Lesson 5 : Medical

Nutrition Therapy
Types of DM
Type 1(5-10%)
Type 2 (90-95%)
Gestational
Other Specific Types from
specific genetic syndromes
surgery
drugs
Malnutrition (old term)
infections
other illnesses
Impaired glucose tolerance (pre-diabetes)
Types of DM
Characteristic Type 1 DM Type 2 DM
Age of Onset Childhood or Age 40 or older*
adolescence
Rapidness of Onset Usually abrupt Usually gradual
Family history Usually no Common
Etiology Unknown- Unknown-
Heredity,autoimmune, Heredity
viral infections
Body weight Usually thin Obesity common
Endogenous Insulin Very little to none Normal, high, or low
Ketosis Common Uncommon
Symptoms Polyuria/dipsia/phagia Polyuria/dipsia or
and weight loss none

* growing incidence in adolescents

ADA Terminology Update
Old Term New Term

IDDM
Type I DM Type 1 DM

NIDDM
Type II DM Type 2 DM
Diagnostic Criteria

Test
Stage FPG RPG OGTT
Diabetes 126 200 2hPG
plus symptoms
200
Impaired Glucose Impaired Fasting Impaired Glucose
Glucose = Tolerance =
Homeostasis FPG 110 and 2hPG140 and
<126 mg/dl <200 mg/dl
Normal < 110 mg/dl 2hPG <140mg/dl

FPG = Fasting Plasma Glucose

RPG = Random Plasma Glucose
OGTT = Oral Glucose Tolerance Test
Epidemiology

Epidemic increase in type 2 diabetes

currently 90 % of all forms of diabetes

Predictions
6-8 % of the world population will suffer from
diabetes in the next quarter of a century
300 million people worlwide
Doubling of the prevalence of DM2
to 215 million in the next 15 years
215
250
160
200
Million 150 100
people
100
50
0
1995 2000 2010
DM2
50% not yet diagnosed in Europe & North America!

Diabetes 1994-2010: Global Estimates and Projections

Jiwa F. Statistical Bulletin. Jan-Mar 1997;2-8
 Diabetes
60

50
Number in Millions

40
US
30 Europe
China
20 India
10

0
1995 2000 2010 2025
Year
Diabetes: A Worldwide
Epidemic
The Rise in Diabetes: Why?
Increasing longevity.
Change in demographics and genetic
predispositions: the greatest growth of patients
will be in Asia, where it is predicted that by
2010, over 60% of the patients suffering from
diabetes will live in this region of the world.
Rising urbanization and change in lifestyle.
Increase in obesity: over 60% of the adult
population in the United States (and Australia)
are either overweight or obese.
Diabetes: A Worldwide
Epidemic
Percent of Individuals Considered Obese
in a Given Country
2% 15% 25% 50% 70%

Japan Europe US Jordan Samoa

Diabetes, Obesity &
Adolescence
In developing nations, more than 70% of the

childhood population presenting with diabetes

suffers from type 2 disease.
In the United States, type 2 diabetes is
preferentially affecting the obese Hispanic and
African-American population.
In the United States, adolescent clinics

describe 1/3 to 1/2 of their new diabetics as

type 2 patients (Henry Ford Health Clinic,
Detroit).
The incidence of diabetes in children has

increased 10 fold when compared with a

decade ago.
Mortality in diabetes patients double that
compared to non-diabetics
35 Ratio 2.5 Ratio 2.2 Ratio 2.1

30 26.9 26.9 32.0

(numberof deaths per 1000 patient years)

25

20
15.5 Control
12.5
15 10.8 Diabetes

10
Mortality

0
10,025 61 6629 279 631 24
(No of patients)
Paris Helsinki
Whitehall
Prospective Study Policemen Study
Study

Balkau Lancet 1997; 350:1680

Causes of Death Among People With
Diabetes
Cause % of Deaths

Ischemic heart disease 40

Other heart disease 15
Diabetes (acute complications) 13
Cancer 13
Cerebrovascular disease 10
Pneumonia/influenza 4
All other causes 5

Geiss LS et al. In: Diabetes in America. 2nd ed. 1995:233-257.

Complications of Diabetes

Macrovascular
coronary artery disease (MI)
cerebrovascular disease (Stroke)
peripheral vascular disease
Microvascular
retinopathy
nephropathy
neuropathy
Diabetes complications

Retinopathy (blindness?)
Nephropathy (kidney problems)
Feet ulceration and/or amputations
Hypertension
Hyperlipidemia (cholesterol?)
Gestational diabetes (during pregnancy)
Diabetes and HIV
Erectile Dysfunction
Diabetes complications
 HbA1c relationship with CV
risk
Glycaemia increase Associated risk increase

1% 21% 14% 43%

increase in increase in increase in increase in
HbA 1c diabetes-related myocardial peripheral
deaths infarction vascular disease
p<0.0001 p<0.0001 p<0.0001

Stratton IM et al.
al. BMJ 2000; 321: 40512.
 Why Treat Diabetes?

DCCT
Diabetes Control and Complications Trial
10-year study in 1441 patients with Type 1 DM
Kumamoto Study
6-year study in 110 Japanese patients with Type 2 DM
UKPDS
United Kingdom Prospective Diabetes Study
20-year study of 5102 newly diagnosed Type 2 DM
The burden of type 2 diabetes can be
reduced
The UKPDS showed that, when glucose levels
are above normal, any reduction in HbA1c is
beneficial

0.9%
= 25%
reduction in HbA1c reduction microvascular
complications

UKPDS 33. Lancet 1998;352:837853.

Preventative Measures
DCCT

Intensive control of blood glucose reduced

risk of diabetic complications
76% reduction retinopathy onset
54% reduction retinopathy progression

54% reduction nephropathy

60% reduction neuropathy

2-3x greater incidence of severe hypoglycemia

DCCT Research Group N Engl J Med. 1993;329: 977-986.

 UKPDS Key Messages

To reduce the complications of diabetes, it is necessary

to control:
blood glucose and HbA1c levels
blood pressure
Epidemiologic analyses showed that for every percentage
point reduction in HbA1c, there was a
35% reduction in microvascular complications
25% reduction in diabetes-related deaths
18% reduction in MI
American Diabetes Association. Diabetes Care. 1999;22(suppl 1):S27-S31.
UKPDS Group. Lancet. 1998;352:854-865.

UKPDS Group. BMJ. 1998;317:703-713.

1998 PPS
Nathan D. Lancet. 1998;352:832-833.
 It Works.at least for some things
DCCT1(1993) Kumamoto2(1995) UKPDS31998)

Retinopathy Up to 76% less 69% less 21% decrease

Nephropathy Up to 56% less 70% less 33% decrease

Neuropathy Up to 60% less

Atherosclerotic 41% fewer 50% fewer ND

Events

Overall Data not Data not 25% decrease

Microvascular Available Available
Complications

1
The DCCT Group. N Engl. J Med 1993. 2
Ohkubo Y, etl. al. Diab Res Clin Pract 1995.
3
UKPDS Group. Diabetes Care 1998.
Goals of Treatment

Alleviate symptoms
Prevent complications
Prevent progression of current
complications
Improve quality of life
ADA Goals of Treatment (cont.)

Index Normal Goal Action

Preprandial <110 80-120 <80,>140
1hr Postpran 100-160 100-180 <100,>200
2hr Postpran 80-120 80-150 <80,>150
2-4 AM 70-100 70-120 <70,>120
Bedtime <120 100-140 <100,>140
A1C <6 <7 >8
Other Glycemic Measures

A1C
measure of how much hemoglobin has been
glycosylated
represents an average glucose over the last 3
months
Fructosamine
measure of proteins that are glycosylated
represents an average glucose over 2-4 weeks
Diabetic control
Normal HBA1C 3.5 6.5%
Targets

HBA1c Fasting plasma

glucose
Low <6.5 <100
risk
Macrovascular >6.5 >100
risk
Microvascular >7.5 >110
risk
Collaborative Management
Nutritional Therapy
Activity
Monitoring of Blood Glucose
Medication - Insulin or Oral Agents
Education
Nutritional Therapy
Cornerstone of care for Diabetic
No one diabetic or ADA diet
Use individualized approach
Consider financial status and cultural and
ethnic influences
Priority placed on amount of CHO, not source
of the CHO
Nutrition

Nutrition Therapy The Most Fundamental

Component of the Diabetes Treatment Plan
Goals:
Near Normal Glucose Levels
Normal Blood Pressure
Normal Serum Lipid Levels
Reasonable Body Weight
Promotion of Overall Health
Nutrition Therapy
Diet Teaching
Goal - independence; effective self-
management.
Include Family.
Follow prescribed plan; accurate portions
Never skip meals
Concern - Alcohol
Concern - Dietetic Foods
Nutrient Components

Protein*
Fat*
CHO*
Sucrose and Fructose
Nutritive Sweeteners
Fat Replacements*
Vitamins and Minerals
Alcohol Intake*
Nutrition Goals for
Type 1 *** *** Type
2intake possible
Increase in energy Reduction of energy

intake for obese

Diet and Insulin nec. to Diet alone may control
control BS blood glucose
Equal distribution of Equal distribution of
CHO through meals for CHO desirable, not
insulin activity essential;low fat
Consistency in daily desirable
intake - control BS Consistency in daily
intake - control wt.
Nutritional Goals (cont)
Type I ** **Type
2crucial
Timing of meals - Timing of meals not

essential
Snacks - frequently Snacks - not
necessary recommended
Additional food for Additional food for
exercise - CHO 20 g/h exercise if on
for moderate physical sulfonylurea or insulin
activity
Dietary Management
of Diabetes
Maintain as near-normal blood glucose levels as
possible by balancing food, insulin and exercise
Achieve recommended serum blood lipid levels
Provide energy intake to maintain or attain healthy
weight
Prevent and treat acute and long-term diabetes-related
complications
Enhance over all health
Dietary Intake in US
(NHANES III)
Mean daily intake
2095 Total kcal
34% Fat
15% Protein
50% CHO
2% Alcohol
Macronutrient
Composition of Various
100% 3
Diets 40
15
80%
49 55
70
60% 55
30
40%
34 30
20% 15
30 30
15 15 15
0%

PRO (% kcal) FAT (% kcal)) CHO (% kcal) ETOH (% kcal)

Major Dietary Guidance
Tools
Recommended Dietary Allowances
1989 10th Edition currently being revised
Dietary Reference Intakes (DRIs)
RDAs ,Tolerable Upper Intake Level
(UL), Estimated Average Requirement
(EAR) and Adequate Intake (AI)
Yates et al, Jour Am Diet Assoc. 1998:98:699-706
The Food Guide Pyramid
Human Nutrition Information Service, Home and Garden
Bulletin Number 252, Hyattsville, MD:USDA, 1992
1995 US Dietary Guidelines
USDA and USDHHS, Nutrition and your health: Dietary
guidelines for Americans, 4th edition, 1995; Home and
Garden Bulletin No. 232,Washington, DC:USDA, 1995
Type 1 Diabetes
Mellitus
Nutrition Goals for Type 1
Consider intensive insulin therapy to allow flexibility
in meal patterns
Integrate insulin therapy with usual food intake
Develop an eating pattern based on persons usual
food intake
Monitor blood glucose levels

Ref: Manual of Clinical Nutrition, 2000

 Meal Planning
Term ADA Diet is obsolete
Avoid the terms
no concentrated sweets
low sugar diet
liberal diabetic diet
Medical Nutrition Therapy
Meal plans should be individualized
based on
nutrition assessment
medical history
psycho-social assessment
treatment goals
Carbohydrate Consistency
CHO intake and distribution should be
comparable from one day to the next.
CHO content of meals within the same day
can vary.
Type of Carbohydrate
The total amount of CHO eaten is more
important than the source or type.
Clinical studies do not justify the longtime
belief that sucrose must be restricted.
Glycemic Index
Compares various CHO foods and ranks
them according to effect on BG.
Limitations:
compared 50 g CHO from each source, actual
portion sizes werent necessarily comparable.
looked at BG response when each item was eaten
alone, on an empty stomach. Mixed meals would
produce a different effect.
People may unnecessarily restrict healthful foods.
Sugars and Sweeteners
Sugar, honey, syrup...1 Tbs. =15g CHO
Fructose slightly lower post-prandial
response.
Sugar alcohol is a form of carbohydrate, but
labels can technically state sugar free.
FDA approves 4 sugar substitutes which
have no CHO:
aspartame, saccharin, acesulfame-K, sucralose
Macronutrient Composition

No absolute percentages
CHO and MUFA should be 60-70% kcals
SFA < 10% kcals
Protein intakes of 15-20% kcals
Sample energy distribution

50-60 % CHO
15-20 % Protein
20-30 % Fat
Protein Intake

Small to medium portion of protein once daily

12-20% of daily calories
From both animal and vegetable sources
Vegetable source less nephrotoxic than
animal protein
3-5oz (100-150g) of meat, fish or poultry daily
Patient with nephropathy should limit to less
than 12% daily
Fat Intake

<35% of total calories

Saturated fat <10% of total calories
Polyunsaturated fats 10% of total calories
Cholesterol consumption < 300 mg
Moderate increase in monounsaturated fats
such as canola oil and olive oil (up to 20% of
total calories)
CHO Intake

CHO intake determined after protein and fat

intake have been calculated.
Emphasize on whole grains, starches, fruits,
and vegetables
Fiber same as for nondiabetics (20g to 35g)
Rate of digestion related to the presence of
fat, degree of ripeness, cooking method, and
preparation
Carbohydrate Management
Tools
Food Pyramid
Food Labels
ADA Exchange Lists
Reference Books
The Food pyramid
Nutrition adivice should be practical and catered for
the needs of the consumer
15 % proteins, 55 % carbohydrates & maximum 30
% fat are scientific but not practical advice
In USA food pyramid introduced in 1992
In Belgium adjusted (1997)
 Nutrition Facts
Serving Size 3/4 cup (55g)
Servings Per Container 8

Amount Per Serving

Calories 200 Calories from Fat 10

% Daily Value*
Total Fat 1 g 2%
Saturated Fat 0 g 0%
Cholesterol 0 mg 0%
Sodium 20 mg 1%
Total Carbohydrate 45 g 15%
Dietary Fiber 5 g 20%
Sugars 15 g
Protein 6 g

Vitamin A 0% Vitamin C 0%

Calcium 0% Iron 8%

* Percent Daily values are based on a 2,000

calorie diet. Your daily values may be higher
or lower depending on your calorie needs:

Calories 2,000 2,500

Total Fat Less than 65g 80g

Sat Fat Less than 20g 25g
Cholesterol Less than 300mg 300mg
Sodium Less than 2400mg 2400mg
Total Carbohydrate 300g 375g
Dietary Fiber 25g 30g

Calories per gram:

Fat 9 Carbohydrates 4 Protein 4
Exchange Lists
Calories g CHO g Pro g Fat

Starch 80 15 3 0 -1

Fruit 60 15 0 0

Skim Milk 90 12 8 0-3

Low-fat Milk 120 12 8 5

Whole Milk 150 12 8 8

Vegetable 25 5 2 0

Very Lean Meat 35 0 7 0-1

Lean Meat 55 0 7 3

Medium Fat Meat 75 0 7 5

High Fat Meat 100 0 7 8

Fat 45 0 0 5
Starch Group
15 g CHO
1 slice bread (Belgium
30g)
small tortilla
small potato
1/2 cup pasta (60g)
1/2 cup corn (60g)
1/3 cup rice (70g)
3 cups popcorn (180g)
Fruit Group
15 grams CHO
small apple
small orange
17 grapes
1/2 grapefruit
1 cup cantaloupe
3 prunes
4 ounces orange juice (120g)
Milk Group
15 g CHO each
1 cup milk (200ml)
3/4 cup plain yogurt (150g)
1 cup aspartame yogurt (200g)
Vegetable Group
5 grams CHO each
1 cup raw vegis (225g)
1/2 cup cooked vegis (100g)
1/2 cup vegetable juice
(150ml)
Digestion Timing
Peak Post Prandial BG is typically 1-2 hours
after a standard mixed meal.
Liquids (juice/soda) digest quicker.
High fat meals digest slower.
Meal Planning
Set Carbohydrate Intake
specific amount of CHO set to match prescribed
insulin regimen (less flexible)
Adjust Insulin to Desired Carbo Intake
insulin to carbohydrate ratio
1 unit per 10-15 g carbohydrate
1 unit for every 50 mg/dl elevated above target (above
doses may vary)
Insulin Action Times

Type of Insulin Start Peak Duration

Humalog Lispro 5-15 min 30-90 min 2-4 hrs

Novolog Aspart 5-15 min 30-90 min 2-4 hrs

Regular 30-60 min 2-3 hrs 3-6 hrs

NPH 2-4 hrs 4-10 hrs 10-16 hrs

Lente 3-4 hrs 4-12 hrs 12-18 hrs

Ultralente 6-10 hrs no peak 18-20 hrs

Glargine 1 hr no peak 24 hrs

Insulin Delivery
Syringes
Insulin Pens
Insulin Pump
delivers short acting insulin (sub-Q catheter)
adjustable basal rate (usually 0.5-1.0 u/hr)
programmable bolus for food or BG correction
Insulin Pens

Pre-filled with 300 units. Disposable.

Dial dose in 1 unit increments up to 60 unit dose.
Insulin Pump

Programmable insulin pump

holds 300 units
insulin is delivered through sub-Q infusion set/tubing
Remote control
discrete dosing
Exercise
Improves insulin
sensitivity
Lowers Blood Glucose
Uses Glycogen Stores
muscle
liver
Increases release of
FFA from adipose
Exercise Guidelines: Type 1
DM
Metabolic Control
Avoid exercise if BG >250 mg/dl,

ketones present.
Use caution with exercise if BG>300 mg/dl,
without ketones.
Eat CHO if BG < 100 mg/dl
Exercise Guidelines: Type 1
DM
Blood Glucose Monitoring
Monitor BG before and after exercise.

Monitor BG throughout longer duration or

very intense exercise.
identify need to increase food or decrease insulin.
learn how various forms of exercise alter glycemic
response.
Exercise Guidelines: Type 1
DM
Insulin Adjustments
If exercise is planned for just after a meal,

consider reducing the short acting insulin that

covers that meal.
If exercise is planned for 3-4 hours after a
meal, consider reducing the long-acting
insulin.
For unplanned exercise, consider adding
carbohydrate.
Exercise Guidelines: Type 1
DM
Food Intake
Consume CHO before, during, or after

exercise to prevent hypoglycemia.

Always keep CHO foods readily available
during exercise.
Late-onset Hypoglycemia
Related to repletion of glycogen stores.
Can occur up to 24 hrs after exercise.
indicates that insufficient carbohydrate was
available in relation to insulin and exercise.
Depleted glycogen stores are best replaced
when CHO is consumed within 30 min of
exercise completion.
Treating Hypoglycemia
Check BG when s/sx of hypoglycemia
For BG < 70 mg/dl
take 15 grams of CHO
4 oz (120ml) juice
1 Tbs. (15g) sugar, jam, honey
3-4 glucose tabs
recheck BG in 15 minutes, repeat PRN
If unconscious, NPO: administer glucagon or
IV dextrose.
Alcohol Precautions
Alcohol inhibits gluconeogenesis which
impairs the ability to recover from low BG.
Glycogenolysis is not affected by EtOH.
Counter-regulatory response depends on
glycogen stores.
ADA recs:
limit to 1-2 drinks, consumed with CHO foods, if
no other contraindications.
Blood Glucose Meters
Plasma referenced
Fingertip vs Offsite
Memory
Downloadable
Some measure ketones
Insurance companies
dictate which meter
they cover.
Continuous Glucose Monitor

Subcutaneous sensor attached to unit worn on belt.

Typically worn for 3 days.
Measures BG continually.
Download graph of BG.
Elucidates potentially unknown BG excursions.
Blood Glucose Targets
Before Meals
normal < 110
goal 90 - 130
Peak Post Prandial
normal < 140
goal < 180
Bedtime
normal < 120
goal 110 -150
Hemoglobin A1c
Target A1c BG
ADA < 7 4 60
ACE & IDF < 6.5 5 90
6 120
7 150
8 180
9 210
10 240
11 270
Type 2 Diabetes
Mellitus
Nutrition Goals for Type 2

Weight loss of approximately 10-20 lb (4.5-

9.0 kg)
Space meals throughout day
Avoid excessive CHO intake at one meal
May need consistent mealtime depending on
insulin use or insulin secretagogues
Exercise

Ref: Manual of Clinical Nutrition, 2000

Key Topics
Statistics/Overview
Weight Control
Lipid Control
Blood Pressure Control
Exercise
Other Complications
Diabetes Prevention Program
Research Group
3234 adults with impaired glucose tolerance
Randomized (3 years)
standard lifestyle plus Metformin
standard lifestyle plus placebo
intensive lifestyle modification
Lifestyle Modification
Weight loss (decrease weight by 7 %)
individualized counseling
healthy, low calorie, low-fat diet
A 16 lesson curriculum on diet, exercise, behavior
modification
Exercise 150 minutes per week
Results
Intensive lifestyle modification group
reduced incidence of diabetes by 58 %
Metformin
reduced incidence of diabetes by 31 %
Exercise

Potential Benefits
Improved Glucose tolerance
Weight loss or maintenance or desirable weight
Improved cardiovascular risk factors
Improved response to pharmacologic therapy
Improved energy level, muscular strength,
flexibility, quality of life, and sense of well being
Exercise Prescription

Interest
Capacity
Motivation
Physical status
Individualized approach
Types of exercise

Walking
Biking and stationary cycling
Lap swimming and water aerobics
Weight lifting
At least 3-4 times a week, 30-40 minutes per
session, 50 to 70% of maximum oxygen
uptake
Metabolic Staging of
Type 2 Diabetes

Peripheral
insulin Hyperinsulinemia
resistance
Impaired
glucose Defective glucorecognition
tolerance

Early diabetes -cell failure

Late diabetes

Saltiel AR, Olefsky JM. Diabetes. 1996;45:1661-1669.

STAGES OF TYPE 2
DIABETES
LIFESTYLE
MONOTHERAPY
100
%
COMBINATION
THERAPY
CELL

FUNCTION REQUIRE
INSULIN
UKPDS:HOMA
ANALYSIS IGT PP DM DM DM
BS 1 2 3

10 5 0 5 10
YEARSFROMDIAGNOSIS
Pre-diabetes
HHS and ADA are using this new term to
describe IFG (impaired fasting glucose) and
IGT (impaired glucose tolerance).
16 million people have pre-diabetes.
Most will develop diabetes within 10 years.
Prevention strategies
screen at risk populations ( > 45 yrs, obese)
lose 5-10% of weight
modest exercise 30 min/day
Weight Control

Energy In = Energy Out

CHO: 4 kcals/g Metabolism
Protein: 4 kcals/g Daily Activities
Fat: 9 kcals/g Exercise
EtOH: 7 kcals/g
Nutrition Therapy

Provide Follow-up assessment of the meal

plan to
Determine effectiveness in terms of glucose and
lipid control and weight loss
Make necessary changes based on weight loss,
activity level, or changes in medication
Provide ongoing patient education and support
Weight Loss

Improves Glucose Control

Increases Sensitivity to insulin
Lower lipid levels and blood pressure
Corresponding lowering of the dosage of
pharmacologic agents
For a Successful Outcome

Modest Energy Restrictions

Spreading energy intake throughout the day
Increased Physical Activity
Behavior Modification
Psychosocial Support
Energy Intake
Women: 100 # for the first 5 ft of height plus 5 # for
each additional inch over 5 ft.
Men: 106# for the first 5 ft. of height plus 6# for each
additional inch over 5 ft.
Add 10% for larger body build, Subtract 10% for
smaller body builds
Multiply resulting weight by:
Men and Physically Active Women: 15
Most Women, Sedentary Men, and Adults over 55: 13
Sedentary Women, Obese Adults over age 55: 10
Weight Loss
1 pound body fat = 3500 kcals stored energy
Energy deficit of 500 kcals/day to lose 1 lb/wk
Energy deficit of 250 kcals/day to lose 1/2 lb/wk

Create energy deficit by:

Eating less calories
Exercise more
Guidelines for Weight Loss
Limit eating for emotional or situational reasons.
Limit non-nutritious energy sources.
Limit added fats.
Use lean meats.
Use lowfat dairy products.
Use lowfat cooking methods.
Choose low calorie beverages.
Eat a balanced diet and dont skip meals.
Exercise regularly.
Getting to the Heart of the
Matter
The number 1 cause of death for people with
diabetes is heart disease.
Minimize risk factors:
* control BG * dont smoke
* control BP * control lipids
* control weight * exercise regularly
Treatment Goals
Blood Pressure < 130/80

Total Chol < 200 mg/dl

LDL Chol < 100 mg/dl
HDL Chol > 40 mg/dl
Triglycerides < 150 mg/dl
Heart Healthy Diet
Decrease saturated, hydrogenated, and
trans-fatty acids. (< 7% kcals)
Limit dietary cholesterol. (<200 mg/d)
Increase intake of omega-3 fatty acids.
Increase intake of soluble fiber. (10-25 g/d)
Include plant stanols/sterols. (2 g/d)
Dietary Fats Defined
Saturated Fats
solid at room temperature
animal fats
Hydrogenated Fats
vegetable oils in origin, modified to solidify
Trans Fatty Acids
occur mostly in hydrogenated fats

All of the above fats can raise LDL cholesterol.

Dietary Fats Defined
Polyunsaturated Fats
safflower, corn, sunflower, sesame, cottonseed
Monounsaturated Fats
olive, canola, peanut, avocados
Omega-3 Fatty Acids
fish: salmon, tuna, mackerel, herring, sardines
vegetarian sources: flaxseed, walnut, soybean,
canola, evening primrose.
 Dietary Cholesterol
Only found in animal products.
Most concentrated sources:
eggs (212 mg/yolk)
shrimp (194 mg/3.5 oz, 100g)
squid (231 mg/3.5 oz, 100g)
liver (389 mg beef, 631 mg chicken, 3.5 oz, 100g)
meat (75-95 mg/3.5 oz, 100g beef, chicken, pork)
Soluble Fiber
Binds bile acids in the intestine, so that the
bile acids are not absorbed in the terminal
ileum.
New bile acids are made from circulating
cholesterol, thus lowering serum chol.
Best Sources:
oats, beans/legumes, rice bran, barley
carrots, broccoli, sweet potatoes,
citrus, papaya, apples, strawberries
Homocysteine Alert
Elevated homocysteine levels may increase
the risk of heart disease.
Adequate intake of these vitamins can lower
homocysteine levels:
Folate: fruits, vegetables, legumes, avocado,
yeast, wheat germ, fortified cereals and grains.
Vit B6: whole grains, legumes, fish, chicken...
Vit B12: milk, cheese, meat, fish, chicken, eggs
Blood Pressure Control
Lifestyle Modifications
control weight
exercise regularly
limit sodium
limit alcohol
eat diet rich in potassium
eat adequate amounts of calcium (?)
Reduce Sodium Intake
Limit to 2,400 mg/d
Low Sodium Strategies:
avoid the salt shaker
limit use of processed foods
limit fast food restaurant meals
season with herbs, spices, garlic, ginger, lemon,
onions, flavored vinegar
Potassium
Unless patient is limiting potassium for renal
disease, or hyperkalemia, encourage a diet
rich in potassium. Sources include:
apricots, avocados, bananas, cantaloupe, kiwi,
mangos, oranges, strawberries
artichokes, tomatoes, potatoes, yams, legumes,
parsnips, winter squash
milk, yogurt
lean meat, fish, skinless poultry
Exercise
Improves insulin sensitivity/lowers BG
Helps with weight control
Lowers blood pressure
Lowers LDL and triglycerides
Raises HDL
Improves circulation and strengthens heart
Improves bone density
Relieves stress, improves sleep
Complications = Restricted
Diets
Nephropathy
protein restriction 0.8 g/kg/day
potassium, phosphorus, sodium, fluid restrictions.
Gastroparesis
small frequent meals
lowfat, low fiber, puree/liquid consistency
difficulty matching insulin kinetics and digestion
timing.
 Dietary Management of
Diabetes: Guidelines
Same as for the general population

Total fat: 30% or less of total energy

(20% or less in obese)

If elevated triglycerides, reduce CHO and increase fat to 35-

40% of energy
Saturated fat -- 10% of total energy

Protein: 10 - 20% of total energy intake

CHO: 55% of total energy intake

Dietary Management of
Diabetes: Guidelines
Carbohydrates and Sweeteners
Emphasis on total CHO rather than simple or complex

Can have sucrose as part of CHO allotment up to a

maximum of 10% of calories

Different foods have different effects on blood sugar

level -- glycemic index
Nutrition Consult
Individualized Meal Planning
Conduct Initial Assessment of Nutritional Status
Diet History, Lifestyle, Eating Habit
Provide Patient Education Regarding
Basic principles of diet therapy
Meal planning
Problem solving
Developing individualized meal plan
Emphasize one or two priorities
Minimize changes from the patients usual diet
Priorities for Meal Planning

If require insulin (two injections of mixed short and

intermediate acting insulin):
Timing of meals and snacks important
Quantity and quality of food important
Watch CHO content
Snacks at time of peak insulin action

With more intensive use of insulin (including regular

insulin before meals)
Have more flexibility in food and timing
Priorities for Meal Planning

Type II diabetes with no insulin:

Gradually reduce total and saturated fat

Spread calories throughout the day
Avoid large amount of food at one time
Space meals at least 4-5 hours apart
Aim for healthy body weight
Promote appropriate exercise
Diabetic Exchange System
Are tools for enabling food choices based on categories
of foods and serving sizes
Patients need to be fairly literate
Canadian and American and European systems differ
Glycemic Index (GI)
An indicator of the impact of foods on the response of
blood glucose

Foods with a low GI are digested and absorbed more

slowly than foods with a high GI

Low GI foods increase amount of CHO entering colon

and increase fermentation

Used for making food choices by diabetics and people

with impaired glucose tolerance
Glycemic Index Value:
Examples
Food Glycemic Index
bread 100
cereal 72
milk 39
sucrose 87
orange juice 74
Artificial Sweeteners
Sugar alcohols (sorbitol, mannitol, xylitol cause less rise
in blood glucose

Non-nutritive Sweeteners
Aspartame (Equal, Nutrasweet, candarel)

Saccharin (Sweetn Low, Sugar Twin)

Alcohol Inake

Alcohol
Moderate amounts can be consumed when diabetes

is well controlled

No more than two drinks per day

Should always take alcohol with food

Some Special Situations

Delayed meals
Eat a snack if expect meal will be delayed

Carry available source of CHO i.e. Glucose tablets or

hard candy to avoid hypoglycemic reaction
Some Special Situations

Strenuous exercise
Eat extra food before activity and take 15-30 grams of
CHO for every 30 min of strenuous activity (15 g CHO
for each hour of less strenuous exercise)

Eat hearty snack after activity

If activity is pre-planned may reduce insulin dosage

prior to activity
Some Special Situations

Illness
Lack of appetite often with illness
Substitute foods that are well tolerated
Drink sugar containing liquids
For each missed meal give 50 g CHO in small
frequent feedings over 3-4 hours
Type I should not miss insulin as illness often causes
rise in blood glucose
Hypoglycemia: Treatment
Give quickly absorbed CHO immediately (1/3 can coke 33cl, 2
sugar cubes, 15 g glucose tablets)

Repeat treatment every 15-20 minutes if symptoms continue

If unconscious give intravenous glucose or glucagon injection

Diabetes in Children
75% of Type 1 diabetes occurs before 18 years
Peak onset is 6 -11 years

Balance between allowing for normal growth and

development, and need for glycemic control

Need meal plan that fits childs lifestyle and promotes

optimal compliance
Management Goals in
Children
Support normal growth and development
Control blood glucose
Prevent acute and chronic complications
Achieve optimal nutritional status
Gestational Diabetes
Nutrition management similar to Type 1 and Type 2.

Diet tends to be slightly lower in CHO and higher in

protein and fat (30-35%)

Requires individualized approach

Pyramid of Health Action
AHA Dietary Guidelines for Healthy
American Adults and

Unified Dietary Guidelines *

Saturated fat < 10% of calories

Total fat < 30% of calories

Polyunsaturated fat <10% of calories
Monounsaturated fat ~ 15% of calories
Cholesterol < 300 mg/d
Carbohydrates > 55% calories
Total calories to achieve and maintain desirable weight
Salt intake limited to < 6 gm/d (2.4 Na)
Alcohol only in moderation (<1-2/d)

*AHA Nutrition Committee, Circ 1996;94:1795-1800

AHA Conf on Prev Nutr. Circ 1999;100:450-456
AHA Discussion of
2000 US Dietary
Guidelines?
Eat a nutritionally adequate diet
consisting of a variety of foods
5 servings of fruits/vegetables
6+ servings of whole grains
Limit intake of foods high in saturated
fat, cholesterol and total fat
monounsaturated fat
trans fatty acids
omega 3 fatty acids
cholesterol level
2000 U.S. Dietary
Guidelines?
(cont)
Achieve and maintain an appropriate body

weight
Healthy BMI
Obesity recognized as an independent risk factor
Physical activity
Increase consumption of complex CHO and
fiber
Amount and type
2000 US Dietary Guidelines
(cont)
Reduce intake of sodium
contribution of ca, mg, K
contribution of obesity
physical activity and alcohol
Consume alcohol in moderation, if at all?
Red wine vs other types of alcohol
2000 US Dietary Guidelines
(cont)
Special Populations:
children
post-menopausal women
elderly
minorities
Populations at increased CVD risk
Elevated LDL-C or pre-existing CVD
Diabetes
Hypertension
Obesity
2000 DGs - Treatment: Obesity and
CVD
Diet Composition Recommendations
Total kcal adequate and appropriate
to prevent weight gain
achieve small, incremental weight losses
provide adequate nutrition, flexibility
Low saturated fat (<10% kcal)
Increase MUS to replace SF
Total Fat < 30% kcal