Medical Nutrition: Diabetes Mellitus

Bien Matawaran, MD

Goals of MNT
s Primary prevention to prevent diabetes
Use MNT and public health interventions in those with
obesity and pre-diabetes
s Secondary prevention to prevent complications
Use MNT for metabolic control of DM
s Tertiary prevention to prevent morbidity and mortality
Use MNT to delay and manage complication of DM

11.21.2007

Diabetes Mellitus
s Is a group of diseases characterized by increased blood
glucose concentration resulting from defects in insulin
secretion, action or both
s Abnormalities in the metabolism of carbohydrates, fats, and
proteins

Specific Goals of MNT

s For youth with Type 1 diabetes
Provide adequate energy to ensure normal growth and
development
s For youth with Type 2 diabetes
Facilitate changes in eating and exercise habits that
reduce insulin resistance and improve metabolic status
s For pregnant and lactating women
Provide adequate energy and nutrients needed for
successful outcomes
Important to follow weight changes
Be very strict with regards to diet intake, make sure
that they eat and dont ever restrict on their calories,
because pregnant women with DM tend to be over
anxious with the health of their baby in mind
s For older adults
Provide for the nutritional needs of an aging individual
Prone in developing hypoglycemia unawareness,
therefore educate them properly
s For patients receiving insulin or insulin secretagogues
Provide information on prevention and treatment of
hypoglycemia and exercise-related blood glucose
problems
Use of self-glucose tests
s For individuals at risk for diabetes
Decrease risk by increasing physical activity and
promoting food choices that facilitate moderate weight
loss or at least prevent weight gain

Etiologic Classification
s Type 1 DM
B-cell dysfunction leading to absolute insulin deficiency
s Type 2 DM
Predominant insulin resistance with relative insulin
deficiency or
Predominant secretion defect with insulin
s Gestational DM
s Other specific types
Type 1 DM
s Results from autoimmune destruction of pancreatic B-cells
s May be idiopathic
s Absolute insulin deficiency secondary to inflammation of the
islet cells (isletis)
s Lean body make up
s Presents with ketoacidosis as initial sign
s Abrupt onset of symptoms before age 30
s Insulin dependent
Type 2 DM
s Insulin resistance and B-cell failure
s Age above 30 years
s Strong genetic predisposition
s Lack of physical activity and obesity
s Not insulin dependent initially
s Undiagnosed for many years

Insulin Combinations
s Insulin rises postprandially, otherwise you have basal insulin
levels
Insulin treatment for type 1: inject basal and then again
after eating
s Lispro or Aspart
Every time before eating + basal insulin analogue
(Glargine: long-acting and peakless)
CHO counting give appropriate doses of insulin to
cover anticipated peaks after eating
s Regular insulin + intermediate-acting insulin (NPH)
12-14 hours (give 2x a day)
Covers prandial rises; instruct patient to eat snacks in
between
Prescribe same amount of calories but distribute
amount (6 meals/day)

Gestational DM
s Any degree of glucose intolerance with onset or first
recognition during pregnancy
s Whether pregestational or recent onset
Management of DM
s Primary Goal: maintenance of close-to-normal blood glucose
level without causing hypoglycemia
HbA1C
Preprandial glucose
Postprandial glucose

< 7%
< 90-100 mg/dl
< 180

Standards of Medical Care

s Medical Nutrition Therapy
s Diabetes self-management education
s Physical activity
s Psychosocial assessment and care
s Pharmacological therapies
Assessment of glycemic control (SMBG and HbA1C)
s Assess glycemic control SMBHG/HbA1C
s Appropriate management
Decrease in HbA1C
2% in newly diagnosed type 2 DM
1% in patients with average diabetes duration of 4 years

Risk Factors for Type 2 DM

Patient
Characteristics
Age >/=45 years old
Overweight/obese
BMI >25 kg/m2
Physical Inactivity
Race Asians

Medical Nutrition Therapy (MNT)

s Is an integral component of diabetes management and
diabetes self-management education
s Process by which the nutrition prescription is tailored for
people with diabetes based on medical, lifestyle, and personal
factors

Medical History
Family
history
Coronary artery
disease
CVA
Previous hx of
IFG/IGT/GDM
(IGT impaired
glucose tolerance)
(IFG impaired fasting
glucose)

Clinical Findings
Hypertension
Dyslipidemia

Nutrition Recommendation and Intervention for Primary

Prevention
1. Moderate weight loss (7% body weight)
2. Regular physical activity (150 min/wk)
3. Reduce intake of fat
4. Dietary fiber intake of 14kg/1000 kcal
5. Food containing whole grain (1/2 of grain intake)

Nutritional Intervention
s Should start even before diagnosis for those at risk
s Should be incorporated in the management even if compliant
with medications
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6.
7.

Low-glycemic index foods that are rich in fiber and other

important nutrients are to be encouraged
Moderate alcohol intake may reduce risk for DM
- one to three drinks (14-45g alcohol)/day
- U or J shaped association

Fiber
s Structural and storage polysaccharide and lignin in plants
that are not digested in the stomach or absorbed in the
small intestine
s Increase fiber containing CHO sources (75g per serving),
10-25 g/day, 14g/1000kcal
s Palatability, bloating and gas

CARBOHYDRATES (50-60% OF TER)

Principles of Nutritional Care
Energy
Type 1 Diabetes
s Normal growth and development (insulin-anabolic hormone,
therefore increases BW)
s Physical activity
s Maintenance of DBW

Characteristics of a Fiber Rich Meal

1. Processed more slowly
2. May be less caloric
3. May prevent risk of heart diseases and colon cancer
4. 20-30% reduction in the risk of development of type 2 DM
High fiber
>5g/serving, 10-25g/day, 14g/1000 kcal
Palatability, bloating, gas formation
Do not recommend in patients with diabetic
gastroparesis

Type 2 Diabetes
s Need for weight reduction or prevention of excessive weight
gain
Nutriture

Sedentary
activity

Underweight
Normal
overweight

35
30
25

Light activity
Kcal/kg DBW
40
35
30

Moderate
activity

Nutritive Sweeteners
s Sucrose
Aka table sugar
Dietary sucrose has no more effect on diabetes control
than does isocaloric amounts of starch
s Fructose
Reduction in postprandial glycemia vs. starch and
sucrose
Large amounts (15-20% of total daily energy) of
fructose increases fasting total and LDL cholesterol
s Sugar alcohols
Polyols
Are only partially absorbed from small intestines,
allowing the claim of reduced energy
2 calories/gram or the calorie of other nutritive
sweeteners
Less posprandial glucose response versus sucrose or
glucose
Reduce dental caries
Side effect of diarrhea
Ex. Erythritol, Sorbitol, Mannitol

45
40
35

ADA Carbohydrate Recommendations

s Average minimum RDA for carbohydrates- 130 g/day
s 50-60% of TCA
s The TOTAL amount of carbohydrates is more important than
SOURCE or TYPE of carbohydrates
ADA Carbohydrate Recommendations
1. A dietary pattern that includes carbohydrates from fruits,
vegetables, whole grains, legumes, and low fat milk is
encouraged.
2. Low carbohydrate diets (< 130g/day), are not recommended.
3. Monitoring CHO, whether by CHO counting, food exchanges
or experience-based estimation remains a key strategy.
4. The use of GI and GL may provide a modest additional
benefit.
5. sucrose-containing foods can be substituted for other
carbohydrates in the meal plan or, if added to the meal plan,
covered with insulin.
6. As for the general population, diabetics are encouraged
to consume a variety of fiber containing foods.
7. Sugar alcohol and non-nutritive sweeteners are safe when
consumed within the daily intake levels given by FDA.

Non nutritive sweeteners

s Aspartame (Equal, Nutrasweet)
Is the most widely used
Heat labile, therefore cannot be used for baking
Broken down to phenylalanine and aspartic acid
Headache has been reported
s Sucralose (Splenda)
Made from sucrose through a multi-step process in
which 3-H-O2 groups are replaced with 3 chlorine
atoms
No effect on glucose homeostasis in diabetics
600x sweeter than sucrose
Heat stable, therefore can be used for baking
s Acesulfame K
s Neotame
s Saccharin

Glycemic Index
s Relative area under the post prandial glucose curve (AUC)
comparing 50 g of carbohydrates of standard food--glucose or
white bread
s Developed to compare the postprandial responses to constant
amounts of different CHO containing foods
s Does not take into account the total CHO in a typical food
serving
s Measure of glycemic response after food consumption
(postprandial)
s Expressed as a percentage of glycemic response observed
after reference food consumption
s A low GI diet improves glycemic control
s Low GI
Med GI
High
s 55
56-70
70
s High GI is (+) correlated with insulin resistance and
prevalence of metabolic syndrome
s Long term GI diet improves glycemic control, long intake of a
low GI diet may play an important role in the treatment of DM
and other d/o.
s Lower GI, better glycemic control

ADI Acceptable Daily Intake

s Amount of food additive safely consumed on a daily basis
over a persons lifetime without risk
s Actual intake is much less than ADI
FATS (20-30% OF TER)
ADA Fats Recommendations
s Limit saturated fat to 7% of total calories
s Intake of trans fat should be minimized
Saturated and trans fatty acids are the principal dietary
determinants of plasma LDL cholesterol
s Limited dietary cholesterol to 200 mg/day
s Two or more servings of fish per week (except commercially
fried fish fillets) which provide N-3 (omega 3)
polyunsaturated FA are recommended

Glycemic Load
s Product of the glycemic index and the amount of
carbohydrates (in grams) in a carbohydrate containing.. .
s Used to compare the glucose raising effect of food with their
differing amounts of CHO.
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Dietary fats

A flexible plan or a variety of approaches is required to deal

with differing needs

Dietary Educational Tools

s Food Pyramid
s Signal system (healthy food choices)
s Zimbabwe hand jive
s Plate model
s Food exchange system
s CHO counting
s Glycemic index
Signal System
s Based on a traffic lights concept
s Red foods (to be taken in small amounts)
Those rich in fat
Sugar (refined CHO)
High glycemic index foods
Low fiber content
s Yellow foods (to be taken in moderation)
High glycemic index food
Low fiber content
s Green (healthy choice)
Low glycemic index
High fiber
Low in fat

PROTEIN (15-20% OF TER)

ADA Protein Recommendations
1. For individuals with diabetes and normal renal function,
maintain usual protein...
2. In type 2 DM, ingested CHON can increase insulin response
without increasing plasma glucose concentration, therefore,
CHON should not be used to treat acute or prevent night
time
ADA Protein 3* Recommendations
s Microvascular complications
Reduction of protein intake to
r 0.8-1.0 g/kg body weight/day for diabetics and the
earlier stages of CKD
r May improve measures of renal function (urine
albumin excretion rate, GFR)
r 0.8-1.0 g/kg BW/day in DM early stages of CKD
r 0.8 g/kg BW/day later stages of CKD

Zimbabwe hand jive

s
s
s
s

CHO : size of fist

Vegetables/fiber: two hands, can have as much as they want
CHON: cupped palm, thick as a finger
Fats: tip of thumb

Plate method
s Vegetables: half
s CHON: 1/4
s Starch: 1/4
s Milk: 1 exchange (glass)
s Fruit:1 exchange (desert plate)

Protein
s RDA is 0.8 g of good-quality protein per kg/body weight/day
(on average- 10% of calories)
s Good quality CHON sources = defined as having high
PDCAAS (CHON, digestibility corrected Amino Acid scoring
pattern) scores and provide all 9 indespensable Amino acid.
eg. meat, poultry, fish, egg, milk, cheese, soy
s In meal planning, it should be >0.8g kg/day to account for
mixed protein quality in foods
s Meal replacements
Taken when meal/s will not be taken
Cannot be given when there is regular meal intake

Carbohydrate Counting
s Is based on the concept that each choice of CHO equals
approximately 15 grams of CHO
s The average person needs about 3-4 choices (45-60 gms)
of CHO each meal. This number could be more or less
depending on calorie needs, medication and activity
s Estimate the amount (grams) of CHO in a particular food
then match their CHO intake to the appropriate mealtime
insulin dose.
s 1-2 units of insulin is injected before eating for 15-20g of
CHO

VITAMINS AND MINERALS

ADA Micronutrient Recommendations
s There is no clear evidence of benefit from vitamin/mineral
supplementation in people with DM (compared with the
general population) who do not have underlying deficiencies
s Routine supplement of antioxidants, such as Vit. E and C and
carotene, is not advised because of lack of evidence of
efficacy and concern related to long term safety.
s Benefit from chromium supplementation in individuals with DM
or obesity has not been demonstrated and therefore cannot be
recommended.

Advantages
Improved glucose control
Flexibility in food choices
Simplification
of
meal
planning

Disadvantages
Potential weight gain
Unhealthy eating
Hypoglycemia
High lipid levels

Planning Individual Food Pattern Using Food Exchange List

The Dietary Prescription
1. Compute for DBW
2. Determine nutritional status
3. Compute for TER/TCA (Krause)
4. Distribute TER among CHO, CHON & FATs
5. Calculate in grams

ALCOHOL
s Daily intake should be limited to a moderate amount (</= 1
drink/d for females and </= 2 drinks/d for males)
s Alcohol should be consumed with food so as to reduce the risk
of nocturnal hypoglycemia in individuals using insulin or insulin
secretagogues.
s In DM, moderate alcohol consumption (when ingested alone)
has no effect on glucose and insulin concentration nut CHO
ingested with alcohol (mixed drink) may raise blood glucose.

Dietary Prescription
s
s

TCA
Normal nutriture

The diabetic "make-up"

s Unconsumed food replaced with an equivalent amount of
fruit exchange
s 1 exchange of unsweetend fruit juice = = 10g
s Available glucose from
r CHO food = 100% ~ 1.0
r CHON food = 58% ~ 0.58
r Fat food = 10% ~ 0.1

Planning an Individual Food Pattern

s There is no single "ideal diabetic diet"
s Patients must be made aware of the rationale for restrictions
s A uniform approach to meal planning does not work for
everyone
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