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Lesson 5 : Medical Nutrition Therapy

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.

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Lesson 5 : Medical Nutrition Therapy

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  1. Lesson 5 : Medical Nutrition Therapy

  2. 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)

  3. Types of DM * growing incidence in adolescents

  4. ADA Terminology Update

  5. Diagnostic Criteria FPG = Fasting Plasma Glucose RPG = Random Plasma Glucose OGTT = Oral Glucose Tolerance Test

  6. 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

  7. 215 250 160 200 Million people 100 150 100 50 0 1995 2000 2010 DM2 Doubling of the prevalence of DM2 to 215 million in the next 15 years 50% not yet diagnosed in Europe & North America! Diabetes 1994-2010: Global Estimates and Projections Jiwa F. Statistical Bulletin. Jan-Mar 1997;2-8

  8. Diabetes Number in Millions Year

  9. 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.

  10. Diabetes: A Worldwide Epidemic Percent of Individuals Considered Obese in a Given Country 2% 15% 25% 50% 70% Japan Samoa Europe Jordan US

  11. 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.

  12. Ratio 2.5 Ratio 2.2 Ratio 2.1 35 32.0 26.9 26.9 30 25 Control 15.5 20 (numberof deaths per 1000 patient years) 12.5 Diabetes 10.8 15 10 Mortality 5 0 10,025 61 6629 279 631 24 (No of patients) Helsinki Policemen Study Paris Prospective Study Whitehall Study Mortality in diabetes patients double that compared to non-diabetics Balkau Lancet 1997; 350:1680

  13. Causes of Death Among People With Diabetes Cause % of Deaths 40 15 13 13 10 4 5 Ischemic heart disease Other heart disease Diabetes (acute complications) Cancer Cerebrovascular disease Pneumonia/influenza All other causes Geiss LS et al. In: Diabetes in America. 2nd ed.1995:233-257.

  14. Complications of Diabetes • Macrovascular • coronary artery disease (MI) • cerebrovascular disease (Stroke) • peripheral vascular disease • Microvascular • retinopathy • nephropathy • neuropathy

  15. Diabetes complications • Retinopathy (blindness?) • Nephropathy (kidney problems) • Feet ulceration and/or amputations • Hypertension • Hyperlipidemia (cholesterol?) • Gestational diabetes (during pregnancy) • Diabetes and HIV • Erectile Dysfunction

  16. "therapies for weight reduction" 2

  17. Diabetes complications

  18. HbA1c – relationship with CV risk Glycaemia increase Associated risk increase 1%increase in HbA1c 43%increase in peripheral vascular diseasep<0.0001 21%increase in diabetes-related deathsp<0.0001 14%increase in myocardial infarctionp<0.0001 Stratton IM et al. BMJ 2000; 321: 405–12.

  19. 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

  20. 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 = 25% reduction microvascular complications 0.9% reduction in HbA1c UKPDS 33. Lancet 1998;352:837–853.

  21. Preventative MeasuresDCCT • 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.

  22. 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. Nathan D. Lancet. 1998;352:832-833. ©1998 PPS

  23. It Works…….at least for some things 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.

  24. Goals of Treatment • Alleviate symptoms • Prevent complications • Prevent progression of current complications • Improve quality of life • Alleviate symptoms • Prevent complications • Prevent progression of current complications • Improve quality of life

  25. ADA Goals of Treatment (cont.)

  26. 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

  27. Diabetic control • Normal HBA1C 3.5 – 6.5% • Targets

  28. Collaborative Management • Nutritional Therapy • Activity • Monitoring of Blood Glucose • Medication - Insulin or Oral Agents • Education

  29. 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

  30. 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

  31. Nutrition TherapyDiet Teaching • Goal - independence; effective self-management. • Include Family. • Follow prescribed plan; accurate portions • Never skip meals • Concern - Alcohol • Concern - Dietetic Foods

  32. Nutrient Components • Protein* • Fat* • CHO* • Sucrose and Fructose • Nutritive Sweeteners • Fat Replacements* • Vitamins and Minerals • Alcohol Intake*

  33. Increase in energy intake possible Diet and Insulin nec. to control BS Equal distribution of CHO through meals for insulin activity Consistency in daily intake - control BS Reduction of energy intake for obese Diet alone may control blood glucose Equal distribution of CHO desirable, not essential;low fat desirable Consistency in daily intake - control wt. Nutrition Goals forType 1 ****** Type 2

  34. Timing of meals - crucial Snacks - frequently necessary Additional food for exercise - CHO 20 g/h for moderate physical activity Timing of meals not essential Snacks - not recommended Additional food for exercise if on sulfonylurea or insulin Nutritional Goals (con’t)Type I ****Type 2

  35. 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

  36. Dietary Intake in US(NHANES III) • Mean daily intake • 2095 Total kcal • 34% Fat • 15% Protein • 50% CHO • 2% Alcohol

  37. Macronutrient Composition of Various Diets

  38. 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

  39. Type 1 Diabetes Mellitus

  40. 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 person’s usual food intake • Monitor blood glucose levels • Ref: Manual of Clinical Nutrition, 2000

  41. Meal Planning • Term “ADA Diet” is obsolete • Avoid the terms • no concentrated sweets • low sugar diet • liberal diabetic diet

  42. Medical Nutrition Therapy • Meal plans should be individualized • based on • nutrition assessment • medical history • psycho-social assessment • treatment goals

  43. 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.

  44. 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.

  45. 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 weren’t 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.

  46. 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

  47. Macronutrient Composition • No absolute percentages • CHO and MUFA should be 60-70% kcals • SFA < 10% kcals • Protein intakes of 15-20% kcals

  48. Sample energy distribution • 50-60 % CHO • 15-20 % Protein • 20-30 % Fat

  49. 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

  50. 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)

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