting ◼ Rationale ◼ Flexibility in food choices ◼ Improved glucose control ◼ Requires more self monitoring and decisions ◼ Principles ◼ Total rather than type of CHO emphasized ◼ Fat and protein have minimal effect on glucose ◼ Careful of weight gain! ◼ Used for all types of DM ◼ Healthy eating is “bottom-line” ◼ Progression: Level 1, 2, 3 CHO Counting: Level 1 EMPHASIS: Consistent CHO at meals and snacks ◼ Teach what foods contain CHO and how much ◼ Use food records to determine usual CHO intake at meals and snacks ◼ Consider ◼ Usual CHO intake and distribution ◼ Nutrition goals ◼ Medications ◼ Physical activity ◼ Evaluate effectiveness of CHO counting plan with SMBG records CHO Counting: Level 2 EMPHASIS: Relationship among food, activity and blood glucose level – pattern management ◼ Build on Level 1 ◼ Use a Diabetes Diary ◼ Skills needed: ◼ Math ◼ Ability to use resources ◼ Understand role of CHO, protein, fat ◼ Pattern management CHO Counting: Level 3 EMPHASIS: Use insulin CHO ratios Prerequisites: ◼ Master Level 1 and 2 ◼ Intensive insulin therapy (MDI, CSII) ◼ Able to self adjust and supplement insulin ◼ Food, blood glucose and insulin records kept for 1-2 weeks to find insulin to CHO ratio CHO Counting: Level 3 ◼ Insulin to CHO ratio ◼ Based on matching fast acting CHO to fast acting insulin ◼ Individualized based on patient’s weight and food records - ◼ Food intake ◼ Activity CHO Counting: Level 3 ◼ Two Methods of CHO Counting Level 3 ◼ Method 1: using CHO grams*** ◼ Method 2: using CHO choices CHO Counting: Level 3 Method 1: Using CHO Grams ◼ Step 1 Determine I:C ratio g CHO consistently consumed at meal #u of fast-acting insulin needed to meet glucose goals Example: 60 g consistently consumed = 10 I:C ratio 6 u needed to meet target range ◼ Step 2 Adjust for ↑ or ↓ in CHO grams g CHO consumed I:C ratio Example: 80g / 10 = 8 u insulin needed to cover 80 g CHO CHO Counting: Level 3 Method 2: Using CHO Choices ◼ Step 1 Determine I:C ratio #u fast-acting insulin needed to meet glucose goals # CHO choices consistently consumed ◼ Step 2 Adjust for ↑ or ↓ in CHO choices # CHO choices X (units / CHO choice ratio) Example: 9u = 1.5 u / CHO choice 6 CHO choices If 8 CHO choices meal: 8 x 1.5 = 12 u needed to cover 8 CHO choices Medications ◼ Oral Meds ◼ Adjunctive Injectable Meds ◼ Insulins Target Organs of Glucose Lowering Medications  Oral Glucose-Lowering Medications Class Brand Action Side-effects Biguanides Metformin (Glucophage) Decrease hepatic N/V, diarrhea, glucose gas ◼ Decrease Hepatic Glucose production Sufonylureas ◼ Biguanides Glipizide (Glucotrol) Insulin secretagogue Hypoglycemia Glyburide (Glynase) (pancreas) ◼ Insulin Secretagogues (hypoglycemia) Glimeparide (Amaryl) ◼ Sulfonylureas ◼ Glinides-Meglitinides Meglitinides (less Repaglinide potent secretagogue) (Prandin) Insulin secretagogue Hypoglycemia ◼ Insulin Sensitizers (nausea, Nateglinide (Starlix) loss (pancreas) of appetite) ◼ Thiazolidinediones (TZDs) Thizolidinediones Pioglitizone (Actos) Insulin sensitizer at Weight gain, ◼ Alpha-glucosidase inhibitors (diarrhea, gas) (TZDs) Rosiglitizone (Avandia) the muscle fluid retention ◼ DPP4 Inhibitors Alpha-glucosidase ◼ Sitagliptin Arcabose (Precose) Slows intestinal CHO Diarrhea, gas, inhibitors Miglitol (Glyset) absorption nausea ◼ SGLT2 Inhibitors Sodium-glucose ◼ Canagliflozin Canafligozin (Invokana) Decrease glucose Bladder transport inhibitors Empaglifloxin (Jardiance) reabsorption in the infection ◼ GLP-1 Receptor Agonoists (N/V/D) (SGLT) kidney ◼ Exanitide Dipeptidyl peptidase Sitigliptin (Januvia) Increase intestinal Insignificant Pancreas must produce insulin for oral med use  Adjunctive Injectable Agents Class Brand Action Side-effects GLP-1 Exanatide Activates GLP-1 (glucagon-like-peptide N/V receptor ◼ GLP-1 Receptor (Byetta) Agonist (incretin) receptors Byetta (Incretin mimetic). agonist Liraglutide For T2DM on oral Enhance insulin agents production prior to insulin need. (Victoza) Suppress glucagon secretion (Nausea) Reduce food intake Dulaglutide ◼ Mimics hormone (Tulicity) GLP-1 (glucagon-like-peptide; incretin) (For T2DM) ◼ Enhance insulin production ◼ Suppress glucagon secretion ◼ Reduce food intake Amylin ◼ Symlin (Amylin Pramlintide analog). Activates amylin For T1DM and T2DMN/V receptors on mimetics insulin, unable (Symlin) to achieve Slows BG release of goals. food (Nausea) into the intestine ◼ Aids in BG regulation Suppress glucagon ◼ Slows release of food into the intestine Induce satiety ◼ Suppress glucagon For TIDM and T2DM ◼ Induce satiety Mechanism of Incretins (GLP-1 and GIP) and DPP-4 Enzyme  Insulin Action Times Insulin Onse Peak Duration t Rapid acting 250 ◼ Secretagogues increase hypoglycemia risk ◼ Caution with CVD, retinopathy, neuropathy ◼ Benefits ◼ Wt control, insulin sensitivity, lower CVD risk factors, lower circulating insulin, higher glucagon ◼ Glu improves for ~ 48 hours after exercise Potential Problems with Exercise ◼ Hypoglycemia if using insulin or insulin secretagogues ◼ Due to increased insulin sensitivity ◼ Hyperglycemia ◼ Due to greater than normal increase in counterregulatory hormones ◼ Exercise guidelines ◼ Frequent blood glucose monitoring before, during and after exercise ◼ Reduce insulin or ingest carbohydrate Exercise & Carbohydrate with Insulin or Insulin Secretagogue ◼ Add 15 g carbohydrate for every 30 to 60 minutes of activity (depending on intensity) ◼ No adjustment for exercise