Medical Nutrition Therapy For Diabetes Mellitus PDF

MEDICAL NUTRITION THERAPHY FOR DIABETES MELLITUS Report by: Group 5  WHAT IS DIABETES MELLITUS? Diabetes mellitus is a condition where your body can't properly regulate blood sugar levels. This happens because your pancreas either doesn't produce enough insulin or your cells don't...

MEDICAL NUTRITION THERAPHY FOR DIABETES MELLITUS Report by: Group 5  WHAT IS DIABETES MELLITUS? Diabetes mellitus is a condition where your body can't properly regulate blood sugar levels. This happens because your pancreas either doesn't produce enough insulin or your cells don't respond to it properly. Insulin is a hormone that helps glucose (sugar) from food enter your cells for energy.Recognizing the problem posed by diabetes mellitus, the National DiabetesCommission was created by Republic Act 8191 in 1996  Based on the 2008 survey of FNRI-DOST, 4.8 % of Filipino adults (almost 5 per 100)had a fasting blood sugar (FBS) of>125 mg/dL. A rising mean fasting blood glucose leveland an increasing prevalence of hyperglycemia was noted peaking at age 50-59 years.Prevalence of impaired fasting glucose (IFG) is 2.7%. Hyperglycemia or high FBS levelincreased from 2003 (3.4%) to 2008 (4.8%) though the increase is not signifcant. Diabetes is regarded as a disease of multifactorial inheritance with genetics andenvironment playing a major role. Short sleep duration is associated with impairedglucose tolerance and an increased risk of DM. CLASSIFICATION AND DIAGNOSIS OF DIABETES The classification of diabetes includes four clinical classes: Type 1 diabetes mellitus results from β-cell destruction, usually leading toabsolute insulin deficiency Type 2 diabetes mellitus results from a progressive insulin secretory defect on thebackground of insulin resistance Other specific types of diabetes due to other causes, e.g., genetic defects in β-cellfunction, genetic defects in insulin action, diseases of the exocrine pancreas (suchas cystic fibrosis), drug or chemical-induced DM (such as in the treatment of AIDSor after organ transplantation) Gestational diabetes mellitus diagnosed during pregnancy Insulin, produced by the beta-cells of the pancreas is insufficient as in the case ofType 2 DM or is totally lacking because the beta-cells are damaged as in Type 1 DM  PATHOGENESIS OF DIABETES Diabetes develops due to two main issues: 1. Insulin Deficiency: In Type 1 diabetes, the body's immune system attacks and destroys the insulin-producing cells in the pancreas, leading to little or no insulin being made. 2. Insulin Resistance: In Type 2 diabetes, the body's cells (like muscle and fat cells) don't respond well to insulin, making it hard for glucose (sugar) to enter the cells. Because of these problems with insulin, glucose builds up in the blood and urine, which can cause various health issues. Sometimes, both low insulin production and insulin resistance occur together, making it hard to identify the main cause of high blood sugar levels. The presence of the following risk factors in a patient may increase the probability of developing diabetes: 1) obesity; 2) family history in a first degree relative; 3) delivered a baby greater than 9 pounds; or 4) has been diagnosed to have gestational diabetes or previously impaired glucose tolerance or impaired fasting glucose in the past. Because of multifactorial inheritance, everyone who has diabetes in the family must already prepare in preventing the onset of the disease.  TYPE 1 DIABETES Type 1 diabetes typically affects young, lean individuals and is caused by the immune system attacking the insulin-producing cells in the pancreas. As a result, these patients cannot produce insulin and need to take insulin from outside sources to survive. People with Type 1 diabetes often have a genetic tendency for the disease, and certain triggers (like viruses or toxins) can lead to the destruction of insulin-producing cells. As these cells continue to decline, the body produces less insulin, leading to high blood sugar levels. Without enough insulin, cells can't use sugar for energy, which can harm organs and shorten life expectancy by about 15 years. However, managing blood sugar levels well allows individuals to live healthy, active lives.  TYPE 2 DIABETES Type 2 diabetes, previously known as non-insulin dependent or adult-onset diabetes, is the most common type, making up 90-95% of diabetes cases. It usually develops after age 40, and many people may not realize they have it until serious symptoms or complications arise. The condition results from the body either not making enough insulin or not using it effectively. Three main issues contribute to high blood sugar levels: 1. The liver produces too much glucose. 2. The pancreas doesn't secrete enough insulin. 3. The body's muscles resist insulin.  TYPE 2 DIABETES People often experience a stage called impaired glucose tolerance before developing full diabetes. As insulin resistance increases, insulin secretion tends to decrease. If the pancreas can’t produce enough insulin to overcome resistance, glucose intolerance occurs. Risk factors for Type 2 diabetes include age and obesity. Many cases are underreported, especially among older individuals with other health issues. Obesity is a significant trigger for diabetes, leading to the term "diabesity." Common symptoms of Type 2 diabetes include dry mouth, nausea, blurred vision, and frequent infections. People with this type of diabetes often also have unhealthy cholesterol levels, contributing to a higher risk of heart disease.  GESTATIONAL DIABETES Gestational diabetes mellitus (GDM) is a condition where a pregnant woman experiences difficulty processing carbohydrates, leading to high blood sugar levels. It is usually diagnosed in the third trimester (around the 24th week of pregnancy) due to hormonal changes that create insulin resistance. During pregnancy, although women produce enough insulin, its effectiveness is reduced by hormones from the placenta, like estrogen and cortisol. As the placenta grows, more hormones are produced, increasing insulin resistance. While GDM often goes away after childbirth, women who experience it are at a higher risk of developing Type 2 diabetes later in life. Therefore, it's important for all pregnant women to be screened for GDM. GESTATIONAL DIABETES  METABOLISM IN DIABETES To better understand the metabolic changes that occur in diabetes, review carefully the metabolism of protein, fat, and carbohydrate. The glucose from dietary carbohydrate, protein and fat and liver glycogen, maintains a steady supply of glucose in the blood. Recall that carbohydrate, fat and protein when consumed is converted to glucose during the process of metabolism. In fat, a small portion, 10% (the glycerol portion) is converted to glucose while in protein, a fairly large portion (58%) is available for conversion to glucose. Carbohydrates are estimated to yield approximately 100%. Thus, carbohydrates present in the diet are largely responsible for absorbed glucose and food-induced increase in blood glucose concentration  ROLE OF INSULIN Insulin is a hormone that helps the body store energy after eating. It signals cells to take in nutrients like amino acids, glucose, and fatty acids, promoting the storage of proteins, carbohydrates, and fats, which lowers blood sugar levels. During fasting, insulin helps prevent excessive use of energy stores. It specifically promotes glucose use in muscles and the heart, increases blood flow to muscles, and reduces glucose release from the liver by suppressing another hormone called glucagon. Amylin, another hormone produced alongside insulin, also helps regulate blood sugar by slowing digestion and decreasing appetite. Together, insulin and amylin work to control glucose levels in the body.  CARBOHYDRATE METABOLISM In healthy individuals, blood glucose levels are normally maintained between 54-108 mg/dL (3-6 mmol/dL), with fasting levels often cited as 70-110 mg/dL. In people with uncontrolled diabetes, blood sugar levels rise because insulin is either absent or not working effectively. This prevents glucose from entering cells, leading to high blood sugar (hyperglycemia). When blood sugar exceeds about 160-180 mg/dL, excess glucose spills into the urine (glycosuria), causing energy loss and dehydration. As glucose leaves the body with urine, it also pulls water out, leading to increased urination (polyuria) and excessive thirst (polydipsia) due to dehydration.  FAT METABOLISM In diabetes, the synthesis of fatty acids decreases, leading to less fat formation (lipogenesis), while fat breakdown (lipolysis) increases. The liver's glycogen stores are depleted due to insufficient glycogen synthesis and glucose utilization. As a result, the body breaks down large amounts of fatty acids to meet energy needs. This process releases fatty acids that the liver converts into "ketone bodies" like acetoacetic acid and beta- hydroxybutyric acid, causing a buildup in the blood known as ketosis. This disrupts the body's acid-base balance and can lead to acidosis.  PROTEIN METABOLISM Accelerated breakdown of tissue protein also occurs in uncontrolled diabetes. It not only adds to the glucose level of the blood but increases the amount of nitrogen that must be excreted as a result of deamination. The catabolism of protein tissues is accompanied by the release of cellular potassium and its excretion in the urine. The following blood tests are highly useful in diabetes screening as well as monitoring control. Fasting Blood Sugar Test is made after extracting venous blood from the patient who has fasted for at least 12 hours. A fasting blood sugar (FBS) of more than 126 mg per 100 ml is indicative of diabetes. It is quite common among older persons; however, to have slightly elevated blood sugar levels without having diabetes. Glucose Tolerance Test - An oral glucose tolerance test (OGTT) measures how well a person processes glucose. It's used to diagnose diabetes or impaired glucose tolerance in those with a fasting blood sugar (FBS) between 100 and 125 mg/dL. The test involves fasting, then drinking a glucose solution (usually 75 g in 250 ml of water) and measuring blood sugar levels before and after consumption at 30 minutes, 1 hour, 2 hours, and 3 hours. The following blood tests are highly useful in diabetes screening as well as monitoring control. Glycosylated hemoglobin (HbA1c)- is a blood test that measures average blood sugar levels over the past 2-3 months. It's a key indicator of long- term blood sugar control in people with diabetes. Self-Monitoring Blood Glucose (SMBG) allows people with diabetes to check their blood sugar at home and adjust treatment accordingly. Regular monitoring and insulin therapy can reduce diabetes complications. Blood testing is more accurate than urine testing, as glucose spills into urine only above 180 mg/100 ml. SMBG helps identify low (hypoglycemia) and high (hyperglycemia) levels and, when used properly, maintains blood glucose between 70 and 140 mg/100 ml using a fingerprick and a meter with test strips. Urine examination can assess total volume, specific gravity, glucose, and fatty acids. A positive test for glycosuria is typically an indication of diabetes, though other conditions can also cause sugar in the urine, such as pentosuria, lactosuria in nursing mothers, alimentary glycosuria from enzyme deficiencies, and renal glycosuria due to reduced reabsorption by the kidneys. Glucose concentration in urine can be tested using various methods, including colorimetric techniques with paper indicators, sticks, powders, or tablets. Urine is checked before meals and at bedtime, with some practitioners suggesting the double void method, where the first urine is discarded, and the second sample is tested to avoid measuring concentrated urine. The presence of fatty acids (ketone bodies) in urine indicates incomplete fat oxidation (ketonuria), which is serious and requires immediate dietary and insulin adjustments. WHAT ARE THE COMPLICATIONS OF DIABETES? HYPOGLYCEMIA (INSULIN SHOCK) Symptoms: Sweating, pallor, trembling, dizziness, weakness, hunger, confusion, headache. Cause: Excess insulin, missed meals, increased exercise. Treatment: 15g carbohydrate (fruit juice, regular soda, glucose tablets) for mild hypoglycemia. HYPERGLYCEMIA/DIABETIC KETOACIDOSIS (DKA) Symptoms: Vomiting, nausea, abdominal pain, dry skin, acetone breath, Kussmaul breathing. Cause: Insulin deficiency, excessive food intake, or illness. Treatment: Insulin, fluids, electrolytes, and glucose infusion as needed.  RETINOPATHY Cause: Damage to small blood vessels in the retina. Symptoms: Blurry vision, potential blindness. Prevention: Blood sugar control, regular eye exams, blood pressure monitoring.  DIABETIC CATARACT a specific type of opacity of the lens occurs when diabetes has not been adequately controlled. This problem in vision occurs commonly in elderly diabetics and rarely in children.  NEUROPATHY Types: Peripheral neuropathy (feet/legs), autonomic neuropathy (heart, digestive system). Symptoms: Tingling, numbness, burning sensations, pain. Management: Regular foot exams, proper footwear, blood glucose control. DIABETIC GASTROPARESIS The other set of nerves commonly affected in uncontrolled DM involves the gastrointestinal tract and the condition is called gastroparesis. There is partial paralysis of the nerves leading to the muscles of the stomach. This needs nutrition therapy similar to GERD.  NEPHROPATHY Stages: Stage 1 (mild damage), Stage 2 (mild-to- moderate damage), Stage 3 (moderate), Stage 4 (severe, pre-dialysis), Stage 5 (end-stage renal failure). Symptoms: Proteinuria, hypertension, fatigue, fluid retention. Prevention: Regular screening for microalbuminuria, blood glucose, and blood pressure control. CARDIOVASCULAR AND PERIODONTAL DISEASE Cardiovascular Disease (CVD): Silent heart attacks, hypertension, erectile dysfunction. Periodontal Disease: Common in Type 2 diabetes, due to inflammation of gums. Management: Blood pressure, cholesterol control, regular dental visits. DIABETIC SKIN LESIONS Any damage to the skin of the diabetic patient either heals very slowly or never heals. Very often, a gangrenous condition develops at the site of injury. Atherosclerosis and poor circulation of the blood are causative factors for delayed healing. Nutrition therapy: reduction of dietary cholesterol to less than 300 mg; moderate reduction of total fat to 30% of total calories using up to 10% as polyunsaturated, less than 10% saturated and the remaining percentage (10-15%) as monounsaturated.  DIABETIC FOOT The diabetic foot is a manifestation of chronic neuropathy, aggravated in many cases by vascular insufficiency and infection. Sensory loss allows tolerance of repeated trauma from tight shoes and improper weight bearing, which leads to skin breakdown, skin ulceration, tissue necrosis, and fracture. Preventative care: Proper footwear, regular foot checks, hygiene Treatment: Wound care, debridement, surgery if necessary  MANAGEMENT OF DIABETES Basic control of diabetes rest on a balance of four important factors: insulin, diet, exercise and coping with stress. 1. Insulin or oral hypoglycemic agents (compliance with MD's prescribed drugs kind, dose, and time to take each). 2. Healthy eating; (eat at regular times of the proper kind and amount of food and beverages, including water, as instructed by an RND) 3. Regular exercises suitable for one's medical condition. Observe the kind, duration and intensity. 4. Avoid stress factors. Controllable types are anger and other emotional causes, adequate rest and sleep, financial problems, unnecessary worries, alcohol and smoking, environmental factors like sanitation and safety, fresh clean air. Uncontrollable factors include one's genotype or genetics, some medical conditions of unknown etiology, some emotional problems unless one seeks professional/psychiatric help. Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Content areas Include: Describing the diabetes disease process and treatment options Incorporating nutritional management into lifestyle Incorporating physical activity into lifestyle Using medication(s) safely and for maximum therapeutic effectiveness Monitoring blood glucose and other parameters and interpreting and using the results for self- management decision making Preventing, detecting, and treating acute complications Preventing detecting, and treating chronic complications Developing personal strategies to address psychosocial issues and concerns Developing personal strategies to promote health and behavior change.  For Diabetic Patients: People with diabetes often have little to no insulin, so they rely on commercial insulin injections to Insulin, Oral regulate their blood sugar. Physiologic insulin: when injected, works quickly in the body. It Hypoglycemic starts to act immediately. Peak Time: Its strongest effect happens within 30 minutes to 1 hour after injection, which means it is best at lowering blood Agents and sugar during this period. Duration: The effect lasts for about 2-3 hours before it gradually wears off. Injectables Discovery: Insulin, which changed diabetes treatment forever, was discovered in 1921 by Banting and Best in Toronto, Canada. Composition: Insulin is a protein that contains various naturally occurring amino acids. This protein structure is essential for it to function properly in the body. :By 1964, scientists were able to make insulin in labs, a major advancement that increased its availability for patients. Standardized Unit: One standardized unit of insulin helps the body use around 1.5 to 3.0 grams of glucose, effectively lowering blood sugar levels.  THREE GROUPS OF INSULIN 1. Animal Insulin Insulin, Oral Source: Extracted from the pancreas of pigs or cows. Characteristics: Historically used before synthetic insulin was Hypoglycemic developed. Less commonly used today due to advancements in synthetic insulin. 2. Human Insulin (Synthetic) Agents and Source: Produced by recombinant DNA technology, where bacteria or yeast are engineered to produce insulin identical to Injectables human insulin. Characteristics: This is the most common form of insulin used today and is available in various formulations to meet the needs of individuals with diabetes. 3. Insulin Analogues Source: Genetically modified human insulin that is altered to work more like natural insulin produced by the body. Characteristics: Designed to have a more predictable action profile, insulin analogues are used to better match the body's natural insulin release and control blood sugar.  Type of Insulin Usage Peak Action Duration Appearance 1. Rapid-Acting Before, with, or 0-3 hours 2-5 hours Clear Analogues after meals Six Main Types 2. Long- Acting Analogues Once daily No peak (steady 24 hours Clear Of Insulin release) 3. Short- Acting 15-30 minutes 2-6 hours Up to 8 hours Clear Analogues before meals 4. Medium and Once or twice Long Acting 4-12 hours Up to 30 hours Cloudy daily Analogues Combination of Varies Varies (depends on 5. Mixed Insulin medium and short (depends on Cloudy mix) acting insulin mix) Combination of Varies 6. Mixed medium acting Varies (depends on (depends on Cloudy Analogue insulin and rapid mix) mix) acting analogue Methods of Insulin Theraphy Insulin pen | A device that looks like a pen, but contain little cartridges that holds insulin. Users select the desired dose of insulin by turning a dial on the pen. After setting the correct dose, a plunger is pressed that causes a small needle to enter the skin and deliver insulin to the user. Insulin injections | A high-pressure air mechanism delivers the insulin through the skin. External insulin pump | A needle connected to plastic tubing is inserted just under the skin near the abdomen. The piece of tubing is connected to a programmable insulin pump (about the size of a paper) attached to the belt or placed in a pocket. Each patient program the insulin pump according to his/her needs so there is a continual baseline amount of insulin entering the body. Implantable insulin pump (implanted) | A small disc shaped pumps are surgically implanted, usually on the left side of the abdomen, and deliver small continuous amount of insulin throughout the day. A remote control gives the user the ability to administer the insulin depending on the level of glucose in the blood.  General Schedule: - Type 1 patients typically need at least three injections daily. -Morning Intermediate-acting insulin. -Before Dinner Short-acting insulin. Insulin -Bedtime Intermediate-acting insulin. Multi-Dose Regimen: Administration for - Short-acting insulin before each meal. - 1–2 daily injections of long- or intermediate-acting insulin. Diabetes 1 Continuous Subcutaneous Insulin Infusion (CSII): - Delivers a steady basal dose of insulin. - Allows bolus doses at mealtimes or for snacks. - Requires close blood sugar monitoring. Intensive Insulin Therapy Benefits: - Provides flexibility in meal timing and choices. - Requires commitment to regular blood sugar monitoring. Dietary Considerations: - Collaboration with a dietitian is essential. - Plan caloric intake based on insulin doses and eating habits. - Space meals according to insulin type and peak action times. - Individualized plans enhance cooperation and consistency  Purpose: Oral - Used for managing type 2 diabetes when diet alone is insufficient. Hypoglycemic Important Notes: - May cause hypoglycemia if food intake is delayed or insufficient. Drugs - Not a substitute for a controlled diet. Avoid use in: - Diabetes complications like acidosis and coma. - Juvenile, unstable, or severe diabetics. Six Classes of Oral Hypoglycemic Medications: 1. Alpha-Glucosidase Inhibitors 2. Biguanides 3. DPP-4 Inhibitors (e.g., Sitagliptin) 4.Meglitinides (e.g., Nateglinide, Repaglinide) 5. Sulfonylureas(First and Second Generation) 6. Thiazolidinediones (e.g., Pioglitazone, Rosiglitazone)  Diabetes Medications: Work in different ways to Oral lower blood sugar. Used when diet and exercise are insufficient for blood sugar control. Hypoglycemic Sulfonylureas Indicated: Recently diagnosed type 2 diabetes. Drugs Action: Stimulate the pancreas to secrete more insulin. Absorption: Readily absorbed from the gastrointestinal tract. Food Interaction: Glipizide absorption is affected by food, so take ½ hour befor a meal. Excretion: Primarily excreted through the kidneys. Caution: Not recommended for those with significant renal or hepatic disease. Effect: Reduces fasting and 24-hour mean glucose levels. Alpha-Glucosidase Inhibitors Action: Slow the absorption of glucose/carbs from the gut. Effect: Reduces HbA1C levels by 0.5 to 1%. Indicated: For patients with high postprandial glucose. Side Effect: Flatulence, which may be troublesome for some users.  Meglitinides (e.g., Repaglinide): Biguanides (e.g., Metformin): - Stimulate the pancreas to - Reduces glucose production in produce more insulin. the liver. - Reduces high blood sugar - Increases cell sensitivity to after meals. insulin. - Lowers HbA₁c by 1-2%. - Decreases fasting glucose, 24- - Indicated for patients with hour mean glucose, and HbA₁c recently diagnosed type 2 DM by 1-2%. and high postprandial glucose - Indicated for obese patients levels. with recently diagnosed type 2 - D-phenylalanine derivatives DM. (e.g., Nateglinide) also help quickly reduce high post-meal blood sugar  DPP-4 Inhibitors (Gliptins, e.g., Thiazolidinediones (Glitazones, Sitagliptin): e.g., Rosiglitazone, - Block the enzyme DPP-4, Pioglitazone): which destroys incretin (a - Make cells more sensitive to hormone that helps regulate insulin. insulin and glucose). - Take 4-6 weeks (or up to 3 - Increase insulin production months) to show full effects. when needed and reduce liver - Decreases fasting and glucose production. postprandial glucose levels. - Always prescribed with other - Lowers HbA₁c by 0.5-1%. blood glucose-lowering - Indicated for obese or insulin- medications, with effects resistant patients. depending on the combination.  Combination Medications: - Often prescribed when a single drug isn't enough. - Examples include: - Metformin + Sulfonylureas - Thiazolidinediones + Sulfonylureas - Rosiglitazone + Metformin (Avandamet) - Glipizide + Metformin (Metaglip) - Glyburide + Metformin (Glucovance) - Sitagliptin + Metformin (Janumet) - Repaglinide + Metformin (Prandimet) - Convenient but can make it harder to identify the cause of side effects.  Injectables Pramlintide Acetate (Brand Name: Symlin): - Synthetic form of the hormone amylin. - Administered via injections taken with meals. Benefits: Injectable Diabetes Drugs - Modestly improves A1C levelswithout causing increased - Are medications administered via hypoglycemia or weight gain. injection to help control blood sugar - May even promote modest weight loss. levels. Side effects: - Primary side effect is nausea, which improves over time. - As the patient determines the optimal dose, side effects tend to Antihyperglycemic Synthetic Analogs: decrease. - Created as synthetic versions of Usage: human substances. - Used with insulin for tighter blood glucose control. - Specifically, they are synthetic - Must be injected separately from insulin because of chemical versions of amylin, a hormone used by differences. the pancreas to lower blood glucose Approved for: - People with type 1 diabetes who are not meeting A1C goals. levels. - People with type 2 diabetes using insulin and not meeting their - Amylin is produced alongside insulin A1C goals. by β-cellsin the pancreas. Risks: - Works in coordination with insulin and - Increases the risk of severe hypoglycemia. glucagonto maintain normal blood - Careful selection and close monitoring by healthcare providers glucose levels. are necessary Injectables Injectables Injectables Incretin Mimetics -Non-insulin medications given by injection to manage type 2 diabetes. Work by increasing levels of incretin hormones which help the body produce more insuliwhen needed. Reduce the amount of glucose produced by the liver when not needed. Slow down digestion and stomach emptying. Exenatide (Brand Name: Byetta) -The first incretin mimetic for type 2 diabetes. A synthetic version of exendin-4, a hormone found in Gila monster saliva.Lowers blood glucose by increasing insulin secretion, with a low risk of hypoglycemia unless combined with sulfonylureas. Primary side effect: nausea which often improves over time. Benefits: -Generally leads to modest weight loss. Improves glycemic control.Approved for patients with type 2 diabetes who haven’t met A1C targets with metformin, a sulfonylurea or a combination of both. Injectables Type 1 Diabetes Management: - Recommended components of therapy include: 1. Multiple-dose insulin injections(3-4 injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion(CSII) therapy. 2. Matching prandial insulin to carbohydrate intake, premeal blood glucose, and planned activity. 3.Insulin analogs may be recommended, especially if hypoglycemia is a concern. Type 2 Diabetes Management - Emphasis on lifestyle interventions(diet, exercise, stress management) and drug therapyat each visit.A1C levels should be checked every 3 months until they are below 7%, and then at least every 6 months.Treatment should be adjusted if A1C is ≥7%. Combination Therapy - Some patients may benefit from a combination of oral medications and insulin injections.This can reduce the number of daily injections. Combination therapy is prescribed based on individual needs to effectively control diabetes, as determined by a physician. Nutrition Theraphy Importance of Dietary Management Proper dietary management is crucial in treating diabetes mellitus. The diet should be individualizedto meet each patient’s specific needs. Patients must understand the reasoning behind dietary restrictionsfor effective management. The diabetic diet is a modification of a normal dietand should provide adequate nutrients. Key Components of a Diabetic Diet Should provide sufficient caloriesbased on the patient’s activity level.Must help maintain desirable body weight. Should be adequate in macronutrients (carbohydrates, fats, proteins) and micronutrients(vitamins, minerals). Diet Prescription The diet prescription should be created by a physician. A patient interview, usually conducted by a dietitian, is important to gather: Diet history Socio-economic conditions Food attitudes and eating habits do Energy Energy Allowance for Diabetes Management: Individualized Calculation: Energy needs are determined based on individual factors: height, weight, age, sex, and activity level. Detailed calculations are described elsewhere (Chapter 7, cited in the text). Primary Goal: The primary goal is to achieve and maintain a healthy body weight through careful management of total energy intake. Activity Levels: Calorie needs vary depending on activity level: Energy Type 2 Diabetes Considerations: - Individuals with Type 2 diabetes often need caloric restriction and moderate weight loss (10-20 pounds) to improve blood glucose control, even if ideal weight isn't reached. - Weight reduction should begin early in treatment, while insulin secretion is still adequate. - Exercise, behavioral changes (eating habits), and psychological support are important for successful weight management. Protein Allowance Protein Allowance in Diabetic Patients: - Protein allowance is calculated after determining caloric needs and desirable body weight. It's generally the same as for a non-diabetic individual. Standard Allowance: For adult men and women, the standard protein allowance is computed at 1.1 grams per kilogram of desirable body weight. Nephropathy Exception: If the patient has nephropathy (kidney disease), a lower protein intake is recommended. - Nephropathy Management: Restricted protein diets help to: - Modify underlying glomerular injury. - Control hypertension. - Delay progression of renal failure. Severe Restriction Warning: Severely restricting protein intake (less than 0.6-0.8 grams per kilogram per day) is not recommended, as it can lead to protein malnutrition. Animal vs. Vegetable Protein: Emerging evidence suggests that animal protein may play a more significant role than vegetable protein in the progression of renal disease. Carbohydrate Allowance Estimation: Carbohydrate allowance is guided by blood sugar, urinalysis, and insulin requirements. For normal adults, carbohydrates provide 50-70% of total energy. Diabetic patients follow the same micronutrient guidelines. Food Sources: Grains, vegetables, and fruits are good sources of carbohydrates and dietary fiber. Simple Sugars: Based on the Diabetes Control and Complications Trial (DCCT), sucrose (table sugar) is not contraindicated for diabetics, as its absorption rate is similar to starches. This contradicts the traditional restrictive approach. Caution on Simple Sugars: Despite the DCCT findings, most physicians still advise caution in sucrose consumption to avoid abuse. Fructose: Fructose may raise blood glucose less than isocaloric amounts of sucrose or starch, but high fructose intake can negatively impact serum cholesterol levels. Glycemic Index: Foods with low glycemic indices are recommended. The glycemic index quantifies the 2-hour blood glucose response to a food, relative to a standard food (white bread). The response is affected by fiber content, carbohydrate type, and digestion time. Carbohydrate Allowance Glycemic Load (GL): GL combines the glycemic index (GI) and total carbohydrate content of a food serving. High GL diets (high GI foods with high carbohydrate content) increase cardiovascular risk. Carbohydrate Importance: Carbohydrates are vital for fiber, water- soluble vitamins, minerals, and energy. The brain and CNS require glucose; intakes below 130 g/day are not recommended. Total Caloric Intake: Regardless of macronutrient ratios, total caloric intake must align with weight management goals. Macronutrient Individualization: Macronutrient composition should be tailored to the patient's metabolic status (lipid profile, renal function) and food preferences. Plant-Based Diets: Well-planned plant-based (vegan or vegetarian) diets can improve metabolic control. Carbohydrate Allowance Fat Allowance Individualized Intake: Fat intake should be tailored to individual health goals. General Recommendation: Aim for 25-30% of total calories from fat; up to 35% may be acceptable. Diabetics: Diabetics should limit saturated fat to ⅓ or less of their total fat intake due to increased atherosclerosis risk. Unsaturated Fats: Unsaturated fats should comprise ⅔ of total fat intake (⅓ monounsaturated, ⅓ polyunsaturated). Cholesterol: Limit cholesterol intake to 300 mg/day. Vitamins and Minerals Well-Controlled Diabetes: Vitamin and mineral needs are the same as for non-diabetics; supplementation is unnecessary with adequate diets and controlled glycosuria. Supplementation may be necessary for: - Poorly controlled diabetes. - Patients on extremely restricted diets. - Strict vegetarians. - The elderly. - Pregnant or lactating mothers. - Patients taking medications affecting micronutrient metabolism. - Patients in critical care. Antioxidant Therapy: Antioxidants like vitamins E and C, and beta- carotene, are under ongoing research.  PLANNING THE DIET FOR DIABETES A diabetes meal plan is a guide that tells a patient how much and what kinds of food he can choose to eat at meals and snack times. People with diabetes have to take extra care to make sure that their food is balanced with insulin and oral medications, and exercise to help manage their blood glucose levels. Meal planning approaches include the Food Guide Pyramid, Exchange Lists, Plate Method, and Carbohydrate Counting. The Food Guide Pyramid can provide an excellent resource for meal planning. In addition to the Pyramid guidelines, individuals with diabetes should: 1. Eat meals and snacks at regular times every day 2. Eat about the same amount of food each day 3. Check blood glucose about 1.5-2 hours after eating to be sure they are not overdoing carbohydrates. The American Diabetes Association suggests 180mg/dl as a good upper limit for this. The Food Exchange System classifies foods into groups according to how much carbohydrates, protein and fat they contain per serving sizes that are specified. Plate Method is the simplest where the plate is divided into imaginary quarters: 1/4 contain starches, 1/4 for meat, and 1/2 for vegetables. Carbohydrate Counting works for patients who want more freedom and flexibility than the food exchange system. The key is keeping the total carbohydrate content of the meal the same. Initially, the patient and the registered dietitian determine the total amount of carbohydrate that will be consumed per meal or snack. Once the goal is determined, the patient learn to determine the amounts of carbohydrates in different portion sizes of carbohydrate foods to count his/her carbohydrate intake. Patients using carbohydrate counting may tend to focus on carbohydrate alone and forget about limiting fat, protein, or consuming adequate vitamins, minerals, and fiber.  Sample Diabetic Diet Prescription The following steps are used to determine the diet prescription: 1. Assessment of desirable body weight and caloric prescription which is eventually translated into carbohydrate, protein, and fat allowances. Sample Patient: A 5'2 adult diabetic woman who is overweight and engage in light activities whose desirable body weight is 52 kg. Energy: 52 kg x 30 kcal/kg = 1560 kcal Protein: 52 kg x 1.12 g/kg = 58.2 or 60g Protein Calories: 60 x 4 = 240 kcal Non-protein Calories: 1560-240 = 1320 kcal Carbohydrates: 70% of 1320 = 924 kcal = 924 / 4 = 231 or 230g Fats: 30% of 1320 = 396 kcal = 396 / 9 = 44 or 45g Diet Prescription: Energy CHO PRO FAT 1560 kcal 230g 60g 45g  Sample Diabetic Diet Prescription 2. Actual planning of the meal based on the prescribed diet using the exchange lists. The FNRI-DOST published a shortened method of calculating the diet for diabetes using the Food Exchange Lists for Meal Planning. The lists are made up of food groups of measured foods of the same value that can be substituted in meal plans. To simplify meal planning, the foods have been divided into 7 groups, or exchanges. For example, vegetables are listed in one group and fats are listed in another group. Foods in any one group can be substituted or exchanged with other foods in the same group, for as long as the equivalent portion of the exchange if followed. The number of kcal in any food expresses the energy value of the food.  Sample Diabetic Diet Prescription Determine the number of serving of rice, meat/fish/poultry, and fat exchanges to complete the diet prescription in the following way: 1. Subtract the grams carbohydrate (48) furnished by the vegetable, milk and fruit from the grams carbohydrate prescribed (230); and divided the result by 23, which is the amount of grams carbohydrate in one exchange. 230 - 48 = 184 / 23 = 8 rice exchanges 2. Subtract the grams protein (26) furnished by the food groups from the prescribed protein (60). Divide the difference by 8 60 - 26 = 34 / 8 = 4.25 or 4 exchanges of meat Consider the type of meat/fish to be used whether low, medium, or high fat. Allow 1, 6, or 10 grams fat for low, medium, or high fat meat 3. Follow the same procedure for fat, using 5 as divisor since a fat exchange contains 5 grams of fat. 45 - 19 = 26 / 5 = 5.2 or 5 fat exchanges  Sample Diabetic Diet Prescription 3. Planning of a whole day’s menu, based on the meal plan illustrated. Food Distribution. Distribution of meals and snacks depends on the individual lifestyle and activity patterns and is based on assessment data. With existing use of more flexible insulin regimens, dividing the meal plan into various fractions of intake through the day is usually not necessary. With consistent food intake from day-to-day, insulin therapy can usually adjusted to match patient’s customary food intake. Small frequent feedings may require insulin for Type 2 DM and is also good intervention for Type 2 DM. Insulin regimen should be coordinated with usual meals and snacks. To prevent hypoglycemia during physical activity, food distribution or insulin dose should be adjusted. Artificial Sweeteners. Food prepared without sugar can be palatable with artificial sweeteners. The use of caloric (sweetener other than sucrose) and non-caloric sweeteners is acceptable in diabetes meal planning. Commercially available granulated non-caloric sweeteners contain, on average, only 4 kcal per individual packet. Tablets and liquids contain 0 calories per serving. Patients using caloric sweeteners should be observe and monitor the sweeteners effect on blood glucose. Any sweetener should be used in moderation. Non-caloric sweeteners currently approved for use by the U.S Food and Drug Administration (USFDA) includes saccharin, aspartame, acesulfame K, sucralose, and neotame. The FDA has determined an acceptable daily intake (ADI), which is defined as the amount that can be safely consumed on a daily basis over a person’s lifetime without any adverse effects. Saccharin is widely used sweetening agent available as Sweet’n Low and Sugar Twin. It may be added to beverages and foods that do not require cooking. The sweetening power of 1/4 gram of saccharin is equivalent to about 1 teaspoonful of sugar; it is 300 times as sweet as sucrose. The acceptable daily intake of saccharin is 15 mg/kg body weight or 1000 mg/day for adults and 500 mg/day for children. Aspartame is an artificial sweetener widely used in a variety of products. 200 sweeter than sucrose and available in this country as Nutra Sweet and Equal. No adverse effects have been found in long-term toxicity tests in dogs and rats according to the USFDA. ADI is 50 mg/kg/day. Acesulfame K is a non-nutritive sweetener 200 times sweeter than sucrose and suited for baking. It is available commercially as Sunette or Sweet One. The safety level established by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) is 9 mg/kg of body weight; by the USFDA, 0-15 mg/kg. Sucralose is a non-nutritive high intensity sweetener derived from ordinary sugar. It is 600 times sweeter than sucrose and commercially available as Splenda. Its ADI is set at 0-5 mg/kg/day by JECFA and by the European Commission’s Scientific Committee on Food. Neotame is the newest non-nutritive sweetener approved by the USFDA in 2002. It is a derivative of the dipeptide composed of the amino acids, aspartic acid and phenylalanine. 7,000 - 13,000 sweeter than sucrose. Its safe expected daily intake is 0.1 mg/kg/body weight. Alitame is another non-nutritive sweetener (brand name is Aclame) expected to get approval from the USFDA. It is 2,000 sweeter than sucrose and formed from the amino acids L-aspartic acid and D-alanine, and novel amine. Alitame contains 1.4 kcal/g, highly stable and can withstand temperature in cooking and baking. It is approved for the use in a variety of food and beverage product in Australia, New Zeeland, Mexico, and the People’s Republic of China. The JECFA established the ADI for alitame at 1 mg/kg body weight. Cyclamates. 30 times as sweet as cane sugar, and were used to sweeten softdrinks in Britain in 1964 and 1967 when their use was permitted in all foods without restrictions. However, in 1969, their use was immediately stopped both in the U.S and in UK following a toxicity report on rat. Caloric or Nutritive Sweeteners include sucrose, fructose, and sorbitol and other sugar alcohols. Fructose (pure crystalline). This is not to be confused with high fructose corn syrup (HFCS) which may contain 42, 55 or 90% fructose. Fructose is 1.0 to 1.8 times sweeter than sucrose. The maximum accepted daily intake is 75g. Fructose as well as sorbitol is often used in “sugar-free” or “diabetic” commercial products. They should not be used freely because of their caloric content. Sorbitol, Mannitol, and Xylitol are sugar alcohol derivatives also added to diabetic foods and drinks for sweetening purposes. They are absorbed far slower into the blood stream and therefore have been considered by some doctors as advantageous for diabetics. Sorbitol contains 2.6 kcal/g and 3/5 as sweet as sucrose; Mannitol has 1.6 kcal/g and 1/2 as sweet as sucrose; and Xylitol contains 2.4 kcal/g and as sweet as sucrose. Excessive sorbitol (30-50g/day) and mannitol (20g/day) may cause diarrhea and abdominal cramping especially in children. Stevia (Rebaudioside A) has been designated by the USFDA as being generally recognized as safe (GRAS). This is the latest sugar substitute that is closest to table sugar, but most expensive. It is manufactured from stevia leaves from plants grown in the tropics and subtropics (Asia, South America, etc.); available as tablets, liquids, powders, and extracts. Popular commercial brands are Truvia and SweetLeaf. 1 tsp of a concentrated powder has the sweetness of a cup of sugar. A pack of 1/2 tsp Truvia = 2 tsp sugar. Fiber. Current evidence suggests that high-fiber diets, especially soluble fibers may offer some improvement in carbohydrate metabolism, may lower cholesterol and low-density lipoprotein cholesterol and increase the satiety effect of a meal. Filipinos on the average consume 5 grams of crude fiber per day, and this is equivalent to 9.2 to 10.1 grams of dietary fiber, comparable to American intake. The American Diabetes Association recommends that the diabetic diet contain 20-35 grams of dietary fiber per day from a wide variety of food sources rather than from fiber supplements. Fiber should be increase gradually along with concomitant increase in carbohydrate and fluid content of the diet. Alcohol. Alcohol has many disadvantages for clients with diabetes. It may cause specific problems with hypoglycemia, neuropathy, glycemic control, obesity, and/or hyperlipidemia. Alcohol contains 7 kcal/g and its use may contraindicated in individuals on a hypocaloric diet. Although the use of alcoholic beverages is not encouraged, if individuals with diabetes choose to drink alcohol, the following guidelines are recommended. 1. Alcohol should be consumed in moderation, not more than 2 equivalents of alcohol once or twice a week. Each of the following is equal to one equivalent. 1 1/2 oz. distilled beverage 12 oz. beer 4 oz. wine 2. Individuals taking hypoglycemic medication such as insulin or oral agents should not drink alcohol in a fasted state as hypoglycemia may ensue. 3. Alcohol should only ingested with meals to avoid potential hypoglycemic effect. 4. Alcohol and its equivalent caloric content should be calculated into the meal plan. Its best substituted for fat exchanges. One equivalent is equal to 90 kcal ( 2 fat exchanges). EXERCISE? A regular exercise (continuous activity lasting at least 20-30 minutes and performed at least 3-4 days a week) has been shown to promote weight loss, improve insulin sensitivity, and sometimes glucose tolerance in individuals with both types of DM. However, before undertaking an exercise or fitness program, an individual should receive a complete medical evaluation. Exercise should be tailored to the individual’s capabilities, preferences, age and lifestyle because of possible risks of exercise for individuals with diabetes. Exercise may produce hypoglycemia, normoglycemia or hyperglycemia in Type 1 DM patients. Underinsulinized patients or in poorly controlled diabetes with pre-exercise blood glucose of 250-300 mg/dl, increased hyperglycemia may prevail. Arrhythmia or myocardial infraction and worsening microvascular diabetic complications in people with other atherosclerotic cardiovascular disease are other risks of exercise especially if it is not properly paced. EXERCISE? SMBG is important in deciding when to exercise as well as when and how to treat potential hypoglycemia in Type 1 DM patients. People with Type 1 DM who exercise at about the same time daily should have a meal plan that provides enough kcal to cover the exercise. Type 1 diabetic patients who exercise sporadically or less than daily may choose to lower the insulin dose and/or increase food intake to regulate blood glucose levels, after consultation with the physician. Normally, 15g of rapidly absorbed carbohydrates is recommended for every half to one hour of moderate exercise. Intense exercise may require more carbohydrates before, during and after exercise. Fluids should also be increased to prevent dehydration. EXERCISE? In person with Type 2 diabetes, glycemic control can improve with exercise due to increased insulin sensitivity. When postprandial hyperglycemia is common, exercise after eating will be most beneficial. At least 150 minutes per week of moderate to vigorous aerobic exercise spread out at least 3 days during the week, with no more than 2 consecutive days between bout of aerobic activity is recommend to take into account the needs of those whose diabetes may limit vigorous exercise. Resistance training should also be part of the exercise, done at least twice a week on nonconsecutive days. Moderate exercise correspond to approximately 40-60% of maximal aerobic capacity and for most people with type to diabetes, brisk walking is a moderate-intensity exercise American Diabetes Association and the American College of Sports Medicine Guidelines (2010).  DIABETES AND SURGERY To be able to withstand surgical procedures, the diabetic as well as the nondiabetic individuals should have a good store of glycogen. Patients on oral hypoglycemic drugs should stop intake a day prior to surgery. Insulin is then used when control of hyperglycemia is needed. Insulin- treated patients require dosage adjustments. Sufficient food of high carbohydrate content and sufficient insulin to oxidize the carbohydrate should be given up to 12 hours before operation. In emergency operations where coma and acidosis are more likely to occur, it is necessary to give parenteral glucose and saline. Feedings high in carbohydrate either in the form of glucose or saline solutions should be given within 3 hours after operation. As soon as liquids can be taken by mouth, orange juice, ginger ale and gruels with glucose may be used at the start. When full liquid diet is permitted, the diet given should meet the protein, fat and carbohydrate allowance of the patient.  MANAGEMENT OF DIABETES IN PREGNANCY During the last half of pregnancy, the diabetic pregnant woman requires an increase diet similar to those of the nondiabetic pregnant woman, and a corresponding adjustment of insulin dosage. Oral medications are not prescribed. Diabetes increases the hazards of pregnancy because of dangers of glycogen depletion, hypoglycemia, acidosis, and infection. Urine ketones during pregnancy signal starvation ketosis. This can be caused by inadequate calorie or carbohydrate intakes. Physicians should advise diabetic patients of the risks and hazards of pregnancy and delivery. Breastfeeding is not contraindicated in woman with diabetes. Once pregnant, necessary precautions about carbohydrate intake, omission of meals or snacks, or prolonged intervals between meals are given. Urine testing should be done before breakfast. Ketonemia during pregnancy has been associated with reduced IQ scores in children.  DIETARY GUIDELINES FOR GESTATIONAL DIABETES Dietary plan should match age and weight goals that will maintain blood glucose, control blood pressure, optimize fetal growth and development, and prevent complications of diabetes. Three small meals and between-meals snacks should be stressed. Fruit exchange is not given for breakfast but planned later as mid-morning snack. For obese pregnant women with BMR over 30, a caloric restriction of about 25 kcal/kg actual weight a day is recommended. On the average, a typical caloric intake is about 1700 kcal/day for obese pregnant women. Choose starchy foods like whole grains and foods that are high in dietary fiber.  DIETARY GUIDELINES FOR GESTATIONAL DIABETES 3 serving of fruits, one at a time or distributed for lunch, mid-afternoon snack, and dinner; 5-6 servings of nonstarchy vegetables preferably those with dark bright colors, 2-3 glasses of low-fat milk or equivalent and the right kind of fats and oils. Keep saturated fats under 10% of total fat. The caloric distribution is 40-45% from carbohydrates, 25-30% from protein, and 30-35% from fat. Vitamins and mineral supplements prescribed by the doctor contains 600 mcg folic acid, adequate vitamin C and other B-vitamins. For minerals, supply iron no less than 30 mg/day, adequate calcium, magnesium, and trace minerals like chromium, zinc, and selenium. Caution on sodium intake when there is pre-eclampsia or risk of high blood pressure. MANAGEMENT OF DIABETES IN CHILDREN Challenges: Rapid growth, fluctuating activity, infection susceptibility Treatment: Insulin adjustments, regular monitoring Nutrition: Age-appropriate energy needs, balance of carbs, fats, and proteins Energy Requirements: 80 kcal/kg (1-9 years), 55 kcal/kg (10-18 years). Macronutrient Distribution: 50% carbohydrates, 35% fats, 15% protein. Additional Considerations: Growth, activity, and development. ROLE OF THE NUTRITIONIST-DIETITIAN IN DIABETES MANAGEMENT Conduct nutritional assessments Develop personalized meal plans Provide education on food choices and lifestyle adjustments Collaborate with healthcare team SUGGESTED STRATEGIES FOR INDIVIDUALIZING DIETARY GUIDELINES FOR PERSONS WITH DIABETES MELLITUS 1. Strategies to reach and maintain target weight: Assist the client in calculating his own desirable weight. Also discuss a reasonable weight goal with the client and help establish short- and long-term goals for weight loss. Discuss the rationale for reaching and maintaining a target weight in relation to diabetes and lipid management. Discuss the role of exercise in weight and diabetes management. Review current activity levels, and establish a goal for regular activity. Review the types of foods normally consumed, and suggest lower calorie alternatives (Substitute lean cuts of meat for chops and luncheon meat, substitute fruit for dessert) Discuss low calorie foods available in restaurants. SUGGESTED STRATEGIES FOR INDIVIDUALIZING DIETARY GUIDELINES FOR PERSONS WITH DIABETES MELLITUS Have the client keep a daily food record and review the types and amounts of foods consumed Demonstrate the impact of weight loss on blood glucose levels by reviewing blood glucose records. 2. Strategies to increase complex carbohydrate- and fiber-containing foods: Review the types of carbohydrates and their food sources. Review what fiber is and its food sources. Discuss the impact of complex carbohydrates and fibers on weight, lipids and glucose management. Have the client keep food and blood glucose records, and have the client observe the changes in blood glucose levels and weight in relation to food intake. Identify ways the client can incorporate more complex carbohydrates and fiber. SUGGESTED STRATEGIES FOR INDIVIDUALIZING DIETARY GUIDELINES FOR PERSONS WITH DIABETES MELLITUS Compare menus low and high in complex carbohydrates and fiber. 3. Strategies to limit the use of sugar in the diet: Review the rationale for reducing total sugar content in the client's diet. If know about the ADA guidelines on the use of sugar, explain how easy it is to abuse this guideline. Have the client identify ways to reduce sugar content in their diet. Provide the client with information regarding the use of sugar substitutes. Review food labels for sugar content by identifying hidden and obvious sources of sugar. Have the client keep food and blood glucose records to observe the impact of foods high in sugar on glucose management. Based on the information 'collected establish a guide for safe use of sugar. SUGGESTED STRATEGIES FOR INDIVIDUALIZING DIETARY GUIDELINES FOR PERSONS WITH DIABETES MELLITUS 4. Strategies to reduce the amount of fat in the diet: Review what fat is and its food sources. If the client has kept a food record, review the major food sources of fat and discuss alternative food choices. Discuss the role of fat in the diet and compare its calories per gram (9 kcal/g) with the calories per gram of protein and carbohydrate (4 kcal/g). Review guidelines for reducing fat in the diet. Discuss the client's current cooking techniques, and review low-fat cooking techniques. If the client is preparing foods using low-fat cooking techniques, be sure to give positive reinforcement. Using butter pats (food models), demonstrate the fat content of some of the client food choices (Example: 16 potato chips = 2 pats butter, 1 slice cheddar cheese = 2 ½ pats butter, 10 green olives = 1 pat butter, etc.) SUGGESTED STRATEGIES FOR INDIVIDUALIZING DIETARY GUIDELINES FOR PERSONS WITH DIABETES MELLITUS Review the amount and type of meat eaten daily. If appropriate, encourage the client to decrease the amount consumed by half and/or change the types of meats eaten. 5. Strategies to eat a variety of foods daily Discuss the major nutrients (carbohydrates, protein, fats, vitamins, minerals, and water) and their impact on general health and diabetes management. Use the Nutritional Guidelines for Filipinos. Review basic food groups and compare with the client's food record to identify possible changes in food choices. Discuss ways to plan meals by using the Food Pyramid Guide. Plan example menus with the client, or suggest ways to incorporate all of the food groups from a review of the client's food record. SUGGESTED STRATEGIES FOR INDIVIDUALIZING DIETARY GUIDELINES FOR PERSONS WITH DIABETES MELLITUS 6. Strategies to eat meals and snacks at regular times for individuals taking insulin: Review the time of meals and snacks, taking into consideration the frequency of insulin administration and the type of insulin used. Establish set times for meals and snacks and discuss the ways to vary the timing of them.  SUMMARY The specific treatment for diabetes mellitus depends on the type, but in general, the goals of treatment are: 1. optimum nutrition 2. normal or reasonable weight 3. normal blood sugar level 4. minimum glycosuria 5. absence of ketoacidosis 6. prevention of short-term and long-term complications. The goal is to keep A1C level below 6.5%, fasting blood sugar below 100 mg/dl (5.5 mmol/L), and postprandial glucose below 140 mg/dl (7.8 mmol/L). Registered dietitians can encourage lifestyle changes and select appropriate interventions based on key recommendations, e.g. consistency in day-to-day carbohydrate intake, adjusting insulin doses to match carbohydrate intake, substitution of sucrose-containing foods, usual protein intake, cardio-protective nutrition interventions, weight management strategies, regular physical activity, and use of self-monitored blood glucose data.  SUMMARY The goals of medical nutrition therapy as they apply to specific clinical situations; to provide adequate energy to ensure normal growth and development, and to integrate insulin regimens into usual eating and physical activity habits for youth with type 1 DM; to facilitate changes in eating and physical eating habits that reduce insulin resistance and improve metabolic status for youth with type 2 DM; to provide adequate energy and nutrients need for optimal outcomes for pregnant or lactating women; to provide the nutritional and psychosocial needs for aging individual; to provide self-management education for treatment (and prevention) of hypoglycemia, acute illnesses or insulin secretagogues; and to decrease cardiovascular risk by encouraging physical activity and promoting food choices that facilitate moderate weight loss or at least prevent weight gain. Medical nutrition therapy provided by registered dietitians is an effective and essential therapy in the management of diabetes (Franz et al, 2010). MEDEM is mnemonic to support the importance of monitoring, education, diet, exercise and medication as steps of diabetes management. Patient education should begin as early as when the diseases is diagnosed and should continue throughout the life span. When the patient has been adequately educated, he or she may be ready to undertake self management to enhance his/her ability to obtain good metabolic control for a better quality of life. A healthy social life is vital in reducing stress levels and helps people with diabetes to take control of their condition. THANK YOU!