Nutritional Management of Diabetes: Strategies for Health and Well-being

Nutritional Management of Diabetes Akbar Fazel-Tabar Malekshah MPH, PhD

31 1.5 9 12.5 173 HbA1c=8.7 . 9 93 47 FBS=190 8.5 . 2hpp =270 3 - 4 - 5 - 4 - 2 - 1 - 3 - 2 - 1 -

3 12.5 27 72 163 2hpp =270 . 27 FBS=190 . HbA1c=8.7 8.5

27 . 78 MicroAlb=112 169 57 2hpp =290 FBS=230 HbA1c=8.7

Types of Diabetes Type 1 Type 2 Cystic Fibrosis Related Diabetes (CFRD) Gestational Diabetes Mellitus (GDM) Others; steroid induced hyperglycemia

Prevention or delay diabetes with lifestyle intervention or metformin can last at least 10 years In 2.8 year of Diabetes Prevention Program: diabetes incidence in high risk adult 58% with intensive lifestyle intervention. Whereas, In metformin group 31% Misra A. Lancet, 2009 6

After 10 years follow up, diabetes incidence rates: lifestyle intervention were 4.8 cases in 100 people per year metformin group were 7.8 cases in 100 people per year placebo group were 11.9 cases in 100 people per year Misra A. Lancet, 2009 7

Lifestyle changes : Modification of dietary habits (increase healthy food choices) Regular physical activity (leading to moderate weight loss) cornerstone of all levels prevention and treatment of diabetes 8

Goals for nutrition therapy of diabetes General: Consume a health-promoting selection of nutrients Maintain energyneeds in a timely manner Address special requirements (e.g., pregnancy) Tailor for therapeutic needs (e.g., renal disease) Modern nutrition in health and disease. 2006, p: 1050 9

RECOMMENDATIONS: Monitoring Weight management Energy requirement Nutrition principle & recommendation Physical activity 10

Weight management Lifestyle changes lead to: weight loss of ~10% (10 -12 kg) over 3 -6 months maintain weight loss of 4.5 kg after 2 to 4 years weight loss of 3 kg from baseline improved lipid profile * Krause s Food & nutrition Therapy.2008, p:772,773 11

Nutrition principles & recommendations: Macronutrients Carbohydrates GI & GL Fiber sweeteners Fats MUFA PUFA SFAs protein 12

Dietary constituents that tend to fiber, fructose, Lactose Fat glycemic response 16

Many factors influence the glycemic response to food included: Differences in fiber content Ingestion time Fat, protein, water-soluble fiber, and other factors influence gastric emptying time Modern nutrition in health and disease. 2006, p: 1051 17

Glycemic load (GL) of a food: GI of the food amounts of grams of CHO content of that food Quality & Quantity Both the amount (grams) and type of a carbohydrate are important 18

Simple carbohydrates should make up less than one third of total carbohydrate intake. Modern nutrition in health and disease 2006, P: 1051 19

Dietary fiber is a major dietary component in the management of diabetes. Because of the specific benefits of increased fiber intake for persons with diabetes we recommend intake of approximately 35 g/day or 15 to 25 g/1000 kcal With an emphasis on higher-fiber choices such as whole-grain breads, high-fiber cereals, generous intakes of fruits and vegetables, and regular use of legumes. Modern nutrition in health and disease. 2006, p: 1054 20

Sweeteners Nonnutritive (non-caloric) are approved for use by the FDA: Saccharin (bladder cancer) aspartame (phenylketonuria) acesulfame-K sucralose 21 Modern nutrition in health and disease 2006, P:1054

Protein General public : DRI range is : 10-35% of total calories RDA is : 0.8 g/BW/d good quality Pro Diabetic individuals : similar to general public but does not exceed 20% of total energy 22

Protein In the presence of diabetic nephropathy, protein should not exceed 0.8 g/kg or approximately 10% of total calories. High-biologic-value protein should be given consideration, although protein should be included from both animal and vegetable sources. 23 Modern nutrition in health and disease. 2006, P: 1052

Fat Specific percentages of dietary SFA and trans fatty acids and amounts of cholesterol are not available but should limited Since the CVD risk for diabetics is similar to those with a past history of CVD, the goal for dietary fat intake for diabetics is the same as those with a past history of CVD 24

Fat National Cholesterol Education Program (NCEP)recommend: total fat 25-35% of total calories saturated fat < 7% Dietary cholesterol intake should be <200 mg/d PUFA intake should be ~ 10% of total energy MUFA intake should be ~ 15% of total energy Intake of trans-fat should be minimizedor eliminated 25 * Krause s Food & nutrition Therapy.2008, p:778

W-3 fatty acids properties lower serum cholesterol moderately and serum triglyceride levels markedly decrease platelet aggregation Without impaired glucose homeostasis 26 Modern nutrition in health and disease 2006 P:1053

N-3 polyunsaturated fatty acids 2 or 3servings of fish(not commercially fried) per week provide dietary n-3 PUFA VLC n-3 FA supplements TG in type 2 diabetes with hypertriglyceridemic but may be LDL-C Intake of 2-3 gr of plant stanols and sterols (in plant oil) per day TC and LDL-C by 9% to 20% Cholesterol intake less than 200 mg/day. * Krause s Food & nutrition Therapy.2008, p:778 27

Diabetes Management Oral Hypoglycemics/Insulin Therapy: Insulin Injections Blood glucose monitoring Nutritional guidelines Prevention of: Hypoglycemia Hyperglycemia Stress/sick day management Urine ketone testing

Insulin Insulin is a hormone that allows cells to extract glucose from the blood and use it for energy. Insulin is produced by the beta cells of the pancreas. It regulates protein and lipid metabolism. Diet & diabetes, AFM

Hormones Synthesised in glands, hormones are chemical signaling molecules which have a specific regulatory effect upon the activity of body tissues. Hormones are transported around the body in the blood so that they can act on tissues at a distance from the gland in which they were produced. Hormones can only act in those tissues where they have specific receptors in the cells. Diet & diabetes, AFM

The short term effects of diabetes Out-of-control diabetes, when severe, leads to the body using stored fat for energy and a subsequent build-up of acids (ketone bodies) in the blood. This is known as ketoacidosis and is associated with very high glucose levels. It requires emergency treatment and can lead to coma and even death. Recurrent or persistent infections (including tuberculosis). Both hyperglycaemia and hypoglycaemia (abnormally low blood glucose resulting from treatment) may cause coma and, if untreated, may be fatal. Type 2 diabetes, the metabolic syndrome and cardiovascular disease in Europe

The long term effects of diabetes The long term effects of diabetes can be divided into macrovascular complications microvascular complications. Macrovascular complications affect the larger blood vessels, such as those supplying blood to the heart, brain and legs. The most common macrovascular fatal complication is coronary artery disease. Strokes are also a common cause of disability and death in people with diabetes. Microvascular complications affect the small blood vessels, such as those supplying blood to the eyes and kidneys. The microvascular complications of diabetes are retinopathy, nephropathy and neuropathy. Type 2 diabetes, the metabolic syndrome and cardiovascular disease in Europe

The major diabetic complications Stroke (cerebrovascular disease) Visual impairment: diabetic retinopathy, cataract and glaucoma Heart disease (cardiovascular disease) Bacterial and fungal infections of the skin Kidney disease (diabetic nephropathy) Severe hardening of the arteries (atherosclerosis) Autonomic neuropathy (including slow emptying of the stomach and diarrhea) Sexual dysfunction Poor blood supply to lower limbs (peripheral vascular disease) Necrobiosis lipidoica Sensory impairment (peripheral neuropathy) Gangrene Ulceration Type 2 diabetes, the metabolic syndrome and cardiovascular disease in Europe

Diagnosing diabetes If someone has the typical symptoms of diabetes the diagnosis is clear: - increased thirst - excess urine - weight loss - a clearly raised plasma glucose level Ketones in the urine accompanied by high plasma glucose levels is also a clear indication of diabetes. However, diagnosis is less straightforward for those with minor degrees of hyperglycaemia, and in the person without symptoms, two abnormal results on separate occasions are needed. Type 2 diabetes, the metabolic syndrome and cardiovascular disease in Europe

Nutrition Checklist 2013 REFER for nutrition counseling by a registered dietitian FOLLOW Eating Well with Food Guide INDIVIDUALIZE dietary advice based on preferences and treatment goals CHOOSE low glycemic index carbohydrate food sources

Nutrition Checklist (continued) 2013 KNOW alternative dietary patterns for type 2 diabetes ENCOURAGE matching of insulin to carbohydrate in type 1 diabetes ENCOURAGE nutritionally balanced, calorie-reduced diet in overweight or obese patients

For Patients with BMI 25 kg/m2 Nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight Weight loss of 5-10% of initial body weight Improved insulin sensitivity, glycemic control, blood pressure control, lipid levels

Choose low glycemic index carbohydrates www.guidelines.diabetes.ca

Figure 1 Nutritional management of hyperglycemia in type 2 diabetes 2014 Clinical assessment Lifestyle intervention by Registered Dietitian Initiate intensive lifestyle intervention or energy restriction + increased physical activity to achieve/maintain a healthy body weight Provide counselling on a diet best suited to the individual based on preferences, abilities, and treatment goals using the advantages/disadvantages listed below If not at target Continue lifestyle intervention and add pharmacotherapy Timely adjustments to lifestyle intervention and/or pharmacotherapy should be made to attain target A1C within 2 to 3 months for lifestyle intervention alone or 3-6 months for any combination with pharmacotherapy

Properties of Macronutrients 2014 Dietary interventions A1C Advantages Disadvantages HDL-C, CRP, hypoglycemia - Hi-CHO (low-glycemic index [GI]) TC, LDL-C HDL-C, GI side effects Hi-CHO (high fibre) TG - Hi-MUFA TG Micronutrients, renal load Lo-CHO BP, TG, preserve lean mass Micronutrients, renal load Hi-protein TG Methyl-Hg exposure, environmental impact Long chain omega 3 fatty acids A1C = glycated hemoglobin CRP = C reactive protein TC = total cholesterol CHO = carbohydrate MUFA = monounsaturated fatty acid LDL = low-density lipoprotein BP = blood pressure TG = triglycerides FPG = fasting plasma glucose GI = gastrointestinal = <1% decrease in A1C HDL = high-density lipoprotein

Properties of Dietary Patterns 2014 Dietary Pattern A1C Advantages Disadvantages LDL-C, HDL-C Vitamin B12 Vegetarian Diet BP, CRP, TC, HDL-C, TC:HDL-C, TG Weight, BP, CRP, LDL-C, HDL-C Weight, TC, HDL-C, TC:HDL-C, TG Weight Mediterranean Diets none DASH none LDL-C, micronutrients, adherence Micronutrients, adherence, renal load FPG, adherence Atkins diet Protein Power Plan Weight, LDL-C:HDL-C - Ornish Weight, LDL-C:HDL-C FPG, adherence - Weight Watchers Weight, LDL-C:HDL-C FPG, adherence - Zone Diet TC, LDL-C Dietary Pulses GI side effects LDL-C, apo-B, apo-B:apo-A1 none Nuts weight Meal Replacements Temporary intervention

Recommendations 1 and 2 1. People with diabetes should receive nutrition counseling by a registered dietitian to lower A1C levels [Grade B, Level 2, for type 2 diabetes; Grade D, Consensus, for type 1 diabetes], and reduce hospitalization rates [Grade C, Level 2] 2. Nutrition education is effective when delivered in either a small group or one-on-one setting [Grade B, Level 2]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role-playing, and group discussions [Grade B, Level 2]

Recommendations 3 and 4 3. Individuals with diabetes should be encouraged to follow Eating Well with Food Guide in order to meet their nutritional needs [Grade D, Consensus] 4. In overweight or obese people with diabetes a nutritionally balanced, calorie reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A] 2014

Recommendations 5 and 6 5. In adults with diabetes, the macronutrient distribution as a percentage of total energy can range from 45-60% carbohydrate, 15-20% protein, and 20-35% fat to allow for individualization of nutrition therapy based on preference and treatment goals [Grade D, consensus] 2014 6. Adults with diabetes should consume no more than 7% of total daily energy from saturated fats[Grade D, Consensus] and should limit intake of trans fatty acids to a minimum [Grade D, Consensus] 2014

Recommendations 7 and 8 7. Added sucrose or added fructose can be substituted for other carbohydrates as part of mixed meals up to a maximum of 10% of total daily energy intake, provided adequate control of BG and lipids is maintained [Grade C, Level 3] 8. People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4]

Recommendation 9 9. Dietary advice may emphasize choosing carbohydrate food sources with a low glycemic index to help optimize glycemic control [type 1 diabetes: Grade B, Level 2; type 2 diabetes: Grade B, Level 2]

Recommendation 10 2014 10. Alternative dietary patterns may be used in people with T2DM to improve glycemic control, (including): Mediterranean-style dietary pattern [Grade B, Level 2] Vegan or vegetarian dietary pattern [Grade B, Level 2] Incorporation of dietary pulses (e.g., beans, peas, check peas, lentils) [Grade B, Level 2] Dietary Approaches to stop Hypertension (DASH) dietary pattern [Grade B, Level 2]

Recommendations 11 and 12 11. An intensive lifestyle intervention program combining dietary modification and increased physical activity may be used to achieve weight loss and improvements in glycemic control, and cardiovascular risk factors [Grade A, Level 1A] 12. People with type 1 diabetes should be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2]; or should maintain consistency in carbohydrate quantity and quality [Grade D, Level 4]

Recommendations 13 13. People using insulin or insulin secretagogues should be informed of the risk of delayed hypoglycemia resulting from alcohol consumed with or after the previous evening s meal [Grade C, Level 3] and should be advised on preventive actions such as carbohydrate intake and/or insulin dose adjustments, and increased BG monitoring [Grade D, Consensus].

Physiological Serum Insulin Secretion Profile 75 Breakfast Lunch Dinner Plasma insulin ( U/ml) 50 Dawn phenomenon 25 4:00 8:00 12:00 16:00 Time 20:00 24:00 4:00 8:00