Medical Nutrition Therapy

for Diabetes Mellitus

Raziyeh Shenavar

MSc. of Nutrition

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Diabetes Mellitus

A group of diseases characterized by high blood

glucose concentrations resulting from defects in

insulin secretion, insulin action, or both.

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Types of Diabetes

Type 1 (IDDM)

Type 2 (NIDDM)

Gestational diabetes mellitus (GDM)

Prediabetes (impaired glucose homeostasis)

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Diagnostic Criteria

Diagnosis Criteria

Diabetes

FBS >126 mg/dl

CPG >200 mg/dl

2hPG >200 mg/dl

Pre-diabetes

Impaired fasting glucose FBS 100-125 mg/dl

Impaired glucose tolerance 2hPG 140-199 mg/dl

Normal FBS <100 mg/dl

2hPG <140 mg/dl

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Prediabetes

(Impaired Glucose Homeostasis)

• Two forms; may have either or both

– Impaired fasting glucose (IFG): fasting plasma

glucose(FPG) above normal

– Impaired glucose tolerance (IGT): plasma glucose

elevated after 75 g glucose load

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Type 1 Diabetes

• Two forms

– Immune mediated: beta cells destroyed by

autoimmune process

– Idiopathic: cause of beta cell function loss

unknown

• Symptoms: hyperglycemia, polyuria, polydipsia,

weight loss, dehydration, electrolyte disturbance, and

ketoacidosis

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Type 2 Diabetes

• Most common form of diabetes accounting for 90% to 95% of

diagnosed cases

• Combination of insulin resistance and beta cell failure (insulin

deficiency)

• Progressive disease: hyperglycemia develops gradually and may

not cause the classic symptoms of type 1 diabetes

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Gestational Diabetes Mellitus (GDM)

• Glucose intolerance with onset or first recognition

during pregnancy

• Occurs in about 7% of pregnancies

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• BMI >25

• Physical inactivity

• High-risk ethnic groups

• Previous delivery of baby >9 lbs or GDM

• Hypertension

• HDL <35 mg/dl or triglycerides >250 mg/dl

• IGT or IFG

• History of vascular disease

Risk Factors for Type 2 Diabetes

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Complications of Diabetes

• Macrovascular

– coronary artery disease (MI)

– cerebrovascular disease (Stroke)

– peripheral vascular disease

• Microvascular

– retinopathy

– nephropathy

– neuropathy

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Lifestyle change

– Increase physical activity

– Moderate weight loss

– Education

– Reduced fat and energy intake

– Regular participant follow-up

– Whole grains and dietary fiber

Management of Pre-Diabetes

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Carbohydrate • Low-carbohydrate diets are not recommended

• Sugars do not increase glycemia more than isocaloric amounts of starch

• Factors influencing glycemic response to foods: glycemic index (GI) and glycemic load (GL)

• Carbohydrate counting; portions of food containing 15 g carbohydrate

• Exchange lists

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What is the Glycemic Index?

• All carbs (except fiber) convert to blood glucose eventually

• GI Reflects the magnitude of blood glucose rise in the first 2 hours

• Ranks foods by how much they raise blood glucose levels compared to

glucose or white bread.

• In general, the lower the rating, the better the quality of carbohydrate.

o Usually low in calories and fat, while also being high in fiber,

nutrients and antioxidants.

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What Is Glycemic Load?

• Glycemic load = glycemic index x actual amount of

available carbohydrates consumed

• Reminder that serving size is still important!

• Low G.I. but a very large serving = high glycemic

load

• Total carb intake is a primary factor in glycemic

response of a meal

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Glycemic Index ranking of selected starchy foods

Lower (GI<70) Intermediate (GI: 70-90) Higher (GI>90)

All bran cereals Oat bran Most dry cereals

Oatmeal, muesli,

pumpernickel bread

Whole-wheat bread Most breads

Most pasta Most muffins Most crackers

Barley Long-grain rice White rice, boiled

Most cookies Most cakes

Yams New potatoes Most potatoes

Most dry beans and lentils Sweet corn Pancakes and waffles

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Fiber

• Recommend same as general public:

variety of fiber-containing foods such as

legumes, fiber-rich cereals (>5

g/serving), fruits, vegetables, and whole

grains

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Sweeteners

Sucrose in food plan should be substituted for other carbohydrate

sources or covered with insulin or glucose-lowering medications

• Sugar alcohols (sorbitol, mannitol, xylitol) cause less rise in blood glucose

• >10g/day may cause GI upset

Non-nutritive Sweeteners

• Aspartame

• Sucralose

• Acesulfame Potassium

• Saccharin (Sweet’n Low, Sugar Twin)

• Cylamates

– Both of these not recommended during pregnancy

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Protein

• Does not affect blood glucose levels in well-controlled

diabetes

• 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

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Dietary Fat

Saturated Fat: <7% of total calories

Cholesterol: <200 mg/day in people with diabetes

Minimize intake of trans-fatty acids

Two or more servings of fish per week providing n-3

polyunsaturated fatty acids are recommended

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Micronutrients

• Vitamins+Minerals: Routine supplementation is not

necessary

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Exercise

• Improves insulin sensitivity

• Lowers Blood Glucose

• Uses Glycogen Stores

– muscle

– liver

• Increases release of FFA from adipose

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Insulin

• Insulin formulations classified according to their duration of action as well as time of onset & peak activity.

Types of Insulin Preparations:

– Long acting insulin – best used as background (basal) insulin

• NPH, Lente, Ultralente – Short acting insulin

• Regular, Toronto – quickly absorbed and best used at mealtime

– Rapid acting insulin

• Novorapid, lispro (Humalog)– rapidly absorbed and best used at mealtime

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Insulin Type Onset Peak Effect Duration

Rapid-acting

10-15 min

60-90 min

3-5 hrs

Short-acting

30-min

2-3 hrs

6.5 hrs

Intermediate & Long-acting

NPH

Lente

Ultralente

1-3 hrs 1-2 hrs 4-8 hrs

5-8 hrs 6-12 hrs 2-12 hrs

10-18 hrs 10-18 hrs 18-24 hrs

Action Times of Human Insulin Preparations

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• Lose weight if you are overweight

– Lose weight slowly and safely, 1-2 pounds weekly

– Enjoy foods from all food groups. Avoid fad diets that eliminate

any specific foods or groups of foods.

– Eat smaller portions and exercise more

• Exercise to promote or maintain weight loss (consult with your doctor before beginning)

– 30 minutes most days of the week is recommended

– Include aerobic exercise and resistance training for the best results

– Start slowly and increase the duration and intensity of exercise if you are new to exercise.

Nutrition Therapy for Type 2 Diabetes

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• Obtain carbohydrates mainly from fruits, vegetables, whole grains, legumes,

and low-fat or skim milk.

These foods are the best carbohydrate sources

o They are usually high in fiber and high in nutrients your body needs

• Consume at least 130 grams of carbohydrate each day

Low-carbohydrate diets are not recommended for diabetes management

Carbohydrates contain important nutrients

Choose most of your carbohydrates from fruits, vegetables, and whole

grains

• Use sugar substitutes if desired

Use only sugar substitutes that are approved by the FDA

Sugar substitutes can help you enjoy sweet treats more often

Sugar substitutes don’t appear to cause weight loss or control blood

sugars

Nutrition Therapy for Type 2 Diabetes

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• Limit saturated fats, trans fat, and dietary cholesterol

These types of dietary fats and cholesterol can contribute to

heart disease, which is related to diabetes

When you use fats, use liquid oils instead of solid fats when

possible.

• Trans fat are produced by the food industry by taking liquid oils

and changing them into solid fats.

This process improves the shelf life and stability of flavors

of processed foods

Nutrition Therapy for Type 2 Diabetes

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• GDM occurs in ~3.7 % of all pregnancies (8-18% in aboriginal

populations)

– Justifies screening for all pregnant women

• Increased risk of later diabetes in mother

• Carbohydrate-controlled meal plan, adequate energy, normoglycemia, and absence of ketosis.

– Adequate in energy to promote normal weight gain and prevent ketonuria

• Individualize and adjust meal plan throughout pregnancy

• Use of insulin

• Carbohydrate distribution

• Exercise

Nutrition Therapy for Gestational Diabetes Mellitus

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Calories Fat (grams) Protein

(grams)

Carbohydrate

(grams)

Carbohydrates

80 0-1 0-3 15 Starch: breads, cereals and

grains. Starchy vegetables,

and beans, peas, and lentils

60 - - 15 Fruits

Milk

100 0-3 8 12 Fat-free, low-fat, 1%

120 5 8 12 Reduced fat, 2%

160 8 8 12 Whole

Varies Varies Varies 15 Sweets, desserts, and other

carbohydrates

25 - 2 5 Nonstarchy Vegetables

Food Exchange List in Diabetes

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Calories Fat (grams) Protein

(grams)

Carbohydrate

(grams)

Meat and Meat Substitutes

45 0-3 7 - Lean

75 4-8 7 - Medium-fat

100 8+ 7 - High-fat

Varies Varies 7 Varies Plant-based

proteins

45 5 - - Fats

Food Exchange List in Diabetes-cont’d

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Serving Size Food

Bread

1 slice (30 grams) White

1 slice (30 grams) whole-grain

Beans, Peas, and lentils

½ cup Beans, cooked (black, garbanzo, kidney, lima, navy, pinto,

white)

½ cup Peas, cooked (black-eyed, split)

Starchy Vegetables

½ cup Corn

½ cup Peas, green

½ cup Parsnips

¼ large (3 oz)

½ cup or ½ medium (3 oz)

Potato

Baked with skin

Boiled, all kinds

Fruits

1 small fresh fruit

½ cup canned or fresh fruit or unsweetened fruit juice

1 cup Milk

Food Exchange List in Diabetes-cont’d

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Any Question???

The End…