Type 2 Diabetes Mellitus

The Prevalence of Overweight and Diabetes over 10 Years

25% increase
8.0%
60.0% 56.4%

49% increase
7.3% 7.0% 6.0% 4.9%

50.0% 45.0% 40.0%

5.0% 4.0% 3.0% 2.0%

30.0%

1.0%

1991

2000

1990

2000

Overweight BMI >25 Kg/m2

Diabetes & Gestational Diabetes

Mokdad et al. Diabetes Care. 2000; 23(9):1278-83. Mokdad et al. JAMA. 2000;286(10):1195-200. 2005. American College of Physicians. All Rights Reserved.

WHAT IS DRIVING THE DUAL EPIDEMIC?

CHANGES IN OUR LIFESTYLE!

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es d i et e t ababes Toi D

R. Heine MD

Metabolic Syndrome ?

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Pathogenesis/Pathophysiology Type 2 Diabetes Mellitus is a Progressive Disease

2005. American College of Physicians. All Rights Reserved.

Progression to Type 2 Diabetes

Genetics Insulin resistance Hyperinsulinemia Compensated insulin resistance Normal glucose tolerance Impaired glucose tolerance Genetics -cell "failure" Type 2 diabetes Insulin resistance Hepatic glucose output Insulin secretion
FFA = free fatty acid. Kruszynska Y, Olefsky JM. J Invest Med. 1996;44:413-428. 2005. American College of Physicians. All Rights Reserved.

Acquired Obesity Sedentary lifestyle Aging

Acquired Glucotoxicity FFA levels Other

Causes of Hyperglycemia in Type 2 Diabetes

2 Muscle and adipose tissue: decreased glucose uptake Insulin resistance

ntestine: glucose absorption

Blood glucose

Liver: increased hepatic glucose output

Insulin resistance 3 Pancreas: impaired insulin secretion

1997 PPS

DeFronzo RA. Diabetes. 1988;37:667-687. Lebovitz HE. In Joslin's Diabetes Mellitus. 1994:508-529. 2005. American College of Physicians. All Rights Reserved.

Approach to Treatment

Drugs to Treat Hyperglycemia, Correct Insulin Resistance, or Improve/Preserve B-Cell Function

2005. American College of Physicians. All Rights Reserved.

Pharmacotherapy Tailored for the Multiple Defects of Type 2 Diabetes Phenylalanine Derivatives Meglitinides
Restore postprandial insulin patterns
Sulfonylureas
__________
_ ___ __ __ __

Restore early postprandial insulin release

__________

Generalized insulin secretagogue

Type 2 Diabetes

-glucosidase Inhibitors
________

Delays CHO absorption

TZDs
________

Biguanide
________

Reduces hepatic Insulin resistance

Physiologic Insulin Replacement Therapy

Reduce peripheral insulin resistance

Oral hypoglycemic agent (OHA)

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The majority of patients will ultimately need combination therapy with oral agents and/or insulin treatment.
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And Dont Forget

Healthy Diet Exercise Smoking Cessation

2005. American College of Physicians. All Rights Reserved.

Nutrition therapy decrease fat content and total calories decrease saturated fat, substitute mono/polyunsats Low glycemic index CHOs Increase dietary fiber decrease salt for hypertension healthy diet weight reduction in obese patients Exercise increase energy expenditure with moderate-intensity exercise Lifestyle changes to reduce cardiovascular risk factors (eg, smoking cessation) Training in self-management and SMBG
1997 PPS

Nutrition Therapy, Exercise, Lifestyle Changes

2005. American College of Physicians. All Rights Reserved.

Objectives of MNT
1. To achieve & maintain: Blood glucose in normal range or close to normal as is safely possible a lipoprotein profile that reduces the risk of vascular disease Blood pressure in normal range or close to normal as safely possible 2. To prevent, or at least slow the rate of development of the chronic complications of DM by modifying nutrient intake and lifestyle 3. To address individual nutrient needs, taking into account personal and cultural preferences and willingness to change n 4. To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence. (ADA, 2008)

Objectives of MNT-special consideration

For individual treated with insulin or insulin secretagogues (OHA stimulates insulin excretion): to provide self-management training for safe conduct of exercise, including the prevention of hypoglycemia, and diabetes treatment during acute illness. for elderly & pregnant women - to provide their nutritional needs. (ADA,2008)

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Energy balance, overweight and obesity

In overweight or obese & insulin-resistant individuals: modest weight loss improve insulin resistance. PA & behavior modification are important components of weight loss programs Weight loss medications may be considered in the treatment of overweight and obese individuals with T2DM and can help achieve a 510% weight loss when combined with lifestyle modification.

Nutrition recommendations
CHO in dietary management:
45-65 % of total E (ADA 2006) includes CHO from fruits, veges, legumes, and low-fat milk is encourage for good health (A) Monitoring CHO whether by CHO counting, exchanges, or experience-based estimation, remains a key strategy in achieving glycemic control (A) The use of glycemic index (GI) may provide a modest additional benefit over when total CHO is considered alone (B)

Nutrition recommendations
Fat and cholesterol 25-35 % of total E (ADA 2006) Limit SAFA to 7-10 % of total calories. PUFA 10 % MUFA 10-15 % Intake of trans fat should be minimized. (E) lower dietary cholesterol to <200 mg/day (E) 2 or more servings of fish per week (with the exception of commercially fried fish filets) provide n-3 PUFA are recommended. (B)

Nutrition recommendations
Protein in diabetes management T2DM with normal renal function 1520% of E

ingested protein can increase insulin response without increasing plasma glucose concentrations. protein should not be used to treat acute or prevent nighttime hypoglycemia. (A)

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Nutrition recommendations
High-protein diets are not recommended as a method for weight loss at this time. The long-term effects of protein intake 20% of E on DM management and its complications are unknown. Although high protein diet may produce short-term weight loss and improved glycemia, benefits and short-and long term effect to kidney function to DM px are unknown. (E)

Nutrition recommendations
Px are encouraged to implement lifestyle modifications that reduce intakes of E, and trans FA, cholesterol, and Na and to increase PA in an effort to improve glycemia, dyslipidemia, and BP. (E) Plasma glucose monitoring can be used to determine whether adjustments in foods and meals will be sufficient to achieve blood glucose goals or if medication(s) needs to be combined with MNT. (E)

Nutrition recommendations
Alcohol in diabetes management If px choose to use alcohol, daily intake should be limited to a moderate amount (E) : 1 drink/d for women 2 drinks/d for men) To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food. (E) moderate alcohol consumption (when ingested alone) has no acute effect on glucose and insulin

Nutrition recommendationssecondary prevention

1 unit alcohol contains 15 g CHO, equivalent to: 12 oz beer, 5 oz wine, 1.5 oz distilled spirit (note: 1 oz~30ml, 1 g alcohol=7 kcal) Avoid alcohol in hypertrigliseridemia Alcohol metabolize as fat: 1 unit = 90 kcal = 2 exc fat

sucrose
Dietary sucrose does not increase glycemia more than isocaloric amounts of starch Sucrose can be substituted for other CHO sources in the meal plan or, if added to the meal plan, adequately covered with insulin or another glucose lowering medication (A) Care should be taken to avoid excess energy intake. (ADA 2008)

Fiber
Fiber dietary management: Px are encouraged to consume a variety of fiber-containing foods. However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. (B) 20-30 g/day as normal population or 14g/1000 kcal

Non-nutritive sweeteners
Nonnutritive sweeteners are safe when consumed within the daily intake levels established by the FDA. (A) FDA approved 5 non-nutritive sweeteners: Acesulfame pottasium-200x sweeter than sugar Aspartame (eg. Equal, Nutrasweet)-180 x sweeter than sugar (4kcal/tsp) Neotame -6000x sweeter than sugar Saccharine (eg.Sweet'N Low) -300-400x sweeter than sugar Sucralose (eg. Splenda)-600x sweeter than sugar sugar) Safe for public including DM px and pregnant women (E=12.4 %

Non-nutritive Sweeteners
FDA has established an "acceptable daily intake" (ADI) for each sweetener. This is the maximum amount considered safe to eat each day during lifetime. Acesulfame pottasium: 15mg/kg Aspartame : 5 mg/kg Neotame: Saccharine: 5 mg/kg Sucralose: 5 mg/kg

MNT for controlling diabetes complications

Microvascular complications Reduction of protein intake may improve measures of renal function 0.81.0 g/kg body wt/day in px with DM and the earlier stages of CKD 0.8 g/kg body wt/day in the later stages of CKD

MNT for controlling diabetes complications

Treatment and management of CVD risk Target HbA1c is as close to normal as possible without significant hypoglycemia. (B) For px at risk for CVD, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. (C) Px with symptomatic heart failure, dietary sodium intake of 2,000 mg/day may reduce symptoms. (C) In normotensive & HPT px, a reduced sodium intake (e.g., 2,300 mg/day) with a diet high in fruits, veges, and lowfat dairy products lowers BP (A) In most px, a modest amount of weight loss beneficially affects BP (C)

Hypoglycemia
Ingestion of 1520 g glucose is the preferred tx for hypoglycemia, although any form of CHO that contains glucose may be used. (A) The response to tx of hypoglycemia should be apparent in 1020 min; however, plasma glucose should be tested again in 60 min, as additional treatment may be necessary. (B)

Glycemic Index (GI)

GI category: Low : 0-<55 Intermediate: 55-70 High: >70 Food high in sugar not necessarily high GI eg Sucrose intermediate GI ~ bread, rice and potatoes The use GI and glycemic load (GL) may provide a modest additional benefit over when total CHO is considered alone (B) Low GI foods that are rich in fiber and other important nutrients should be encourage

Substituting high-GI with low-GI foods

High GI foods High GI rice (low amylose) eg glutinous rice, sticky rice Bread, whole meal or white Processed breakfast cereals Low GI foods Low-GI rice (high-amylose) eg Basmati Bread containing high proportion of whole grains Unrefined cereals eg oats or processed cereals with a low GI factor eg All Bran Cereals Biscuits with dried fruits, oats & whole grains eg oats those made with oats, whole grains, barley Temperate-climate fruits eg apples, orange Pasta, legumes, sweet potatoes, sweet corn, basmati rice

Plain biscuits & crackers Cakes & muffins Tropical fruits eg watermelon French fries, baked potatoes, mashed potatoes, tapioca

Thank you and Good Luck