Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

1. Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

2. Diabetes Mellitus A group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both

3. Diabetes and Prediabetes: Types Type 1 (formerly IDDM, type I) Type 2 (formerly NIDDM, type II) Gestational diabetes mellitus (GDM) Prediabetes (impaired glucose homeostasis) Other specific types

4. Prediabetes (Impaired Glucose Homeostasis) Two forms; may have either or both Impaired fasting glucose (IFG): fasting plasma glucose(FPG) above normal Impaired glucose tolerance (IGT): plasma glucose elevated after 75 g glucose load

5. Type 1 Diabetes Two forms Immune mediated: beta cells destroyed by autoimmune process Idiopathic: cause of beta cell function loss unknown Symptoms: hyperglycemia, polyuria, polydipsia, weight loss, dehydration, electrolyte disturbance, and ketoacidosis

6. Type 2 Diabetes Most common form of diabetes accounting for 90% to 95% of diagnosed cases Combination of insulin resistance and beta cell failure (insulin deficiency) Progressive disease: hyperglycemia develops gradually and may not cause the classic symptoms of type 1 diabetes

7. Gestational Diabetes Mellitus (GDM) Glucose intolerance with onset or first recognition during pregnancy Occurs in about 7% of pregnancies

8. Risk Factors for Type 2 Diabetes BMI >25 Physical inactivity High-risk ethnic groups (African American, Latino, Native American, Asian America, Pacific Islander) Previous delivery of baby >9 lbs or GDM Hypertension HDL <35 mg/dl or triglycerides >250 mg/dl IGT or IFG History of vascular disease

9. Methods of Diagnosis Fasting plasma glucose (FPG) Casual plasma glucose (any time of day) Oral glucose tolerance test (OGTT)

10. Diagnosis of Diabetes Mellitus and Impaired Glucose Homeostasis Modified from American Diabetes Association: Diagnosis and classification of diabetes mellitus (Position Statement), Diabetes Care 30:S48, 2007. CPG, Casual plasma glucose; FPG, fasting plasma glucose; 2hPG, 2-hour plasma glucose level (measured 2 hours after an oral glucose tolerance test with administration of 75 g of glucose).

11. Algorithm for Type 1 Diabetes

12. Algorithm for Type 2 Diabetes

13. Management of Pre-Diabetes • Diabetes prevention trials • Lifestyle change • Increase physical activity • Moderate weight loss • Education • Reduced fat and energy intake • Regular participant follow-up • Whole grains and dietary fiber

14. Management of Diabetes Trials Diabetes and Control and Complications Trial (DCCT) United Kingdom Prospective Diabetes Study (UKPDS) Management Medical nutrition therapy Physical activity Monitoring Medications Self-management education

15. Insulin Counter-regulatory Hormones Glucagon: a hormone secreted by the A cells of the pancreatic islets of Langerhans in response to hyperglycemia; it has an opposite balancing effect to that of insulin, raising the blood sugar, and thus is used as a quick acting antidote for a low blood sugar reaction of insulin. Epinephrine (adrenaline):Epinephrine is a chemical that narrows blood vessels and opens airways in the lungs. These effects can reverse severe low blood pressure, wheezing, severe skin itching, hives, and other symptoms of an allergic reaction. Epinephrine injection is used to treat severe allergic reactions.

16. Insulin Counter-regulatory Hormones • Norepinephrine: Norepinephrine /nor·epi·neph·rine/ (-ep-ĭ-nef´rin) a catecholamine, which is the principal neurotransmitter of postganglionic adrenergic neurons, having predominant α-adrenergic activity; also secreted by the adrenal medulla in response to splanchnic stimulation, being released • Cortisol: Cortisol is a steroid hormone, more specifically a glucocorticoid, which is produced by the zona fasciculata of the adrenal cortex. It is released in response to stress and a low level of blood glucose. Its functions are to increase blood sugar through gluconeogenesis.

17. Insulin Counter-regulatory Hormones • Growth hormone: Growth hormone (GH or HGH), also known as somatotropin or somatropin, is a peptide hormone that stimulates growth, cell reproduction and regeneration in humans and other animals.

18. Diabetes: Treatment Goals Recommendations for Glycemic Control for Adults With Diabetes Modified from American Diabetes Association: Standards of medical care in diabetes—2007, Diabetes Care 30:54, 2007. *Referenced to a nondiabetic range of 4%-6% using a DCCT-based assay. †Peak levels in patients with diabetes.

19. Lipid and Blood Pressure Goals for Diabetes Recommendations for Lipid and Blood Pressure for Adults With Diabetes Modified from American Diabetes Association: Standards of medical care in diabetes—2007, Diabetes Care 30:54, 2007. HDL, High-density lipoprotein; LDL, low-density lipoprotein.

20. Medical Nutrition Therapy for Diabetes Individualize energy needs and nutrition care based on metabolic profile, treatment goals, changes person is willing and able to make

21. Goals of MNT for Diabetes Mellitus Pre-diabetes Decrease risk of diabetes and CVD by promoting healthy food choices and physical activity leading to moderate weight loss Diabetes Achieve and maintain BG levels in or near normal range, low-risk lipid and lipoprotein profile, low-risk blood pressure Prevent or delay chronic complications Address individual nutrition needs

22. Goals of MNT for Diabetes Mellitus– cont’d Specific situations Meet unique needs to youth with type 1 or type 2 diabetes, pregnant and lactating women and older adults with diabetes Self-management training for individuals treated with insulin or insulin secretagogues for safe exercise, prevention and treatment of hypoglycemia, and treatment of acute illness

23. Carbohydrate Low-carbohydrate diets are not recommended Sugars do not increase glycemia more than isocaloric amounts of starch Factors influencing glycemic response to foods: glycemic index (GI) and glycemic load (GL) Carbohydrate counting; portions of food containing 15 g carbohydrate Exchange lists

24. Fiber Research results are mixed Recommend same as general public: variety of fiber-containing foods such as legumes, fiber-rich cereals (>5 g/serving), fruits, vegetables, and whole grains

25. Sweeteners Sucrose in food plan should be substituted for other carbohydrate sources or covered with insulin or glucose-lowering medications Reduces intake of healthy foods or increases calorie intake Fructose has no benefit over sucrose Reduced calorie sweeteners: sugar alcohols and tagatose Nonnutritive sweeteners: saccharin, aspartame, neotame, acesulfame potassium, and sucralose

26. Protein Does not affect blood glucose levels in well-controlled diabetes Does not slow absorption of carbohydrate Recommend usual protein intake (15% to 20% of kcals)

27. Dietary Fat People with diabetes have similar risk to those with past history of CVD Recommend: Total fat 25% to 35% of total kcals Saturated fatty acids <7% Minimized or eliminate trans fat Very long omega-3 polyunsaturated fatty acids Plant sterol and stanol esters; 2 to 3 g/day

28. Alcohol Abstain if history of abuse, pregnancy, medical problems; moderation for others Moderate amounts of alcohol with food have minimal effect on glucose and insulin Excessive alcohol (3+ drinks/day) contributes to hyperglycemia

29. Micronutrients No clear evidence of benefits of supplements High-risk groups Chromium probably not beneficial

30. Physical Activity/Exercise Integral part of treatment plan for diabetes Improve insulin sensitivity Reduces cardiovascular risk factors Weight control Improves well-being May prevent type 2 diabetes in high-risk individuals Glycemic responses to exercise in type 1 and type 2 diabetes

31. Potential Problems with Exercise Hypoglycemia if using insulin or insulin secretagogues Due to increased insulin sensitivity Hyperglycemia Due to greater than normal increase in counterregulatory hormones Exercise guidelines Frequent blood glucose monitoring before, during and after exercise Reduce insulin or ingest carbohydrate

32. Insulin Guidelines for Exercise Moderate to strenuous activity >45 to 60 minutes: decrease rapid- or short-acting insulin (1 to 2 U) Prolonged vigorous exercise: may need 15% to 20% decrease in total daily insulin dose

33. Exercise Prescription At least 150 min/week of moderate-intensity aerobic physical activity; or at least 90 min/week of vigorous aerobic exercise Distribute over at least 3 days/week with no more than 2 consecutive days without activity Resistance exercise 3×/week

34. Oral Glucose-Lowering Medications Newer glucose-lowering medications used alone or in combination to achieve euglycemia in type 2 diabetes Four classes Insulin secretagogues: sulfonylureas (first and second generation) and meglitinides (repaglinide and nateglinide) Biguanides: metformin Thiazolidinediones: TZDs (pioglitazone, rosiglitazone) a-glucosidase inhibitors: acarbose, miglitol

35. Glucose-Lowering Medications–cont’d Insulin secretagogues Sulfonylureas and meglitinides Promote insulin secretion by b-cells Insulin sensitizers Enhance insulin action Biguanides (metformin) and TZDs Require presence of exogenous or endogenous insulin Enzyme inhibitors (a-glucosidase inhibitors) Inhibit enzymes that digest carbohydrates in small intestine; delay carbohydrate absorption and lower postprandial glycemia Acarbose (Precose) and miglitol (Glyset)

36. Insulin Essential to survive in type 1 diabetes May be needed to restore glycemia in type 2 diabetes Onset, peak, and duration Inhaled insulin Individualize type and timing of insulin regimen based on eating and exercise habits and blood glucose levels Insulin pump

37. Action Times of Human Insulin Preparations Adapted from Bode BW: Medical management of type 1 diabetes, ed 4, Alexandria, Va, 2004, American Diabetes Association.

38. Monitoring Self-monitoring of blood glucose (SMBG) up to 8 times per day Training and record-keeping Used to adjust insulin doses and food Continuous ambulatory blood glucose monitoring Urine and blood ketones

39. MNT for Type 1 Diabetes Integrate insulin regimen into usual eating habits and physical activity schedule Multiple injections (3+/day) of insulin pump Half insulin as basal or background; other half before meals Total energy intake and CHO intake to avoid weight gain

40. MNT for Type 2 Diabetes Lifestyle interventions to improve metabolic abnormalities (glycemia, dyslipidemia, hypertension) Progressive: usually need to add medication to MNT Blood glucose control, improve food choices, increase physical activity, moderate energy restriction to promote weight loss Teaching: carbohydrate sources, serving sizes, number of servings, meal planning, limiting fats SMBG

41. MNT for Type 1 Diabetes in Youth Maintain normal growth and development Nutrition prescription based on nutrition assessment Use typical food and nutrition history Adjust with age, physical activity, and growth rate Individualize food plans and insulin regimens Realistic blood glucose goals Reduce risk of CVD Meal planning approaches: CHO counting etc.

42. MNT for Type 2 Diabetes in Youth Accompanies childhood obesity Cessation of excessive weight gain, promote normal growth and development, achieve blood glucose and A1C goals Address comorbidities: hypertension and dyslipidemia Behavior modification strategies Metformin

43. MNT for Preexisting Diabetes and Pregnancy Preconception counseling Hormonal changes in first trimester lead to erratic BG levels; adjust meal plan Increased need for insulin in second and third trimesters Adjust meal plan to provide additional kcals Avoid hypoglycemia and ketosis

44. MNT for Gestational Diabetes Mellitus About 7% of pregnancies High risk for type 2 diabetes later in life Screening and testing Carbohydrate-controlled meal plan, adequate energy, normoglycemia, and absence of ketosis Individualize and adjust meal plan throughout pregnancy Use of insulin Carbohydrate distribution Exercise

45. MNT for Older Adults Increased prevalence of diabetes and IGT with age Similar recommendations to younger population Concern for malnutrition Hyperglycemia and dehydration can lead to hyperglycemic hyperosmolar state (HHS)

46. Nutrition Care Process Nutrition assessment Nutrition diagnosis Nutrition intervention Developing a food/meal plan Self-management training Facilitating behavioral changes and goal setting Nutrition monitoring and evaluation Follow-up

47. Acute Complications Hypoglycemia Autonomic/adrenergic symptoms: shakiness, sweating, palpitations, anxiety, hunger Neuroglycopenic symptoms: slow performance, difficulty concentrating, confusion and disorientation, slurred speech, irrational behavior, extreme fatigue, seizures, unconsciousness Treatment Hyperglycemia and diabetic ketoacidosis DKA is life-threatening but reversible Dawn phenomenon Somogyi effect

48. Common Causes of Hypoglycemia Modified from American Diabetes Association: Medical management of type 1 diabetes, ed 4, Alexandria, Va, 2004, American Diabetes Association.

49. Long-Term Complications Macrovascular diseases Dyslipidemia Hypertension Microvascular diseases Nephropathy Retinopathy Neuropathy

50. Hypoglycemia of Nondiabetic Origin Symptoms usually with BG <65 mg/dl Postprandial (reactive) hypoglycemia Alimentary hyperinsulinemia Idiopathic reactive hypoglycemia Fasting (food-deprived) hypoglycemia Factitious hypoglycemia Management: 5 or 6 small meals/day