Diabetes & Endocrine Center Salinas Valley Medical Clinic Dana Armstrong, RD, CDE 1 MEDICAL NUTRITION THERAPY Dana Armstrong, RD, CDE Director, Diabetes Services Diabetes & Endocrine Center Salinas Valley Medical Clinic MNT Recommendations 1. Promote/support healthful eating patterns, emphasizing a variety of nutrient dense foods, in appropriate portion sizes, to improve overall health and: • Achieve/Maintain body weight goals • Attain INDIVIDUALIZED glycemia, blood pressure and lipid goals • Delay or prevent the complications of diabetes MNT Recommendations 2. Individualized, consideration given to: • Personal and cultural food preferences • Health literacy and numeracy • Access to healthful food choices • Barriers, willingness and ability to make behavior changes • Health status and health goals
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Diabetes & Endocrine Center Dana Armstrong, RD, CDE ...• For many obese with T2D, weight loss of at least 5% is needed to produce beneficial outcomes in glycemic control, lipids,
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Diabetes & Endocrine CenterSalinas Valley Medical Clinic
Dana Armstrong, RD, CDE
1
MEDICAL NUTRITION THERAPY Dana Armstrong, RD, CDEDirector, Diabetes ServicesDiabetes & Endocrine CenterSalinas Valley Medical Clinic
MNT Recommendations
1. Promote/support healthful eating patterns, emphasizing a variety of nutrient dense foods, in appropriate portion sizes, to improve overall health and:
• Achieve/Maintain body weight goals
• Attain INDIVIDUALIZED glycemia, blood pressure and lipid goals
• Delay or prevent the complications of diabetes
MNT Recommendations
2. Individualized, consideration given to:
• Personal and cultural food preferences
• Health literacy and numeracy
• Access to healthful food choices
• Barriers, willingness and ability to make behavior changes
• Health status and health goals
Diabetes & Endocrine CenterSalinas Valley Medical Clinic
Dana Armstrong, RD, CDE
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MNT Recommendations3. Maintain the pleasure of eating by:
• Provide nonjudgmental messages about food choices• Limiting food choices only when indicated by scientific
evidence4. Provide practical tools for day-to-day meal planning;
don’t focus on individual macronutrients, micronutrients or a single food
MNT Recommendations
• ALL PWD offered a referral for individualized MNT by a RD knowledgeable and skilled in providing diabetes-specific MNT
• Study with 18,404 PWD
• Only 9.1% had one or more
nutrition visits IN NINE YEARS!
• PWD & providers not aware these services are available
Effect of MNTDrop in HbA1C
Type 1 1.0% - 1.9% Type 2 0.3 to 2.0%
Higher reductions in type 2 diabetes of shorter durationSustained when RD provided
ongoing visits
Drop in Lipids
Triglycerides 11-31%
LDL Cholesterol 7-22%
Total Cholesterol 7-21%
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PRIMARYPREVENTION
Nutrition Recommendations and Interventions for the Prevention of Diabetes
Energy Balance, Overweight & Obesity• Modest weight loss improves insulin resistance
• Recommended for all who have or are at risk for diabetes• Decreases free fatty acid mobilization
• Structured program• Lifestyle change, regular physical activity and
reduce energy and fat intake
• Maintaining wt loss for 5 yrs associated with sustained improvements in A1C & lipids
Power in Prevention• Prevent/delay diabetes
• wt, cut fat and calorie intake, physical activity
• 5-7% wt prevents or delays DM by nearly 60%
• If ≥60, lifestyle changes chances of DM by 70%
30.3 M withDiabetes
84.1 M withPre-Diabetes
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Free Fatty Acids & Insulin Resistance• Most obese individuals have elevated levels of FFAs which
cause peripheral (muscle) and hepatic insulin resistance• FFAs inhibit insulin-stimulated glucose uptake and glycogen
synthesis due to intramyocellular lipids (fat inside the cells)• With increased lipotoxicity, chronic diseases associated
with insulin resistance increase (diabetes, heart disease)• The levels and composition of fat in the diet can have a
significant role in insulin resistance Sears and Perry Lipids in Health and Disease (2015) 14:121
Energy Balance, Overweight & Obesity• To decrease wt, fat the most important nutrient to restrict
• 9 cal/gram in fat vs. 4 cal/gram in protein and carbohydrates• 500 calories/day (3500 calories/wk) = 1 pound/wk
• Exercise - modest effect on weight loss• Improves insulin sensitivity• Acutely lowers blood glucose• Important in long-term maintenance of weight loss
Body Mass Index
0
5
10
15
20
25
30
35
40
45
50
Obese
Overweight
Normal
Underweight
_______________
_______________
_______________
_______________
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Dana Armstrong, RD, CDE
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BMI – Asian Americans• Cut point for screening for pre-DM and DM2 is 23 kg/m2
(vs. 25 kg/m2)
• At increased risk for DM at lower BMI levels relative to the general population (screenat23.org)
Primary Prevention - QuestionMartha, 5’3”, 158 lbs (BMI 28), has an elevated A1C of 6.3% and does not want to start medication. What’s her best option?
A. Lose 5-10 poundsB. Lose 8-11 poundsC. Decrease her calorie intake by 5-10%D. Decrease her fat intake by 8-11%
Insulin Resistance - QuestionMartha’s central obesity increases her insulin resistance by which of the following mechanisms?
A. Decreased lipolysis in visceral fat cellsB. FFA inhibition of glucose uptake and glycogen synthesis C. Decreased glucose output by the liverD. Inactivation of insulin in the pancreas
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Dana Armstrong, RD, CDE
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Body Mass IndexMartha’s BMI places her in which weight category?
A. UnderweightB. Normal weightC. OverweightD. Obese
OBESITY MGT FOR TX OF TYPE 2 DIABETES
Diet, Activity and Behavioral Therapy
People who have Overweight or Obesity• Mgt/Wt ↓important for people with T1D, T2D, prediabetes• Intensive lifestyle intervention with frequent follow-up• Wt loss can delay progression from prediabetes to T2D and
is beneficial to the mgt of T2D
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People who have Overweight or Obesity• Reduced calorie interventions show ↓ A1C of 0.3%-2.0%, ↓ meds, quality of life in adults with T2D
• Sustained wt loss (>5 yrs) associate with sustained improvements in A1C and lipid levels
• Focus on 500-750 calorie/day deficit• 1200-1500 calories/day for women• 1500-1800 calories/day for men
People who have Overweight or Obesity• For many obese with T2D, weight loss
of at least 5% is needed to produce beneficial outcomes in glycemic control, lipids, and blood pressure
• Clinical benefits of weight loss are progressive and more intensive weight loss goals (15%) may be appropriate to maximize benefit depending on need, feasibility, and safety
Assessment and Recommendations• BMI calculated and documented at each patient encounter• Providers advise patients who are overweight/obese of
increased risk of CVD and death• Providers assess readiness to achieve weight loss then
• Those that HAVE NO calories • Nonnutritive sweeteners
Nutritive Sweeteners - Sucrose• Does not need to be restricted by PWD• Care taken to avoid excess energy intake• Does not glucose more than isocaloric amounts of starch• Broken down into glucose and fructose
• Fructose metabolized almost completely in the liver; directed toward replenishment of liver glycogen & triglyceride synthesis
• Glucose passes through the liver and goes to the muscle where it is metabolized for energy and to fat cells for storage
• Sugar free = No sucrose
Diabetes & Endocrine CenterSalinas Valley Medical Clinic
*Considered nutritive as it contains more than 2% of the calories in an equivalent amount of sugar, as opposed to non-nutritive sweeteners that contain less than 2% of the calories in an equivalent amount of sugar.
GRAS Sweeteners• Siraitia Grosvenorii• Stevia
Multiplier of Sweetness Compared to SucroseSWEETENER BRAND NAME MULTIPLIERSwingle Fruit Extract Nectresse/Monk Fruit in Raw/PureLo 100-250 xAcesulfame K+ Sweet One/Sunett 200 xAspartame Nutrasweet/Equal/Sugar Twin 200 xStevia Truvia/PureVia/Enliten 200-400 xSaccaharin Sweet ‘N Low/Sweet Twin 200-700 xSucralose Splenda 600 xNeotame Newtame 7-13,000 xAdvantame No brand name yet 20,000 x
If a product says “sugar-free” on the label, it is also low in CHOs.
• Definition of sugar-free = no sucrose• A product can be “sugar-free” but have plenty of carbs• Pillsbury Sugar Free Milk Chocolate Brownies® contains 24
grams of carbs per one brownie
TrueFalse
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High Intensity FDA Approved Sweeteners• For PWD accustomed to sugar-sweetened products, may
be an acceptable substitute in moderation
• Do not have significant effect on glycemic control but can reduce overall calorie/CHO intake
• Most studies show benefits with wt loss, but some research suggests an association with weight gain
High Intensity FDA Approved Sweeteners• For those who consume SSBs regularly, a low-cal or
nonnutritive-sweetened beverage may serve as a short-term replacement strategy
• Overall, people encouraged to decrease both SSB and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake
Dietary Fats• Need fat in diet for absorption of fat-soluble vit A, D, E and
K, function of nerves & brain, healthy skin and body cells• Able to obtain from food – do not need to ADD it to food• Major source of calories• Increases insulin resistance – the
more fat in diet, the more insulin required to manage glucose
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• Mono: Avocados, edamame, olives, raw nuts, sesame seeds • Poly: Walnuts, sunflower seeds, fish (salmon, albacore tuna)• All excepting for fish contain fiber • Natural state, with all vitamins and nutrients
• Processed – not in an original form• Mono: Olive, canola, and peanut oils• Poly: Sesame, corn, soybean, safflower oils• Fewer vitamins and nutrients• No fiber
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Healthy Dietary Fats - Omega-3 Fatty Acids• Eating foods rich in long-chain n-3 fatty acids is
recommended to prevent or treat cardiovascular disease• Two or more servings of fish/week
• Plant products• Palm, coconut and palm kernel oil
• Solid at room temperature
Trans Fat• Made when manufacturers add hydrogen to
vegetable oil – called “hydrogenation”
• Turn liquid oils into solid fats like shortening and hard margarine
• Hydrogenation increases the shelf life and flavor stability of foods containing these fats
Trans Fats
• Strong link between trans fat and heart disease
• LDL
• HDL
• May increase weight gain and abdominal fat
• May contribute to type 2 diabetes
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• Listed under TOTAL FAT• Loophole
• IF there is less than .5 grams of trans fat in a SERVING• Can be listed as “0” grams and state “trans fat free” on label• Manufacturers just decrease the serving size
• Look for the words “hydrogenated” or “partially hydrogenated”
Spotting a Trans Fat –Look on the Label
Dietary Fat• Primary goal is to reduce risk for CVD
• Increase unsaturated fats• Limit saturated fats (7% of calories)• Dietary cholesterol <200 mg/day• Avoid trans fats
•↓ animal products, added fats, and processed foods as much as possible
• Replace with unsaturated fats and not with refined CHOs
QUESTION: WHEN CAN A FOOD HAVE ZERO
CALORIES AND ZERO CALORIES FROM FAT YET BE 100% FAT?
ANSWER: WHEN IT’S A FDA APPROVED
FOOD LABEL!!
9:00
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Protein in DM Management• Typical intake 1-1.5 g/kg body
weight/d or 15-20% of total calories• Protein intake goals should be
individualized based on current eating patterns
• Some research has found successful management of DM2 and increased satiety with meal plans including 20-30% of total calories from protein
Protein in DM Management
No Kidney Disease
• No evidence adjusting daily level of protein intake will improve health in PWD w/o DM kidney disease
• Research inconclusive regarding ideal amount of protein
Kidney Disease (+RMA/↓GFR)
• Maintained intake at 0.8 g/kg body weight/day
• Reducing amt further not recommended as it does not alter glycemic measures, CVD risk measure or course of GFR decline
ProteinAVERAGE Need/Day Intake/Day
Man 56 grams 102 gramsWoman 45 grams 70 grams
VERY EASY to get all the protein needed in a day
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Protein in DM Management• Protein intake can ENHANCE or INCREASE insulin response
to dietary carbohydrates in Type 2 diabetes • Carbohydrate sources high in protein
(i.e. milk and nuts) SHOULD NOT be used to treat acute or prevent nighttime hypoglycemia due to potential concurrent rise in endogenous insulin
High Protein (Low Carb) Diets• May result in improved glycemia• Challenges with long-term sustainability• Can reduce antihyperglycemic meds for patients with DM2• Not recommended for pregnant/lactating women or
people with/at risk for disordered eating or renal disease• Used with caution in patients taking SGLT2 inhibitors due
to potential risk of ketoacidosis
Optimal Mix of Macronutrients• No ideal percentage of calories from
CHOs, protein and fat for all PWD• Distribution based on individualized
assessment of eating patterns, preferences & metabolic goals
• Emphasis on healthful eating patterns with nutrient-dense foods and less focus on specific nutrients
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Dietary Reference Intakes• To meet the body’s daily nutritional
needs while minimizing risk for chronic diseases• 45-65% calories from carbs • 10-35% calories from protein• 20-35% calories from fat
HEALTHYEATING PATTERNS
Specific Concept Recommendations
Eating Patterns• All members of health care team need to be
knowledgeable of nutrition therapy principles and supportive of implementation
• Emphasis: nutrient-dense foods• Examples of patterns with positive results:
• Plate Method• DASH Diet
• Mediterranean Diet• Plant-based Diet
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Plate Method• Simple/effective approach to glycemia
and wt mgt emphasizing portion control and healthy food choices
• Visual guide showing how to control calories (small plate), CHOs (limited to ¼ of plate) and emphasizes low-CHO, non starchy vegetables
• Consider for DM2 not on insulin, those with limited health literacy/numeracy or older and prone to hypoglycemia
Too Simple? Industry Influence?
French Fries
Apple Juice
White Bread BunIce Cream
Hamburger
Harvard School of Public Health
health.harvard.edu
www.hsph.harvard.edu/nutritionsource
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DASH Diet• Sodium intake 1,500-2300 mg per day• Focus on fruits & vegetables (8–10 servings/day), whole
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ALCOHOL IN DIABETES MANAGEMENT
Alcohol is a type of carbohydrate.
• Alcohol is a unique substance• Body processes alcohol before it metabolizes fat, protein or CHOs• A 5-ounce glass of wine typically contains 110 calories, 5 grams of
carbs, and about 13 grams of alcohol (which accounts for 91 of the calories)
TrueFalse
Alcohol in DM Management• Discussed with diabetes mgt team• Abstention
• History of alcohol abuse or dependence• Women during pregnancy• Medical problems
• Liver disease• Pancreatitis• Advanced neuropathy• Severe hypertriglyceridemia
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Alcohol in DM Management• Moderate alcohol consumption has no acute effect on
glucose and insulin concentrations• Carbohydrate co-ingested with alcohol (mixed drink) may
raise blood glucose• Limit intake
• One drink/day for women• Two drinks/day for men
Alcohol in DM Management• What is a drink?
• 5 ounces of wine• 12 ounces of beer• 1½ ounces of a distilled spirit
• ~15 grams alcohol/drink• 7 calories/gram of alcohol
Alcohol in DM Management• Hyperglycemia
• Excessive amounts (>2 drinks per day) on a consistent basis
• Hypoglycemia• Evening consumption may increase the risk of nocturnal
and fasting hypoglycemia, especially in Type 1 diabetes• Consume alcohol with food if using insulin or insulin
secretagogues
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Sugars - QuestionWhich of the following is true about sucrose digestion?A. Sucrose is broken down into glucose & fructose, and the
fructose is metabolized almost completely in the liverB. Sucrose is broken down into glucose & maltose, and the
glucose is metabolized almost completely in the liverC. Sucrose is broken down into glucose & fructose, and the
glucose is metabolized almost completely in the liverD. Sucrose is broken down into glucose & maltose, and the
maltose is metabolized almost completely in the liver
Fats - QuestionOlive oil and canola oil are good sources of:
A. Monounsaturated fatsB. Polyunsaturated fatsC. Saturated fatsD. Trans fats
Fats - QuestionWhich has the most saturated fat per ounce:
A. ChickenB. OlivesC. PeanutsD. Soybean oil
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Fat Distribution
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Chicken Olives Peanuts Soybean Oil
PolyunsaturatedMonounsaturatedSaturated
Kidney Disease - QuestionWhich dietary modification is beneficial for individuals with diabetes and early stage (+RMA, ↓GFR) kidney disease?
A. No modification necessaryB. Reduce protein to 0.8 kg/body weight/dayC. Reduce protein to 0.7 g/kg body weight/dayD. Limit protein to 4 ounces per day
Supplements - Question
You are seeing Brad for nutrition counseling. You perform an assessment and discover he is taking several dietary supplements, which include ginkgo biloba, bilberry, and milk thistle. He says they are very expensive and wants to know if he should continue to take the supplements.
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Supplements - QuestionYour best advice to Brad would be that:
A. Complementary therapies are generally safe because they are “natural”
B. The have a low risk of side effectsC. There is insufficient research to support universal use in
individuals with diabetesD. Supplements are regulated by the FDA
John’s Story
John, who has had type 1 for 25 years and wears and insulin pump, is out celebrating a friend’s birthday at a bar. He’s had 4 rum and cokes and some appetizers. He’s taken insulin for his carbohydrates while he’s been out. When he gets home he checks his blood sugar and he is 162.
Alcohol - QuestionDrinking alcohol puts John at risk for:
A. DKA due to ketone production which occurs with alcohol
B. High blood sugars later during the night or the next day due to gluconeogenesis
C. Hyperglycemia from the alcohol and appetizersD. Hypoglycemia
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SPECIFIC POPULATIONS
Nutrition Interventions for Children & Youth, PWD on Insulin, Pregnancy, Older Adults, Celiac Disease and Eating Disorders
Nutrition Intervention: Youth with Type 1
• Adequate energy to ensure normal growth and development
• Integrate insulin regimes into usual eating and physical activity habits
• New concern – about 25% of new diagnosis now are overweight
Nutrition Intervention: Youth with Type 2• Family and patient must prioritize changes
in eating and physical activity • When insulin not required, metformin
recommended• Victoza approved for use ≥10 yrs old• TODAY study suggested combo tx required
within 2 yrs of diagnosis• Comorbidities may already be present on dx
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Lifestyle Therapy in Youth• Nutrition
• No medication will control blood glucose in the face of uncontrolled eating
• Unlike current approach to type 1 diabetes, fat intake probably should be addressed initially
a minimum of:• 175 grams/day of carbohydrates• 71 grams/day of protein• 28 grams/day of fiber
• Amount and type of CHO will impact glucose levels, especially post-meal
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Nutrition Intervention: Pregnancy• Focus on food choices for appropriate weight
gain, normoglycemia and absence of ketones• After delivery
• High risk Type 2 diabetes• Lifestyle modifications to ↓ wt and ↑ physical activity• Within 5 yrs - 60% will have T2D and within 30 yrs almost
100% will have T2D• T1D diagnosed in 2% of women with GDM (after delivery)
Nutrition Intervention: Older Adults• Obese older adults may benefit from
modest wt loss of 5-10%• Evaluate nutrition status if involuntary wt
change >10 lbs or 10% of body weight in <6 months
• Daily vitamin supplement may be appropriate, especially with reduced calorie intake
Celiac Disease• 1.6-16.4% of T1D (0.3-1.0% general population)• Destruction of small intestine villi with exposure to gluten• Interferes with nutrient absorption • Diagnosis via blood tests and a biopsy of the small intestine
• Screen for IgA tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels
• Screen for tTG-IgG or DGA-IgG antibodies if IgA deficient
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Celiac Disease• Digestive symptoms more common in
infants and young children• abdominal bloating, diarrhea, vomiting,
constipation, weight loss• Digestive symptoms less likely in adults
• Anemia, fatigue, bone loss, depression, missed periods, infertility or recurrent miscarriage, skin rash
Celiac Disease• Treatment – gluten free diet
• ALL forms of wheat (including durum, semolina, spelt/faro) and related grains (rye, barley and triticale) MUST be eliminated
• This is a lifetime requirement
• Referral to a dietitian• Food selection, label reading, and other strategies to help
*Oats are inherently gluten-free, but are frequently contaminated with wheat during growing or processing. Several companies (Bob’s Red Mill, Cream Hill Estates, GF Harvest and Avena Foods) are currently among those that offer pure, uncontaminated oats.
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Nutrition Intervention: Eating Disorders• Seen 10 times more often in women with Type 1 vs. men
with Type 1• One third to half of all women with T1D take less insulin
than needed to control weight• Behavior compromises self-care and metabolic control• Care enormously complicated • Often undiagnosed and untreated
• Binge eating followed by purging• Anorexia Nervosa
• Severe, self imposed restriction on intake, often combined with extreme exercise
• Diabulimia• Not a recognized medical condition• Insulin omission as a tactic to lose weight
Eating Disorders: Clinical Presentation• Weigh less than 85%
of normal
• Intense fear of becoming fat
• Sees self as fat, even though thin
• Extreme exercise
• Misses 3 consecutive menstrual cycles
• Anxiety about or avoidance of being weighed
• Frequent and severe hypoglycemia
• Binging with alcohol
• Severe stress in the family
• Feels unable to stop or control eating
• Denies seriousness of low body wt
• Binge eats 2x’s a week for 3 months
• Frequent DKA
• Excessive exercise
• Use of diet pills, laxatives
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Question - GDMSara has just been diagnosed with gestational diabetes. Her current weight is 176 lbs and her pre-pregnancy BMI was 28. She should be referred to a dietitian for initial MNT:
A. Only if she was overweight at diagnosis
B. Within 48 hours of diagnosis
C. Within 1 week of diagnosis
D. Within 3 weeks of diagnosis
Question - GDMThe recommended total weight gain for Sara’s pregnancy is:
A. 15 poundsB. 15 to 25 poundsC. 25 to 35 poundsD. 28 to 40 pounds
GDM - QuestionDietary Reference Intake for carbohydrate for pregnant women is:
A. 130 grams per dayB. 150 grams per dayC. 175 grams per dayD. 200 grams per day
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Question - Eating DisordersJan is an aerobics instructor with type 1 diabetes on CSII. She teaches 4 classes per day, 6 days a week. She weighs 110 lbs (BMI = 17), and fasting glucose in clinic today is 327 mg/dL. Jan’s BMI places her in which weight category?
A. UnderweightB. Normal weightC. OverweightD. Obese
Question - Body Mass IndexWhich is most important when evaluating her diabetes control?
A. She should eat a snack before each class she teachesB. Her high blood sugar is due to the end of her
honeymoon periodC. She needs to increase her basal rateD. A psychiatrist should be consulted to evaluate her for an
eating disorder
TERTIARYPREVENTION
Nutrition Recommendations for Controlling Diabetes Complications
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Treatment & Management of CVD Risk*• Target A1C as close to normal as
possible without significant hypoglycemia
• Diet high in vegetables, fruits, whole grains and nuts
• Diet low in saturated and trans fats and cholesterol
*Epidemiology of Diabetes Interventions and Complications – follow-up to the DCCT
Treatment & Management of CVD Risk• Sustained weight loss of ≥ 5% is
needed to maintain a decrease in triglycerides
• Sustained weight loss of ≥ 10% is needed to maintain a decrease in total cholesterol and LDL cholesterol
Treatment & Management of CVD Risk - HTN• Predictive of progression of micro/macrovascular
complications• For pts with BP >120/80, lifestyle interventions include:
• Weight loss• Restricting Na+ (<2300 mg/day)• Increase consumption of fruits & vegetables (8-10/day) and LF
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Biggest BP Bang for the Buck
0
5
10
15
20
25
10 kg Weight Loss(5-20 point drop)Restrict Salt to 2.4 g/day(2-8 point drop)Alcohol ≤ 2 drinks/day (2-4 point drop)Aerobic Ex 30 min/day(4-9 point drop)
DROP IN SBP
Sodium Sources
Processed &
Prepared Foods77%
Natural Sources
12%
Added While
Cooking5%
Added While Eating
6%
Nutrition Intervention: Gastroparesis• GASTROPARESIS – The stomach’s ability to move food into
the small intestine is impaired; up to 50% of people with diabetes will develop gastroparesis. The slow stomach emptying characteristic of this condition can cause nausea, vomiting, a feeling of fullness after eating a small amount of food, bloating, discomfort in the upper abdomen, and a lack of appetite. These symptoms can also be accompanied by erratic blood glucose levels.
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Nutrition Intervention: Gastroparesis• Referral to a dietitian for a low-fat,
low-fiber diet• Avoid high-fat and high-fiber foods
• Fat naturally slows digestion• Fiber is difficult to digest
• Take fluids throughout the meal and sit upright for 1-2 hours after meals
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High Blood Pressure - QuestionJohn, 5’10”, 195 lbs (BMI 28), has high blood pressure (148/94) and does not want to start medication. What’s his best option?
A. Lose 20 poundsB. Restrict sodium intakeC. Exercise 20 minutes a day, x/weekD. Decrease his wine to less than 3 glasses a day
Meg’s StoryYou are seeing Meg for nutrition counseling, including basic carbohydrate counting. She has a 5 year history of type 2 diabetes and currently weighs 280 lbs. Her total cholesterol is 224 and LDL is 130. During your assessment she shares with you that she is anxious most of the time, but not about anything specifically; she feels that this is causing her to overeat and not be able to lose weight.
Learning - QuestionWhich of the following learning objectives do you establish?
A. Identify carbohydrate foodsB. Record food intake for 1 monthC. Drink non-caloric beverages instead of sodaD. Eat 3 servings of carbohydrates at dinner each evening
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Weight Loss - QuestionMeg wants to know how many pounds she needs to lose to lower and maintain her total and LDL cholesterol levels. You tell her:
A. 14 lbsB. 20 lbsC. 28 lbsD. 40 lbs
Referral - QuestionYou should also consider referring Meg to a:
A. CardiologistB. More experienced dietitianC. Certified diabetes educatorD. Mental health professional
Gastroparesis - Question
Jane has type 1 diabetes and was recently diagnosed with gastroparesis. She is a runner and has not been able to exercise recently due to nausea, vomiting, bloating, and intestinal pain. She experiences lows about 3 times a week.
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Gastroparesis - Question
What hypoglycemia treatment should she use?A. JuiceB. Regular sodaC. Glucose tablets, gels or hard candiesD. Peanut butter crackersE. A, B and C
Gastroparesis - QuestionWhat beneficial modifications can Jane make?
A. Small, frequent meals; reduce fat and fiber intake; exercise after meals; adjust insulin timing.
B. Small, frequent meals; reduce fluid and fiber intake; increase carb intake; adjust insulin timing.
C. Small, frequent meals; reduce fat intake; increase fiber intake; exercise before meals; adjust insulin timing.
D. Small, frequent meals; reduce carb intake; reduce fiber intake; exercise after meals; adjust insulin timing.
MEAL PLANNING
Eating “By The Numbers”
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Tools
• Basic – Plate Method
• Food records - for individual assessment
• In Depth – Exchanges and Carbohydrate Counting
Food Records• Good place for patient and practitioner to start TOGETHER• Eat “normally” and test blood glucose levels pre and post
meal• Be sure to eat “favorite” foods
• Use written record for review• Evaluate effect of food on BG levels
Exchanges: Advantages• Gives emphasis on more than one
nutrient and the importance of the overall content of foods
• Encourages consistency in the timing and amount of meals and snacks
• People desiring to lose weight might find this approach useful
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Exchanges: Disadvantages• Level of understanding
needed to grasp the concept of "exchanging" foods
• Requires learning where an unlisted food fits into the plan
Exchange CHO Prot Fat Cals Examples
Starch 15 3 0-1 80⅓ c rice, pasta, beans,
½ c corn, peas, 1 oz bread, 1- 4” pancake
Fruit 15 0 0 60
sm apple or banana, ½ pear, 2 T. raisins, 1½ c strawberries,
½ to ⅓ c juice
Milk 12 8 Varies Varies 1 c milk, 1 c yogurt
Other 15 Varies Varies Varies
2” sq brownie, 2 small cookies, ½ c ice cream, 3 T SF or 1 T reg syrup
Exchange CHO Prot Fat Cals Examples
Veggies 5 2 0 25 1 c raw vegetables, ½ c cooked vegetables
Protein 0 7 1-8 35-100
1 oz fish, meat, chicken or cheese, ½ c tofu,
1 egg
Fat 0 0 5 45 1 tsp oil, butter, or mayo, 6 almonds or cashews
Free 0-5 0 0 0-25 SF gelatin, 2 tsp SF jam, coffee, tea, spices
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GENERAL RULE for SERVING SIZESExchange Category Measure
StarchCereals/Grains/Pasta/Potato ½ cup
Beans/Lentils/Peas/Rice ⅓ cup Bread/Roll/Crackers 1 ounce
Fruit
Fresh 1 small pieceDried ¼ cup
Juice/Canned/Applesauce ½ cupCubed Melon 1 cup
GENERAL RULE for SERVING SIZESExchange Category Measure
Milk
Skim, 1%, 2%, Whole 1 cupChocolate ½ cupIce Cream ½ cup
Yogurt 1 cup
Other CHOsCookies 2 small (1¾”) Granola ¼ cup
Cake 1½” square
GENERAL RULE for SERVING SIZESExchange Category Measure
VegetablesRaw 1 cup
Cooked ½ cupJuice ½ cup
ProteinMeats/Chicken/Fish 1 ounce
Cheese 1 ounceEgg 1
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GENERAL RULE for SERVING SIZESExchange Category Measure
FatAvocado 1/8
Butter/Margarine/Oil/Mayo 1 tspNuts/Seeds 1 Tbsp
FreeCoffee, tea Unlimited
SF Syrup 1-2 TbspSF Jam/Jelly 2 tsp
LABELS AND LABEL READING
THE OLD
THE NEW
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You are reading the previous label of granola cereal and planning your breakfast. You decide to eat 1½ cups of granola. How many grams of CHOs are you eating?
Serving Measurement Grams of CHOs
Carbohydrate Counting: Advantages• With the focus on carbohydrate,
food and insulin can be matched more precisely to improve glucose control
• Injected insulin can be matched to grams of carbohydrate eaten at any time during the day
• FLEXIBILITY
You need to take insulin for your 1½ cups of granola cereal. You use insulin pens and your carb ratio is 1:8. How much insulin are you going to take for the food? How much would you take if you used an insulin pump?
Delivery Method Ratio Insulin for the food
Insulin Pen 1:8
Insulin Pump 1:8
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Carbohydrate Counting: Disadvantages• With focus only on carbohydrate, easy to lose sight of
overall nutritional quality of foods
Carb References• Doctor’s Pocket Calorie, Fat and Carb
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https://www.danatech.org/
NOTE: The 1 CUP measure is for your convenience ONLY! ALL information provided by the label is based on the WEIGHT (the information in parentheses) of the food serving.
Carbohydrate Factors• Precise way to calculate carbohydrates• Percentage of all food is carbohydrate• Based on WEIGHT not MEASURE• Need scale and a calculator• Example:
• 15% of the weight (in grams) of an apple is carbohydrate
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Dana Armstrong, RD, CDE
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Article on Carb Factors
Scales – Do the Math For You
Kitrics Nutritional Scale Perfect Portions Scale
The BEST Label of All• SIMPLE FOODS do not have
complicated labels• No fine print or long words
you cannot pronounce on a banana or pear, a box of frozen spinach or a bag of navy beans!
Diabetes & Endocrine CenterSalinas Valley Medical Clinic
You Calculate Insulin Know This Formula!• Needed to calculate total insulin needs for both food and
blood glucose levels• For pens/syringes, round up/down to nearest whole
number• Insulin pump calculations use decimal points
CARBS ÷ CARB RATIO + ( BG - GOAL
BG ) ÷ CORRECTION FACTOR
Your blood sugar is 187, your goal BG is 110 and you are eating the following for breakfast. How many grams of carbohydrates are you having and how much insulin will you need to take by syringe if your carb ratio is 1:9 and your correction is 1:36?
Food Amount CarbsEnglish Muffin 1
SF Strawberry Jam 3 Tbsp
Eggs, scrambled 2
Banana, large 1
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Your blood sugar is 187, your goal BG is 110 and you are eating the following for breakfast. How many grams of carbohydrates are you having and how much insulin will you need to take by syringe if your carb ratio is 1:9 and your correction is 1:36?
Item Calculation InsulinBrk = ____ grams 9
BG = 187
Goal = 110 110
Correction = 36 36
Exchanges - QuestionThe Nutrition Facts panel on a food package of cookies reveals 16 g of total carbohydrate and 3 grams of fat per serving. How many carbohydrate servings and fat servings are in 2 servings of the cookies?
A. 1 carb serving and 1/2 fat servingB. 1 carb servings and 1 fat servingC. 2 carb servings and 1 fat servingsD. 2 carb servings and 2 fat servings
Food Intake - QuestionGrace has type 2 diabetes that is controlled by lifestyle modification. Her typical weekday breakfast is ¼ cup egg substitute, 2 slices turkey bacon, 1 slice whole wheat toast with margarine, and ½ cup apple juice. Her 2 hr pp BG generally runs <140. She has noticed, that on weekends when she eats 2 pancakes with sugar-free syrup, ½ banana, and 1 cup skim milk her 2 hr pp generally runs higher. Why?
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Dana Armstrong, RD, CDE
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Food Intake - AnswerA. Breakfast carbohydrate intake is higher on the weekend
B. Breakfast carbohydrate intake is lower on the weekend
C. Breakfast carbohydrate intake is equivalent at weekday and weekend meals, so physical activity must be lower on the weekends
D. Variation in meal timing is contributing to glucose variation
Food Intake - QuestionGrace’s husband Tom has type 1 diabetes. His insulin:carbratio is 7 and his correction factor is 32 with a target BG of 120. On weekdays his usual breakfast is also a ¼ cup egg substitute, 2 slices turkey bacon, 2 slices of whole wheat toast with margarine, and ½ cup apple juice. On Sundays he usually eats 3 pancakes with 3 T. sugar-free syrup, ½ banana, and 1 cup skim milk.
Insulin Requirement for BreakfastOn Wednesday morning his blood sugar is 235 mg/dL. How much insulin does he require for his breakfast?
A. 8 unitsB. 9 unitsC. 10 unitsD. 11 units
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Math Calculations
• ¼ c egg sub • 2 slices bacon• 2 slice toast • margarine • ½ c juice
On Sunday morning his blood sugar is 75 mg/dL. How much insulin does he require for his breakfast?
A. 9 units
B. 10 units
C. 11 units
D. No insulin as his blood sugar is low
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Dana Armstrong, RD, CDE
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Math Calculations
• 3 pancakes • 3 T. SF syrup• ½ large banana• 1 cup milk
• Total
• __________• __________• __________• __________
• __________
Math Calculations
• Insulin for food _______ /_______ = ________
• BG over goal _______ - _______ = ________
• Insulin for BG _______ / _______ = ________
• Total _______ + _______ = ________
Insulin Requirement for BreakfastJohn’s carb ratio is 11 and his correction factor is 50 with a target BG of 100. His BG is 155 and he is eating 1 cup of oatmeal, ½ cup milk, and ¾ cup of strawberries. How much insulin does he need?
A. 3 units
B. 4 units
C. 5 units
D. 6 units
Diabetes & Endocrine CenterSalinas Valley Medical Clinic