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What is Medical Nutrition Therapy (MNT)?

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1. *assessment* of the patient's nutrition and diabetes self-management knowledge and skills 2. identification and negotiation of individually designed nutrition *goals* 3. nutrition *intervention* involving careful match of both a meal-planning approach and educational materials to the patient's needs, with flexibility to encourage implementation by the patient 4. *evaluation* of outcomes and ongoing monitoring

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Goals of MNT for Diabetes Mellitus

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1. Achieve and maintain - Blood glucose in the normal range - Lipids to reduce the risk of vascular disease - Blood pressure in the normal range 2. Prevent or slow chronic complications 3. Address individual nutrition needs 4. Maintain the pleasure of eating

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Specific situations where the primary MNT goal is to meet their unique nutritional needs

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-youths with type 1 diabetes -youths with type 2 diabetes -pregnant and lactating women -older adults with diabetes

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MNT Goals for individuals treated with insulin or insulin psychotropics

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To provide self management for safe conduct of exercise, including the prevention and treatment of hypoglycemia and diabetes during acute illnesses

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Barrier to MNT in patients with prediabetes

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Lack of reimbursement for these services

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Things a nutrition counselor should keep in mind when counseling a diabetic patient

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-Personal needs -willingness to change -ability to change

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A1C Decreases associated with MNT in patients with newly diagnosed type 1 diabetes

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1%

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A1C Decreases associated with MNT in patients with newly diagnosed type 2 diabetes

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2%

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Effectiveness of MNT in Diabetes Mellitus

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-*Most effective at the time of diagnosis* -Improvements in A1C, lipids, and blood pressure -Multiple visits are important for reinforcement, revision -Diabetes management requires a multi-disciplinary team including physician, certified diabetes educator, and registered dietitian. -Team may also include exercise specialists and psychologists or counselors.

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When is MNT most effective?

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At the time of diagnosis

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requirements for Medicare Reimbursement for Medical Nutrition Therapy (MNT) by RD

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MNT by Registered Dietitian for diabetes *(if glucose >125 mg/dl on 2 tests)* - 3 hours in first year - 2 hours follow-up in subsequent years - Need MD referral every calendar year Diabetes self management training (DSMT), usually in group setting - Up to 10 hours in the first year - Additional 2 hours in subsequent years

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Calories/Energy Balance

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- Fewer calories/carbohydrates = less glucose produced through metabolism of food - Weight loss reduces insulin resistance - less visceral and subcutaneous adipose tissue leads to: Fewer free fatty acids to interfere with the ability of insulin to suppress hepatic glucose production Production of fewer pro-inflammatory chemicals - Modest weight loss (5-10%) prevents/ slows progression from prediabetes to DM2.

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Exercise

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-weight loss more likely -Increases uptake and oxidation of fat by muscle, reducing serum FFA, improving insulin sensitivity -Burns glucose as fuel -Leads to improvements in short-term and long-term blood sugar levels (A1C) independent of weight loss -prevent/slow progression from pre-diabetes to diabetes

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Improve insulin sensitivity independent of weight loss

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Exercise and physical activity

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Acutely lower blood sugar

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Exercise and physical activity

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True or false: carbs need to be restricted or severely limited and diabetic diets

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False

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carbohydrate Recommendations

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-carbs in diabetic diet - 50% of calories -carbs in avg. diet - 50% of calories - minimum daily carb intake for everyone - *130 gm*

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Carbohydrate recommendations for blood sugar control

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*emphasis is on the quantity of carbohydrate* rather than the quality of carbohydrate, but the quality (type) does make some difference.

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Simple or refined carbohydrates

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Sugars, sweetened drinks, desserts -usually cause more rapid blood sugar increase

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Complex or unrefined carbohydrates

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Whole fruits, whole grain breads and pasta, legumes (kidney beans, lentils, etc) -usually contain more nutrients

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Variables that influence effect of carb containing foods on blood glucose

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Type of food Type of starch in the food Style of food preparation Ripeness of fruits and vegetables Degree of processing

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Glycemic Index

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blood sugar raising effect of a measured carb dose in individual foods after a 12 hour fast -Develop to compare the postprandial responses to similar amounts of different carbohydrate containing foods

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high glycemic index

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>70

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Low glycemic index

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<55

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Other factors that reduce the glycemic index of meals

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-Fat and protein

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Diets that are considered to have a low glycemic index

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Diets including high fiber foods such as whole grains, fruits, vegetables, nuts, and legumes

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high-fiber diet

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*>50 g/day* -T1DM ? reduces glycemia -T2DM ? reduces hyperinsulinemia, glycemia, and lipemia

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Type of fiber with the most influence on blood glucose levels

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Soluble fiber

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Fiber recommendations for the general population

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-25 g/day for women -38 g/day for most men

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Fructose

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-Metabolized by the liver -large amounts increase triglycerides and insulin resistance (? hepatic lipogenesis)

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Sugar Alcohols (sorbitol, mannitol)

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-Provide an average of 2 calories/gram -ADA position - Produce a lower post prandial glucose response, no evidence that typical consumption results in weight control or improved blood sugar long term -Potential laxative effect -diabetic patients are advised to count half the sugar alcohol grams as carbohydrate -large amounts can result in diarrhea and bloating

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Acceptable Daily Intake (ADI) for non-nutritive sweeteners from the FDA

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-amount that can be safely consumed on a daily basis over a person's lifetime without adverse effects -Includes a 100-fold safety factor

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Resistance starch

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-Starch that is physically enclosed within intact plant cell structures -results in increased time for digest in and release of carbohydrate -now being included in many foods with the claim that it will have benefits for blood sugar control although there is no evidence of this

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what effect his protein have on blood sugar?

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- *Small portions (3-4 oz) of high have little effect on blood sugar* - *stimulates insulin secretion* - 10-20% of calories is recommended

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Are high-protein diets recommended in patients with diabetes for weight loss?

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No, because they have not been well studied

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What effect does protein have on the kidneys?

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- Excessive intake is more likely to harm kidney function in people with diabetes compared to those who don't have diabetes -*Current recommendation - should be < 20% of calorie intake (0.8-1.0 gm/kg)*

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What percent of calories should come from fat?

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30-35%

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What effect does that have on glycemic response?

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-slows/prolongs the glycemic response -prevents rapid drops in blood glucose after eating

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Fat distribution to reduce the risk of cardiovascular disease

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<7% saturated <10% polyunsaturated remainder monounsaturated cholesterol <200 mg per day

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The amount of fish recommended per week to obtain omega-3 fatty acids

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2 or more servings

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Micronutrients and the management of diabetes

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-Minimal benefit from vitamin/mineral supplements unless underlying deficiency -Concern about long-term safety and lack of efficacy of anti-oxidants -Benefit of chromium, herbs, cinnamon is not proven

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Alcohol

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-Doesn't raise blood sugar -should be consumed with food to prevent hypoglycemia in T1DM

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Meal planning for patients on Fixed dose insulin (2 x per day, long acting + short acting)

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Consistent meal times from day to day Fixed amount of carbs / meal May need snacks to prevent hypoglycemia

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Meal planning for patients on Intensive Insulin Regimen or Pump (basal + bolus insulin)

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-Carb to insulin ratio determines insulin dose -Pre-meal doses adjusted by patient based on planned carb intake -Meal times more flexible -Snacks not required, will need extra insulin if eating a snack rich in carbs

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Meal planning in general for patients with diabetes mellitus

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-Estimate calorie needs, carb targets ( about 50% of calories) -Adjust meal plan to type of insulin, activity, preference

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Nutrition Management - Type 2

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-Diet plan based on metabolic profile BMI, lipids, BP, A1C or elevated blood sugar -Meal plan that spreads carbohydrate intake evenly over the day is typically recommended -Consistent meal times ; carbohydrate content per meal recommended if on insulin or insulin secretagogues

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Exercise in type 1 diabetes

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-Monitor blood glucose before and after (and during?) exercise -Reduction in insulin doses may be recommended -Plan exercise to *avoid times when insulin action is peaking* -*Exercise 1-2 hours postprandially reduces risk of hypoglycemia* -More carbohydrate during prolonged (;45-60 minutes) or intense (;80% max heart rate) exercise - 10-15 g every 30-60 minutes -More carbohydrate after exercise if meal or snack is not planned -*Don't exercise if glucose >250 + ketones, or >300 - ketones*

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When should patients with type 1 diabetes exercise in order to reduce the risk of hypoglycemia?

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1-2 hours postprandially

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when shouldn't patients with type 1 diabetes exercise?

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If glucose ; 250 + ketones or glucose ;300 - ketones

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T2DM and exercise

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-Hypoglycemia risk depends drug or insulin therapy -For weight loss, replace as few calories as possible without risking hypoglycemia

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Treatment of Hypoglycemia

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*15/15 rule:* - If BS ;70, have 15 gm easily absorbed carbohydrate - Wait 15 min and retest BS - If BS still ;70, take additional 15 gm carb - Repeat as needed

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15 gm easily absorbed carbohydrate

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- 3 glucose tabs - ½ can regular pop - 4 oz juice - Don't include starches, protein, fats - Don't use sugar alcohols, artificial sweeteners - May need to add small snack after treatment, if meal not scheduled soon after

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Diet Behaviors Associated with Improved Glucose Control in DCCT

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- Adherence to meal plan - Consistent snacking behaviors - Appropriate treatment of hypoglycemia - Prompt response to hyperglycemia

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Diet considerations for nephropathy

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-Protein restriction -Potassium restriction, based on serum levels

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Diet considerations for Gastroparesis (autonomic neuropathy)

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- Delayed emptying of foods from stomach - May result in wide blood sugar swings - Nausea, anorexia often present - Low residue diet may be recommended

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Approaches to Diabetic Diet

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- 3/3/3 plus Food Groups - The Plate Method - Carbohydrate counting based on personalized carb-insulin ratio Patients should also consider adequate food variety, calorie content, high fiber foods, low saturated fat foods.

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3/3/3 Diet Counseling

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-At least 3 meals per day -3 food groups at every meal (Protein, Starch, Fruit, Vegetable) -Meals eaten 3-4 hours apart

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Counting Carbohydrates

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- *15 g carb = 1 carb choice* - *3-4 carb choices per meal for most women* with moderate activity + 1 carb at 1-2 snacks - *4-5 carb choices per meal for most men* with moderate activity + 1-2 carbs at 1-2 snacks

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