MEDICAL NUTRITION THERAPY FOR DIABETES

FELINA PINEDA CALIMBO,RND,MPH,ADE

MEDICAL NUTRITION THERAPY

A term that defines specific nutrition services to treat illness, injury, or a medical condition It involves the whole spectrum of what was formerly known as Diabetes Nutrition Education:
Assessment

of Nutrition Status Setting Nutrition Goals Developing a Nutrition Treatment Plan Evaluating the results of the plan

MEDICAL NUTRITION THERAPY

Recognized as the cornerstone of treatment for diabetes, with medication, physical activity, and blood glucose monitoring. MNT implemented by a Registered Dietitian can provide valuable benefits which includes reduced amount of medication, decreased hospital admissions &/or length of hospital stays, reduction of painful and dangerous complications and improved quality of life.

GOAL OF MNT in DIABETES

Educate client to make changes in food and exercise habits that will lead to improved metabolic control

Specifically:
1.

Attainment and maintenance of near normal blood glucose levels thru:

Coordination

of food intake Exogenous and endogenous insulin &/or hypoglycemic agents Physical Activity

Specifically:
2.

Attainment and maintenance of optimal serum lipid levels and blood pressure 3. Provision of adequate kilocalories to
Attain

& maintain healthy body weight for adults & normal growth and development for children Recover from illnesses Meet the metabolic needs of pregnancy and lactation

4. Prevention and treatment of acute and chronic complications of diabetes renal disease, neuropathy, hypertension and CVD 5. Improvement of overall health through proper nutrition

GOAL PRIORITY

A. Type 1 Diabetes persons taking insulin

Type 1 Diabetes it is important to facilitate consistency in timing of meals and snack to prevent wide swings in blood glucose
This

needs coordination in exercise-insulin-food intake

Type 2 DM Goals

It is important to achieve glucose, blood pressure and lipid goals To achieve these goals, diet is an integral part of the treatment Weight reduction will help improve glycemic levels and in the long run, improve metabolic control.

MEAL PLANNING

Exchange list and carbohydrate counting are two approaches in meal planning that allows flexibility while promoting day-to-day consistency in the amount of carbohydrate consumed. Children and adolescents have a greater variation in their daily calorie needs than adults because of their nutritional needs for growth and development and their more erratic activity and eating patterns.

Pregnant diabetics need to closely monitor their blood glucose levels and eat three meals and two snacks daily. The bedtime snack is especially important to avoid morning hypoglycemia.

Meal Spacing

Important in persons with Type 1 diabetes Client must be instructed on the peak hours and effect of insulin to stabilize blood glucose levels Basically, a client can eat up to 6x or every 4 hours while awake

Carbohydrate-Insulin Ratio

Is an advanced method of meal planning used with intensive insulin therapy In this approach, a diabetic must calculate insulin dose based on carbohydrate intake and blood glucose results.

Insulin

Insulin

Insulin is a hormone that helps the body use glucose for energy The beta cells of the pancreas make insulin When the body cannot make enough insulin on its own, a person with diabetes must inject insulin made from other sources (either animal insulin or human insulin made with bacteria in a laboratory)

Facts about Insulin

Insulin must be injected --- it cannot be taken orally because it is digested in the stomach juices, which destroy its effectiveness. The goal of intensive insulin-diet therapy is for food digestion and meal insulin (bolus) to peak in the bloodstream at 1-3 hours and coincide.

Intensive Insulin Therapy

For people with type 1 diabetes, this would mean 3 or more shots of insulin per day or use of an insulin pump It would also mean glucose monitoring (4-7x a day) Adjusting insulin doses to match exercise and food intake

For type 2 diabetes, methods of therapy used for reaching blood glucose goals can be quite different and a trial and error approach may be used. Meeting goals might require a combination approach of two oral diabetes medications or oral medications and insulin

Intensive Therapy

Aims to keep blood glucose levels very close to normal Keep in mind that some risks are involve Hypoglycemia can occur and weight gain may be possible Intensive management for both type 1 and type 2 diabetes requires additional education and frequent visits with health care team

Who can follow the Intensive Therapy?

Healthy adults with type 1 and type 2 Adolescents and older children Women with diabetes who are pregnant or who plans a pregnancy Patients who will have kidney transplantation for diabetic nephropathy

Facts About Insulin

Bolus insulin covers glucose eaten in food; it is given immediately before of after meals. Basal insulin covers hepatic glucose output and counter-regulatory hormones and is given once daily.

Facts About Insulin

There are different types of insulin: rapid acting, short-acting, intermediate acting, long acting peaking and long-acting peakless

Facts About Insulin

The types of insulin vary in three important ways, all related to time. ONSET: how quickly the insulin starts to work Peak activity: when the insulin works the hardest Duration: how long the insulin continues to work

Types of Insulin
Insulin Type Starts working (onset) (HOURS)
Within 10-30 minutes

Lowers blood glucose most (Peak) (hours)

- 3 hours

Finishes working (Duration) (Hours)

3-5 hours

Rapid Acting (Bolus) Aspart(Novolog) Lispro(Humalog) Gluisine (Apidra) Short Acting (Bolus) Human Regular Intermediate Acting(Basal) Human NPH Human Lente Long Acting Peaking (Basal) Ultralente Long-acting, peakless Glargine (Lantus)

- 1hour

1-5 hours

8 hours

1-4 hours 1-4 hours

4-12 hours 4-15 hours

14-26 hours 16-26 hours

4-6 hours 1-2 hours

8-30 hours Flat-basal like

24-36 hours 24 hours

Rapid Acting Insulin

Rapid acting analog insulins are in a clear solution Begins to work 10-30 minutes after it is injected, peaks in about an hour, and continues to work in about 3, possibly up to 5 hours. All rapid acting insulin should be injected immediately before a meal Meals should not be delayed because it leaves the bloodstream quickly Snacks are not needed There is less chance of low blood glucose several hours after a meal

Rapid Acting Insulin

Sometimes, rapid acting insulin may be given after meals for some children (because what they are going to eat is often difficult to predict before meals) People with gastroparesis ( a type of diabetic neuropathy) that affects the digestive system, may also benefit from taking rapid-acting insulin after a meal rather than before

Short-Acting Insulin

Common form is called regular (Humulin R and Novolin R) It comes in a clear solution It usually begins working 30-60 minutes after it is injected Works hardest 1-5 hours after injection and is completely gone after 6-8 hours. The larger the dose, the longer the duration of action

Short-Acting Insulin

Peak of regular insulin occurs about 3 hours after injection Because of its delay in onset and late peak after the meal, regular insulin should be injected at least 30 minutes before a meal. To prevent low blood glucose levels when it peaks, snacks are often needed.

Intermediate-Acting Insulin

NPH Neutral Protamine Hagedorn (Humulin N and Novolin N) and Lente (Humulin L, Novolin L) Begins to work within 1-4 hours after injection Reaches their peak in 4-15 hours Continue to work for up to 14-26 hours after injection Has cloudy appearance

Intermediate-Acting Insulin

Neutral Protamine Hagedorn Protamine is a protein that when added to regular insulin delays the absorption from under the skin, making it work over a longer period of time Lente means slow and is made by adding zinc to regular insulin, which forms crystals that slow the rate of its absorption into the bloodstream, prolonging its action

Long-Acting Peaking Insulin

Ultralente (Humulin U)- long acting insulin that doesnt begin working until 4-6 hours after injection It has a relatively low, prolonged peak, which occurs 8-30 hours after injection It continues to work for up to 24-36 hours Even though it has a peak, its peak is quite blunt and when given before breakfast and before dinner, can produce a basal effect

Long-Acting Peaking Insulin

Ultralente, a long-acting insulin, may be absorbed at different rates in different people For some people, it can function as intermediate-acting insulin, while for others, it is long-acting

Long-Acting Peakless Insulin

Glargine is essentially peakless Its release pattern from the injection site is smooth and continuous, lasting up to 24 hours It can lower fasting (morning) glucose levels without causing overnight low blood glucose It must not be mixed with any other type of insulin

Long-Acting Peakless Insulin

Because it has no peak, injections of rapidacting insulin must be given before all meals, sometimes before snacks, to provide bolus coverage for food intake It can be injected at any time during the day, as long as its the same time each day (usually given at bedtime) It can be used as part of a treatment program aimed at mimicking normal insulin action patterns for persons with either type 1 or type 2 diabetes

Long-Acting Peakless Insulin

Duration of action may be shorter in young children, who may require twice daily injections.

Fixed Mixtures of Insulin

Premixed insulins are solutions of rapid-acting or short-acting insulin + NPH insulin. Most commonly used by persons with type 2 diabetes who have difficulty mixing insulin It can also be convenient for people whose diabetes control is stable with one of these combinations. Disadvantage: mixtures have a fixed ratio of the 2 insulins and daily adjustments are difficult to make

Premixed Insulins

Usually not recommended for persons who can mix insulin themselves and for whom flexibility is important These would include:
Children

and adolescents Anyone with type 1 diabetes Thin (and thus more insulin sensitive) people with type 2 diabetes Pregnant women

Premixed Insulin

Example: 70/30 (Mixture is 70% NPH and 30% Regular)

Insulin & Meals

A typical meal of CHO, fiber, fat and protein, CHO is digested and absorbed in about 1 to 2 hour. Fat takes longer to digest than CHO, so meals containing moderate or high fat, or protein may require additional bolus insulin to overcome insulin resistance. To achieve optimal blood glucose control after a moderate or high fat meal, the bolus dose of insulin may need to be split (some taken with the meal, and some taken after the meal).

Insulin & Meals

A high fiber meal (>5 g/serving) also delays the digestion and absorption of CHO. Best control is achieved when the bolus dose of insulin is split.

Diabetes Survival Skills

Glycemic Control Goals

Before Meals Normal Blood Glucose (HbA1C <6) Person with diabetes with intensive treatment: Glycosylated hemoglobin <7 60-120 mg/dL 70-140mg/dL 2 Hours After Meals 140 mg/dL <180 mg/dL

Person with diabetes 80-160 mg/dL with adequate treatment: (HbA1C)

<200 mg/dL

Hyperglycemia (blood glucose >250 mg/dL)

Causes Too little insulin or oral medication Too much food Less activity than usual More stress than usual Illness, infection, or injury Symptoms/Signs Fatigue Increased thirst Unexplained weight loss Blurry vision Increased hunger Dry mouth and skin Increased urination Treatment Check blood glucose more frequently Take medication as prescribed Follow meal plan, adding more calorie-free liquids Obey the following 4 sick day rules

Hypoglycemia (blood glucose <60mg/dL)

Causes *Too much insulin o oral medication *More activity than usual *Skipping meals *Eating less than usual Symptoms/Signs *Slurred speech *Headache *Tingling of lips *Coma *Weakness *Nervousness *Sweating *Tremors *Hunger *Rapid heart beat *Confusion/disorientatio n Treatment *Test blood glucose immediately *Quickly take 15 gm of CHO (dextrose is best) *glucose tabs *candy (check label: first ingredient should be Dextrose) *Test blood glucose after 15 min *If blood glucose has not risen, repeat previous process *Treatment of low blood glucose should not take the place of a meal or snack

Nutrient Recommendations

Carbohydrates
Complex

carbohydrates in grains, fruits and vegetables are part of a healthy diet. Consistency in the amount of total carbohydrate eaten at meals and snacks is more important than the type of carbohydrate consumed. Together, total carbohydrate and monounsaturated fat should provide 60-70 % total calories.

Carbohydrate Counting

Basic carb counting stresses

sources

of carbohydrates Measuring the amount of carbs in foods Setting goals to eat a consistent amount of carbs at each meal and snack
Advanced

carbohydrate counting takes into consideration: fiber and protein content of a meal, fat-free foods and special situations such as eating out.

General Guidelines

Clients are advised to limit fat intake and select a balanced diet One carbohydrate U = 15 gm of CHO = 1 milk, fruit, starch, or milk exchange Examples of CHO U:
1 cup of milk or plain, unflavored, fat-free yogurt, or soy milk cup cooked cereal, grain, starchy veg 1/3 cup cooked rice, or pasta 1 slice bread or hamburger 1 small fresh fruit 1 tbsp sugar

calories
1000 1200 1500 1800 2000 2500

Total CHO U
9 11 14 16.5 18 23

Breakfast
3 3 4 4.5 5 6

Lunch
2 3 4 4 5 6

Dinner
2 3 4 4 5 6

H.S.
2 2 2 4 3 5

Sweeteners

Gram for gram, sucrose can replace starch without causing a deleterious effect on glucose levels High sugar foods may be high in fat and low in nutrients; they should be used judiciously Foods sweetened with fructose should be avoided because they negatively impact serum lipids even though they produce a smaller rise in blood glucose levels compared to other carbs Natural sources of fructose like vegetables need not be restricted

Fiber

Diabetics may benefit from eating more fiber (it increases satiety, a plus for weight management) and may prevent constipation Not recommended to eat more than the normal individual Recommendation for fiber are the same for the general population, > 25 gm/day for women and =38 gm/day for men

Protein

Need not be higher Current recommendation: 15-20% of TER is adequate Excessive amounts of protein should be avoided

Saturated Fat

Limit to <10% of total calories If LDL is > 100 mg/dL, limit to <7% of calories

PUFA

Should provide up to 10% of total calories Omega 3 fats may help to lower triglyceride levels and other coronary risks without negatively impacting glucose levels

MUFA

Using more MUFA and less carbohydrates is not advisable because it is high in calories and may promote weight gain. Level of MUFA should be based on weight and lipid levels.

Trans Fat

Keep as low as possible

Total Fat

A recommendation for total fat is not made but diets with <30% calories from fat may promote modest weight loss.

Cholesterol

Limit to <300 mg/dL If LDL is >100 mg/dL, lower to <200 mg/dL

Additional Tips

Drink alcohol in moderation when blood glucose has been in good control. Do not drink alcohol on an empty stomach. It may cause a low blood sugar reaction. Maintain daily records of food intake, medication and blood levels.

DIABETIC DIET COMPUTATION

Computation 1

Multiply calories for activity level with desirable body weight (you may use corrected body weight if patient is obese) or Deduct 500 kcal calories from the product (activity level x DBW) to produce a weight loss of 1-2 pounds / week

DIABETIC DIET

1. 2. 3. 4. 5.

CALORIES FOR ACTIVITY LEVEL ACTIVITY LEVEL MALE FEMALE Bed rest mobile 30 Sedentary 35 Light 40 Moderate 45 Heavy 50

27.5 30 35 40

FEMALE
HEIGHT 49 410 411 50 51 52 53 54 55 56 57 58 59 60 WEIGHT(KGS) 43 45 46 48 50 52 54 56 57 59 61 63 65 66

IDEAL BODY WEIGHT FOR FILIPINOS

MALE
HEIGHT 50 51 52 53 54 55 56 57 58 59 60 61 62

WEIGHT (KGS) 51 53 55 56 58 60 62 64 65 67 69 70 72

Computation 2

Use the standard 30 kcal/kg of ABW Deduct 500 kcal for overweight and obese or Add 500 kcal for underweight

Computation 3

Allot 10-12 kcal/lb of Ideal Weight

Male

106 # + 6 # every inch above 5 ft Female 100# + 5# every inch above 5 ft

Add 30% for Sedentary 50% for Moderate 100% for Heavy Activities

International Nutritional Guidelines for People with Diabetes*

Protein Carbohydrates Fat

Monounsaturated FA Polyunsaturated FA Saturated FA Dietary Fiber Glycemic Index

10-20 % TEI 45-55% TEI 30-40% TEI

10-20 % TEI < 10 % TEI < 7 % TEI 20-35 gm/day Low (GI <55) *American Diabetes Association, 2006
Association for the Study of Diabetes,2004

THANK YOU!!!