Nutrition and Diabetes

Nutrition and Diabetes

OS 214: Gastroenterology NIM module

Final Exam

November 14, 2008| FRIDAY Page 1 of 7Kiev.Trix.Ace.Robert

Lecture Outline:I. Diabetes: Nutritional Mechanisms

A. Breakdown of Dietary CarbohydratesB. Metabolism of GlucoseC. Diabetes mellitusD. Hormonal Regulation of Blood GlucoseE. Obesity and Type2 DiabetesF. Gestational Diabetes mellitus

II. Diabetes: Dietary ManagementA. Energy BalanceB. Glycemic ResponseC. Medical nutrition Therapy D. Myth vs. FactE. Glucose Management Tools

III. Diabetes: Filipino SettingA. Filipino ProfileB. Filipno Diet Guidelines

IV. Appendix

I. Diabetes: Nutritional MechanismsA. Breakdown of Dietary Carbohydrates - Carbohydrates: molecules made up of carbonm, hydrogen and oxygen

Compound Description ExamplesMonosaccharides Composed of one

sugar unitGlucose, fructose, mannose, galactose

Dissacharides Composed of Two sugar units

Maltose, lactose, sucrose

Polysaccharides Composed of long chains, usually >10 units

starch

- Processing1. Digestion• amylase from the salivary glands and pancreas

acting on sugar molecules • end products: glucose and maltose2. Absorption and Transport• simples sugars (monosaccharides and pentoses)

are absorbed in the duodenum and jejunum• process is energy-dependent (active transport)

through carrier proteins• glucose is brought to the liver via the portal vein at

the rate of 1g glucose/kg b.w./hour• glucose goes through the glycolytic pathway

(fructose and galactose also ulitize this pathway), to produce energy, or is stored as glycogen

3. Metabolism • monosaccharides are phosphorylated, then

metabolized via glycolysis, petose-phosphate pathway (PPP), or is stored as glycogen

• special sugars given to diabetics such as sorbitol and xylitol are metabolized slowly

B. Pathways for Glucose Metabolism1. glycolytic pathway2. pentose phosphate pathway3. Kreb’s Cycles4. Gluconeogenesis5. Cori Cycle6. Glycogenesis

C. Glucose Handling in Diabetes carbohydrate diets induce prolonged increase in

blood glucose

glucose uptake is not sufficient to balance high glucose in the blood

in patients with DM, small frequent feeding is advised

D. Hormonal Regulation of Blood Glucose1. Insulin: a polypeptide hormone from beta cells of Islets of Langerhans- Actions of Insulin

Increases DecreasesGlucose uptake GluconeogenesisAmino acid uptake and protein synthesis

Glycogenolysis

Fatty acid synthesis LipolysisGlycogenesis proteolsysisGlycolysis overall DECREASE in blood glucose

Insulin-Stimulated Glucose UptakeInsulin binds to tyrosine kinase receptors translocation of GLUT4 (glucose transporters to cell membrane increased glucose uptake by the cell

Insulin SecretionStimulators: a. post-prandial surge of glucose, amino acids and fatty acidsb, incretin hormonesc. acetylcholineRepressors:a. leptinb. sympathetic nervous system (eg, norepinephrine)

2. Chromium: part of a complex that enhances insulin receptor activity (thus, improves glucose uptake by the cell) adequate intake is 35 ug/day for men; 25 ug/day

for women souces: processed meat, broccoli, raw onions,

whole grain deficiencies are rare, but excess amounts do not

have any beneficial effect

3. Glucagon: polypeptide hormone from alpha cells of Islets of Langerhans

Increases DecreasesGluconeogenesis GlycogenesisGlycogenolysis GlycolysisLipolysis Synthesis of glycolytic

enzymesKetgenesis overall INCREASE in blood glucose

Glucagon SecretionStimulators:a. Low blood glucoseb. Increased circulating amino acidsc. Sympathetic nervous system (eg, norepinephrine)Repressors:a. Hyperglycemiab. Increased circulating fatty acidsc. Somatostatin

Metabolic effects of insulin and glucagon (See appendix A)



Final Exam


Epinephrine and CortisolEpinephrine Cortisol

- secretes by the adrenal medulla in response to acute stress (fight or flight response)- increase in glycogen breakdown- Increases gluconeogenesis from lactate and amino acids- increases mobilization of fat via activation of hormone-sensitive lipase- metabolic effects are mediated by both alpha and beta receptors.. the latter predominates in humans

- produced by the adrenal cortex in response to stress, trauma and hypoglycemia- works synergistically with glucagon by activating key gluconeogenic enzymes, phosphoenolpyruvate carboxykinase (PEPCK)- indirectly maintains glucose production (from protein) and facilitates fat metabolism

Fed vs. Fasted StatesFed (post-prandial) Fasted (long term)

- insulin secretion increases- absorbed nutrients are utilized and stored- breakdown of stored nutrients is suppressed

- glucose levels fall- Energy sources are mobilized- insulin secretion drops to basal levels- Glucagon activity increases

* even at low concentrations, insulin inhibits lipolysis

Regulation of Glycogen StoresInsulin Glucagon

- stimulates glycogen synthesis (glycogenesis) by:a. promoting dephosphorylation (activation) of glycogen synthaseb. promoting dephosphorylation (inhibition) of glycogen phosphorylase

- moblizes glycogen (glycogenolysis) by:a. promoting phosphorylation (inhibition) of glycogen synthaseb. promoting phosphorylation (activation) of glycogen phosphorylase

Integrated Regulation of Metabolism (see appendix B)

E. Obesity and Type 2 DiabetesObesity as a Risk Factor for DM• Muscle and adipose tissue lose responsiveness to

insulin with excess gain weight• Delayed blood glucose clearance after a meal• Increased hepatic glucose production• Increased insulin production = pancreas failure • Individuals at risk should be routinely tested

Individuals at Risk• BMI ≥ 25• First degree relative with diabetes• Given birth to a baby > 9lbs. (4 kg)• Impaired glucose tolerance/ elevated fasting

glucose• History of gestational diabetes• African-American, Hispanic or Native-American

ethnicity

• Hypertensive (> 140/90)• HDL ≤ 35mg/dl and/or TG ≥ 250 mg/dl

Obese vs. Lean Glucose Curves

Glucose Curve: Obese

Glucose Curve: Lean The glucose curve for obese individuals exhibits a higher post-prandial blood glucose level surge compared to that of the lean individual’s.

F. Gestational Diabetes• Nutritional status of the mother can affect the fetal

genome• Maternal overnutrition may restrict fetal growth

(via impaired placental development) and increase the risk of neonatal mortality and morbidity

• Gestational diabetes mellitus (GDM), a condition associated with maternal overnutrition and defined as any degree of glucose intolerance

• Hormones released from the placenta interfere with maternal responsiveness to insulin

QUICK OB-ENDO REVIEW!Characteristics associated with a LOW risk of GDM<25 years oldNormal pre-pregnancy weightEthnicity associated with a low prevalence of GDMNo first-degree relatives with DMNo history of abnormal glucose toleranceNo history of poor obstetric outcome

Characteristics associated with a HIGH risk of GDMMarked obesityPersonal history of GDMGlycosuriaStrong family history of diabetes



Final Exam


Nutritional Counseling for Gestational Diabetes • All women with GDM should receive nutritional

counseling from a physician or a registered dietician

• Restricting carbohydrate intake to 35-40% of total caloric intake (30-45 g per meal)

• Reduce hyperglycemia• Improve maternal and fetal outcomes• Distribute carbohydrate intake throughout the day

in three small-to-moderate sized meals and 2-4 snacks , including an evening snack

Role of exercise in GDM• Muscle contractions activate glucose transport

independently of insulin • Insulin sensitivity increases more insulin-

sensitive glucose transporters (GLUT4) move to the plasma membrane

• Increased glucose uptake lowers blood glucose signals an increase in glucagon secretion

• Exercise also triggers catecholamine release• Glucagon and catecholamines stimulate an

increase in the hepatic glucose production and an increase in adipose tissue lipolysis

Insulin Therapy in GDM• If diet and exercise alone cannot control blood

glucose, or if the fetus becomes abnormally large because of elevated blood glucose

• Recommended when nutrition therapy fails to maintain self-monitored glucose at the ff. levels

a. Fasting plasma glucose </= 105mg/dL (5.8 mmol/L)

ORb. 1hr post-prandial plasma glucose </= 155 mg/dL (8.6mmol/L)

ORc. 2-hr postprandial plasma glucose </= 130 mg/dL (7.2 mmol/L)

II. Diabetes and Dietary ManagementA. Energy Balance•Energy balance: energy intake matches energy

requirements•In healthy individuals, energy balance = glucose

homeostasis•Overweight, insulin-resistant individuals will benefit

from a negative energy balance; lower blood glucose levels by inadequate caloric intake, and improve glucose uptake by increasing physical activity

•Chronic excessive caloric intake raises insulin levels, promotes weight gain, and leads to insulin resistance.

B. Glycemic Response• After meals – glucose rises followed by an

increase in insulin levels• Insulin – promotes glucose uptake and utilization.

As a result, glucose levels decrease.• Protein – raises insulin secretion• Fats – raises insulin secretion and delays

digestion and absorption of dietary carbohydrates

• Normal FBS:70-90 mg/dLNormal Post-prandial blood glucose: >140 mg/dL

Glycemic Index• predicts the effect of carbohydrate-containing food

on postprandial glycemia• does not account for the variability of the test food

and considers food item in isolation• high glycemic index foods: bread, pasta, rice,

cereal, baked goods• low glycemic index foods: fruits, vegetables,

whole grains, legumes

Hyperglycemia•defined as FBS >/= 126 mg/dL and may be caused

by recent food intake, insufficient insulin, stress, medications ie steroids, obesity

•potential acute consequences: ketoacidosis, hyperosmolar non-ketotic syndrome

Symptoms: • Hyperosmolar effects of high blood glucose

concentration result in polydipsia, polyuria, nocturia, blurred vision, sudden unexplained weight loss, headache

• Impaired glucose transport into cells results in: polyphagia, sudden unexplained weight loss, poor wound healing, chronic/recurrent skin infections, weakness/tiredness, confusion

Intensive management• Determining blood glucose at least 4x a day• Using an insulin pump, or receiving an insulin

injection 4x a day• Adjusting insulin doses according to food intake

and exercise• Implementing a diet and exercise plan• Seeing members of a health care team monthly

Hypoglycemia• may occur due to: inadequate food intake,

excessive medications ie, hypoglycemic agents, inappropriate timing of medications and meals, excessive exercise or sudden increase in physical activity

Symptoms:• Early Adrenergic Response: sweating, headache,

blurry vision, hunger, weakness, poor coordination, numbness/tingling of mouth and lips

• Late Neurogenic Response: dizziness, confusion, irritability/personality change, shakiness, loss of consciousness, seizures

Treatment: • give a source of simple carbohydrates (4oz.

orange juice or 6oz regular soft drink or 10-20g table sugar)

C. Medical Nutrition TherapyGoals of Medical Nutrition Therapy• Achieving near normal blood glucose and blood

pressure levels• Improving lipid profile• Modifying nutrient intake and lifestyle to delay or

prevent the chronic complication of diabetes• Addressing the nutritional needs of an individual

with special consideration given to personal and cultural preferences and willingness to change

• Maximizing the enjoyment of food by limiting food only when indicated by scientific evidence

(see appendix C)



Final Exam


Guidelines for Macronutrient Distribution(see appendix D)

Determining Carbohydrate Requirements• BMI = weight in kilos / height in m2• if patient is overweight, seta goal for weight loss

at 10% of body weight or BMI<25• obtain patient’s food history and activity data

(24hrs): determine the approximate daily caloric intake and physical activity (PA) level

• determine estimated energy requirement (EER) [PA: 1=sedentary, 1.12=low active, 1.27=active, 1.45=very active)

• males: 662 – (9.53*age in years) + PA*(15.91*weight in kg + 539.6*height in meters)

• females: 354 – (6.91*age in years) + PA*(9.36*weight in kg + 726*height in meters)

• calculate suitable carbohydrate intake per day and per meal

D. Myths vs. FactsMYTH FACT

Honey is better for diabetes management than sugar

Honey has more calories than sugar; main components are sucrose and fructose which will eventually be broken down into glucose, too

Individuals with diabetes can have as much fruit and fruit juice as they want because these items contains “natural sugars: components are fructose, sucrose and glucose

All sugars are basically the same…excessive fructose intake can elevate serum HDL

Individuals with diabetes should limit their fruit intake and avoid drinking fruit juice

Fruit and fruit juice contains many vitamins and minerals and fiber but add little or no fat to the diet; as long as the carbohydrate remains in the acceptable range, fruit and fruit juices should be included in the diet.

A person with diabetes should only drink “diet” soda

A small amount of regular soda can be incorporated into a well-balanced diet; regular soda can be a convenient way to treat episodes of mild hyperglycemia

You can get diabetes from eating too much sugar

High intake of sugar will not lead to diabetes; however, obesity increases the risk of developing diabetes

People with type 1 diabetes can eat as much carbohydrates as they like as long as they compensate with enough insulin

This practice would eventually lead to weight gain then increased fat deposition; poor patient compliance, irregular eating pattern, and

erratic blood glucose control

Individuals with Type 2 diabetes must reach an ideal weight before their diabetes comes under control

Losing 4.5 to 9g (10-20lbs) often improves blood glucose control and reduce lipid levels and blood pressure

E. Glucose Management Tools (see appendix E)

Targets for Metabolic Control: Recommendations for Adults with Diabetesa. Plasma Glucose

Fasting 90-130mg/dl(5.0-7.2mmol/L)Random <180 mg/dl (<10mmol/L)

b. HbA1c <7%• primary target for achieving glycemic control• Indicates level of glycemic control over the last 2-

3 months, assesses treatment efficacy, measures accuracy of self-reported results

c. Plasma LipidsHDL >40mg/dl for men; >50 for womenLDL <100mg/dl(2.6mmol/L)

d. Triglycerides <150 mg/dl (1.7 mmol/L)

Medications Types of Insulin (see appendix F)

Oral Hypoglycemic AgentsAgent Target

OrganAction

amylin mimetics pancreas inhibit glucagon release

sulfonylureas pancreas stimulate insulin secretion

meglitinides PancreasGLP-1 Agonists pancreas stimulate insulin

secretion; inhibit glucagon release

DPP-4 inhibitors Pancreas (via GLP-1 agonists)

inhibit GLP-1 breakdown

alpha-Glucosidase inhibitors

GIT delay digestion of carbohydrates

thiazolidinediones muscle increase insulin sensitivity

biguanides Muscle and liver

increase insulin sensitivity; reduce hepatic glucose production

Physical Activity • During exercise, muscle contractions activity

glucose transport independently of insulin. Afterwards, insulin sensitivity increases.

• Increased glucose uptake lowers blood glucose, which signals an increase in glucagon secretion. Exercise also triggers the release of catecholacmines.

• Glucagon and catecholamines stimulate an increase in hepatic glucose production and an increase in adipose tissue lipolysis.

• Recommend a minimum of 20-30 minutes of moderate activity each day (approx. 150kcal).



Final Exam


The eventual goal is to burn about 200-300 kcal per day to improve overall health and well-being.

III. Diabetes in the Philippine SettingA. Filipino profile• revels in rice, has sweet tooth, likes to order “Meal

A, with extra fries, go large”, remote control lifestyle, masters of manyana

• therefore, Filipinos are at high risk for diabetes!• “MANILA, Philippines—One out of every five adult

Filipinos are diabetic, according to the latest national survey conducted on the prevalence of diabetes in the country. The survey, conducted in 2007 by the Philippine Cardiovascular Outcome Study on Diabetes Mellitus (PhilCOS-DM), further shows that as many as three out of five adults are already diabetic or on the verge of developing diabetes unless they change their lifestyle.” -- Diabetes rising among Filipinos; by Dona Pazzibugan, Philippine Daily Inquirer, 11/11/2008

B. Filipino Diet GuidelinesFat• Bawasan ang pagkain ng taba o mga matatabang

pagkain.• Bawasan ang paggamit ng taba sa pagluluto at

paghuhorno.• Gumamit ng cooking spray sa halip ng cooking oil.• Kumain ng mas kaunting saturated fat. Ito ay

kadalasang nasa mga karne o animal products, tulad ng tocino, longganiza, at sitsaron.

• Bawasan ang pagkain ng mga produktong may halong gata, tulad ng ginatan, suman, bibingka at biko.

• Ihawin ang isda (bangus, tilapia) sa halip na iprito sa mantika.

• Sa pagluluto, gumamit ng mga mantika, tulad ng canola, olive at peanut.

Sweets• Umiwas sa softdrinks. Mas madalas piliin ang

tubig bilang inumin.• Bawasan ang pagkain ng mga matatamis na

gawa sa gata at asukal.• Kumain ng mas maraming sariwang prutas bilang

matamis.

Alcohol• Kapag nais mong uminom ng alak (wine, cervesa,

whiskey, atbp.), uminom lamang ng kaunti at isabay ito sa pagkain.

• Makipag-ugnayan sa propesyonal na tagapangalaga ng iyong kalusugan ukol sa ligtas na dami ng alak para sa iyo.

Milk• Piliin ang mga nonfat o mababang taba na mga

produkto, tulad ng fat-free o mababang taba na gatas , plain o artificially sweetened na non-fat o mababang taba na yogurt, at mababang taba na keso. Subukan ang nonfat dry milk o evaporated skim milk.

• Gumamit ng non-fat dry milk o evaporated skim milk sa kape o mga matatamis tulad ng halo-halo

o palamig (ginayat o kinudkod na mga sariwang prutas na may halong gatas).

Meat• Kadalasang magluto ng mga mababang taba na

mga ulam tulad ng paksiw, ihaw, tinola o sinigang.

• Magluto ng mga karneng ulam (dinuguan, menudo, kari-kari, batchoy) nang walang mga laman-loob, tulad ng atay, tripe at dila.

• Bawasan ang paggamit ng mga masyadong matabang karne, tulad ng pork liempo,sitsaron, at chorizo o longganiza.

• Piliin ang mga beans at peas na walang dagdag na taba sa halip ng karne, makailang beses sa isang linggo. Ang mga ito ay mababang taba at maiinam na kapalit ng karne, manok at isda.

Vegetables•Maaaring kainin ang karamihan sa mga tropical

vegetables (tulad ng ampalaya, okra, bok choy, kangkong, malunggay) kung ang mga ito ay mabibili at hindi mahal.

•Pumili ng mas maraming orange o dark-green na leafy vegetables, tulad ng kalabasa, spinach, carrots at talbos ng kamote.

•Damihan ang bawang, sibuyas, sili, luya, at lemon grass bilang pampalasa sa iyong mga gulay. Subukang maglagay ng iba’t-ibang mga gulay sa iyong sinigang o tinola.

Fruits• Piliin ang mga buong prutas, pero liitan ang mga

portion. Maaari mong kainin ang karamihan sa mga tropical fruits, tulad ng papaya, saging, mangga, pinya at pomegranate.

• Kumain ng kahit man lamang isang prutas na maraming vitamin C araw-araw, tulad ng orange, grapefruit at tangerine.

• Bawasan ang pagkain ng mga fruit preserves, tulad ng sampalok at dried mango at mga prutas na de-lata o nasa syrup, tulad ng langka, kaong, matamis na bao, macapuno at nata de coco.

Grains, beans, etc• Kumain ng mga tubers tulad ng gabi, ube,

cassava at kamote, na kabilang sa mga starchy vegetables. Ang mga root tubers ay mahusay na kapalit sa kanin, noodles at tinapay.

• Kumain ng mas maraming mga beans bilang fiber. Ang mga mahuhusay na halimbawa ay munggo, garbanzos, at kadyos.

• Gumamit ng iba’t ibang mga noodles (pancit), tulad ng bihon, sotanghon at misuwa.

• Bawasan ang serving ng kanin bawat araw



Final Exam


APPENDICES

Appendix A: Metabolic effects of insulin and glucagon INSULIN GLUCAGON

PROTEIN Synthesis Inc. transport of branched chain amino acids to tissues Inc. ribosomnal protein synthesis, particularly in liver and muscle cells

Catabolism Inc. use of alanine and other amino acids from muscle protein for gluconeogenesis

CARBOHYDRATES Energy, storage

Inc. GLUT-4 mediated glucose uptake Inc. glycolysis (activates glucokinase) Inc. glycogen snthesis (increases glucose 6-phosphate levels, activates glycogen synthase, inhibits glycogen phosphorylase) Dec. gluconeogenesis

Synthesis Inc. mobilization of glycogen stores (activates glycogen phosphorylase va increased synthesis of CAMP)Inc. gluconeogenesis (activates phosphoenolpyruvate carboxykinase and other enzymes)

FATS Synthesis, storage

Inc. fatty acid synthesis and esterification Dec. ketogenesis Dec. lipolysis (inhibits hormone-sensitive lipase)

Catabolism Inc. mobilization of triglycerides from adipose tissue Inc. keotgenesis

Appendix B: Integrated Regulation of MetabolismBLOOD LIVER MUSCLE FAT

INSULIN Dec. blood glucose

Protein synthesis Glycogenesis

Protein synthesis Glycogenesis Glucose uptake Glycolysis

Lipogenesis Glucose uptake Glycolysis

GLUCAGON Inc. blood glucose

Gluconeogenesis Glycogenolysis Ketogenesis

Lipolysis

EPINEPHRINE Inc. blood glucose

Gluconeogenesis Glycogenolysis

Glycogenolysis Lipolysis

CORTISOL Inc. blood glucose

Gluconeogenesis Protein catabolism Lipolysis

Appendix C: Goals of Medical Nutrition Therapy

Appendix D: Guidelines for Macronutrient Distribution



Final Exam


Dietary Reference Intake for Healthy Individuals

ADA recommendations for people with Diabetes

Carbohydrates 40-65%

Proteins 10-35% 15-20% of total calories

Fats 20-35%

Saturated Fat <7% of total calories

Cholesterol <200mg/d

Dietary Fibers 38g/day males; 25g/day females

Appendix E: Glucose Management Tools

Appendix F: Types of Insulin

Type Onset Peak DurationRapid Acting – injected right before meals Lispro 5 mins 0.5-1 hour 3 hours Aspart 10-20 mins 1-3 hours 3-5 hours Glulisine <15 mins 1-2 hours 3-4 hoursShort Acting – injected 30-40mins before meals Regular 30 mins 2-5 hours 5-8 hoursIntermediate – works all day if taken in the morning NPH 1-2 hours 6-10 hours 10 hours Lente 2-4 hours 8-12 hours 18-24 hoursLong-acting – usually taken at bedtime Ultralente 4-6 hours 10-18 hours 24-28 hours Glargine 2-4 hours No peak 24 hours Detemir 0.8-2 hours No peak Up to 24 hours

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