DM CH 31 PPT Edited-1

Chapter 31
Medical Nutrition Therapy

for Diabetes Mellitus and
Hypoglycemia of
Nondiabetic Origin
Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.
Diabetes Mellitus
A group of diseases characterized by high
blood glucose (BG) concentrations
resulting from defects in insulin secretion,
insulin action, or both
Diabetes and Prediabetes: Types

Type 1 (formerly IDDM, type I)
Type 2 (formerly NIDDM, type II)
Gestational diabetes mellitus (GDM)
Prediabetes (impaired glucose
homeostasis)
Other specific types
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
Hgb A1C
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
5% to 10% of all diagnosed diabetes
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
Gestational Diabetes Mellitus

Glucose intolerance with onset or first
recognition during pregnancy
Occurs in about 7% of pregnancies
Women with GDM have a 40% to 60%
chance of developing diabetes over the
next 5 to 10 years
Risk Factors for Type 2 Diabetes

BMI >25
Physical inactivity
High-risk ethnic groups (African American, Latino,
Native American, Asian America, Pacific Islander)
Previous delivery of baby >9 lbs or GDM
Hypertension
HDL <35 mg/dL or triglycerides >250 mg/dL
PCOS or acanthosis nigricans
IGT or IFG
History of vascular disease
Methods of Diagnosis
Fasting plasma glucose (FPG)
Casual plasma glucose (any time of day)
Oral glucose tolerance test (OGTT)
Diagnosis of Diabetes Mellitus and

Impaired Glucose Homeostasis
Diagnosis
Criteria
Diabetes
FPG 126 mg/dL (7.0 mmol/L)

CPG 200 mg/dL (11.1 mmol/L) plus symptoms
2hPG 200 mg/dL (11.1 mmol/L)
Prediabetes
Impaired fasting
glucose
FPG 100125 mg/dL (5.67.0 mmol/L)
Impaired glucose
tolerance
2hPG 140199 mg/dL (7.811.0 mmol/L)
Normal
FPG <100 mg/dL (<5.6 mmol/L)

2hPG <140 mg/dL (<7.8 mmol/L)
Modified from American Diabetes Association: Diagnosis and classification of diabetes mellitus (position statement), Diabetes Care
30:S48, 2007.
CPG, Casual plasma glucose; FPG, fasting plasma glucose; 2hPG, 2-hour plasma glucose level (measured 2 hours after an oral
glucose tolerance test with administration of 75 g of glucose).
10
Algorithm for Type 1 Diabetes
11
Algorithm for Type 2 Diabetes
12
Management of Prediabetes
Diabetes prevention trials
Lifestyle change
Increase physical activity
Moderate weight loss
Education
Reduced fat and energy intake
Regular participant follow-up
Whole grains and dietary fiber
13
Management of Diabetes
Trials
Diabetes and Control and Complications Trial
(DCCT)
United Kingdom Prospective Diabetes Study
(UKPDS)
Management
Medical nutrition therapy
Physical activity
Monitoring
Medications
Self-management education
14
Insulin Counterregulatory
Hormones
Glucagon
Epinephrine (adrenaline)
Norepinephrine
Cortisol
Growth hormone
15
Diabetes: Treatment Goals

Recommendations for Glycemic
Control for Adults With Diabetes
Glycemic Control
A1C
<7.0%*
Preprandial capillary plasma glucose
90130 mg/dL (5.0-7.2 mmol/L)
Peak postprandial capillary plasma

glucose
<180 mg/dL (<10.0 mmol/L)
Modified from American Diabetes Association: Standards of medical care in diabetes2007, Diabetes Care 30:54, 2007.
*Referenced to a nondiabetic range of 4%-6% using a DCCT-based assay.
Peak levels in patients with diabetes.
16
Lipid and Blood Pressure Goals

for Diabetes
Recommendations for Lipid and Blood
Pressure for Adults With Diabetes
Lipids
LDL cholesterol
<100 mg/dL (<2.6 mmol/L)
HDL cholesterol
Men
>40 mg/dL (>1.1 mmol/L)
Women
>50 mg/dL (>1.4 mmol/L)
Triglycerides
<150 mg/dL (<1.7 mmol/L)
Blood Pressure
<130/80 mm Hg
Modified from American Diabetes Association: Standards of medical care in diabetes2007, Diabetes Care 30:54, 2007.
HDL, high-density lipoprotein; LDL, low-density lipoprotein.
17
Medical Nutrition Therapy

for Diabetes
Individualize energy needs and nutrition
care based on metabolic profile, treatment
goals, and changes person is willing and
able to make
18
Goals of Medical Nutrition

Therapy for Diabetes Mellitus
Prediabetes
Decrease risk of diabetes and CVD by
promoting healthy food choices and physical
activity leading to moderate weight loss
Diabetes
Achieve and maintain BG levels in normal
range, low-risk lipid and lipoprotein profile, lowrisk blood pressure
Prevent or delay chronic complications
Address individual nutrition needs
19
Goals of Medical Nutrition

Therapy for Diabetes Mellitus
(contd)
Specific situations
Meet unique needs to youth with type 1 or type
2 diabetes, pregnant and lactating women, and
older adults with diabetes
Self-management training for individuals treated
with insulin or insulin secretagogues for safe
exercise, prevention and treatment of
hypoglycemia, and treatment of acute illness
20
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
21
The Glycemic Index

Was developed to compare the physiologic
effects of carbohydrates on glucose
Measures peak response
Does not measure how rapidly BG rises
GL is calculated by multiplying the GI by
the amount of carbohydrates in each food
22
Fiber
25 to 30 g of fiber per day with special
emphasis on soluble fiber
Recommend same as general public
Research on higher fiber intake for people
with diabetes has been inconclusive
23
Sweeteners
Sucrose restriction cannot be justified based on
glycemic response; it should be substituted in a
meal plan for other carbohydrate
Reduces intake of healthy foods or increases
calorie intake
Fructose has no benefit over sucrose
Reduced calorie sweeteners: sugar alcohols and
tagatose
Nonnutritive sweeteners: saccharin, aspartame,
neotame, acesulfame potassium, and sucralose
24
Protein
Does not affect blood glucose levels in wellcontrolled diabetes
Does not slow absorption of carbohydrate
Recommend usual protein intake (15%
20% of kilocalories)
25
Dietary Fat
People with diabetes have similar risk to
those with a history of CVD
Recommendations
Total fat 25% to 35% of total kilocalories
Saturated fatty acids <7%
Minimized or eliminate trans fat
Very long omega-3 polyunsaturated fatty acids
Plant sterol and stanol esters; 2 to 3 g/day
26
Alcohol
Abstain if history of abuse, pregnancy,
medical problems; moderation for others
Moderate amounts of alcohol with food
have minimal effect on glucose and insulin
Excessive alcohol (3+ drinks/day)
contributes to hyperglycemia
27
Micronutrients
No clear evidence of benefits of
supplements
High-risk groups
Supplemental antioxidant vitamins have not
been proven beneficial, and some evidence
indicates that vitamins E and C and
carotene are harmful
No benefit has been shown for
supplementation of chromium
28
Physical Activity and Exercise

Integral part of treatment plan for diabetes
Improve insulin sensitivity
Reduce cardiovascular risk factors
Weight control
Improve well-being
May prevent type 2 diabetes in high-risk
individuals
Glycemic responses to exercise in type 1
and type 2 diabetes
29
Potential Problems with Exercise

Hypoglycemia if using insulin or insulin
secretagogues
Caused by increased insulin sensitivity
Hyperglycemia
Caused by a greater than normal increase in
counterregulatory hormones
Exercise guidelines
Frequent blood glucose monitoring before,
during, and after exercise
Reduce insulin or ingest carbohydrate
30
Carbohydrate for Insulin or Insulin

Secretagogue Users
Add 15 g of carbohydrate for every 30 to 60
minutes of activity (depending on intensity)
No adjustment for exercise <30 min
Add carbohydrate if pre-exercise glucose
level <100 mg/dL
No supplementary carbohydrate if not
receiving insulin or secretagogues
CHO ingestion during prolonged exercise
improves performance
31
Insulin Guidelines for Exercise

Moderate to strenuous activity >45 to 60
minutes: decrease rapid- or short-acting
insulin (12 U)
Prolonged vigorous exercise: may need a
15% to 20% decrease in total daily insulin
dose
32
Exercise Prescription
At least 150 min/wk of moderate-intensity
aerobic physical activity or at least 90
min/wk of vigorous aerobic exercise
Distribute over at least 3 days/wk with no
more than 2 consecutive days without
activity
Resistance exercise 3/wk
33
Oral Glucose-Lowering
Medications
Newer glucose-lowering medications used alone
or in combination
Insulin secretagogues: sulfonylureas promote insulin
secretion by beta cells
Glinides: meglitinides differ from sulfonylureas in that they
have shorter metabolic half-lives
Biguanides: metformin suppresses hepatic glucose
production
Thiazolidinediones: TZDs or glitizones decrease insulin
resistance in peripheral tissues
a-Glucosidase inhibitors: acarbose inhibits small bowel
enzymes that digest carbohydrate
34
Glucose-Lowering Medications
(contd)
Insulin secretagogues
Sulfonylureas and meglitinides
Promote insulin secretion by beta cells
Insulin sensitizers
Enhance insulin action
Biguanides (metformin) and TZDs
Require presence of exogenous or endogenous
insulin
Enzyme inhibitors (a-glucosidase inhibitors)

Inhibit enzymes that digest carbohydrates in the
small intestine; delay carbohydrate absorption and
lower postprandial glycemia
Acarbose (Precose) and miglitol (Glyset)
35
Injectable Glucose-Lowering
Medications
Exenatide (Byetta): incretin mimetic or
incretin-like agent
Hormones released during nutrient absorption
that increase glucose-dependent insulin
secretion, slow gastric emptying, decrease
glucagon production, and decrease appetite
Pramlintide (Symlin): synthetic form of

amylin
Hormone normally co-secreted with insulin in
response to food intake
36
Insulin
Essential to survive in type 1 diabetes
May be needed to restore glycemia in type
2 diabetes
Onset, peak, and duration
Inhaled insulin
Individualize type and timing of insulin
regimen based on eating and exercise
habits and blood glucose levels
Insulin pump
37
Action Times of Human Insulin

Preparations
Type of Insulin
Onset of Action
Peak
Action
Usual Effective
Duration
Monitor
Effect In
Rapid Acting
<15 min
12 hr
34 hr
2 hr
0.51 hr
23 hr
36 hr
4 hr
24 hr
410 hr
1016 hr
812 hr
Insulin glargine (Lantus)
24 hr
Peakless
2024 hr
1012 hr
Insulin determir (Levemir)
24 hr
Peakless
1824 hr
1012 hr
Mixtures
0.51 hr
Dual
1016 hr
Insulin lispro (Humalog)

Insulin aspart (NovoLog)
Insulin glulisine (Apidra)
Short Acting
Regular
Intermediate-Acting
NPH
Long Acting
70/30 (70% neutral protamine Hagedorn [NPH],

30% regular)
75/25 (75% neutral protamine lispro [NPL],
25% lispro)
70/30 (70% neutral protamine aspart [NPA],
30% aspart)
Adapted from Bode BW: Medical management of type 1 diabetes, ed 4, Alexandria, VA, 2004, American
Diabetes Association.
38
Monitoring
Self-monitoring of blood glucose (SMBG)
up to eight times per day
Training and record keeping
Used to adjust insulin doses and food
Continuous ambulatory blood glucose
monitoring
Urine and blood ketones
39
Medical Nutrition Therapy for

Type 1 Diabetes
Integrate insulin regimen into usual eating
habits and physical activity schedule
Multiple injections (3/day) of insulin pump
Half insulin as basal or background; other
half before meals
Total energy intake and CHO intake to
avoid weight gain
40

Type 2 Diabetes
Lifestyle interventions to improve metabolic
abnormalities (glycemia, dyslipidemia,
hypertension)
Progressive: usually need to add medication
to MNT
Blood glucose control, improve food choices,
increase physical activity, moderate energy
restriction to promote weight loss
Teaching: carbohydrate sources, serving
sizes, number of servings, meal planning,
limiting fats
SMBG
41

Type 1 Diabetes in Youth
Maintain normal growth and development
Nutrition prescription based on nutrition
assessment
Use typical food and nutrition history
Adjust with age, physical activity, and growth rate
Individualize food plans and insulin regimens
Realistic blood glucose goals
Reduce risk of CVD
Meal planning approaches: CHO counting
42

Type 2 Diabetes in Youth
Accompanies childhood obesity
Cessation of excessive weight gain,
promote normal growth and development
Address CVD risk
Teaching must include carbohydrate foods
and portion size
Physical activity
Bariatric surgery
43

Preexisting Diabetes and
Pregnancy
Preconception counseling
Hormonal changes in first trimester lead to
erratic BG levels; adjust meal plan
Increased need for insulin in second and
third trimesters
Adjust meal plan to provide additional
kilocalories
Avoid hypoglycemia and ketosis
44

Gestational Diabetes Mellitus
About 7% of pregnancies
High risk for type 2 diabetes later in life
Screening and testing
Carbohydrate-controlled meal plan,
adequate energy, normoglycemia, and
absence of ketosis
Individualize and adjust meal plan
throughout pregnancy
Use of insulin
Carbohydrate distribution
Exercise
45

Older Adults
Increased prevalence of diabetes and IGT
with age
Similar recommendations to younger
population
Concern for malnutrition
Dietary restriction is NOT warranted in
long-term care communities
Hyperglycemia and dehydration can lead
to hyperglycemic hyperosmolar state
46
Nutrition Care Process

Nutrition assessment
Nutrition diagnosis
Nutrition intervention
Developing a food or meal plan
Self-management training
Facilitating behavioral changes and goal setting
Nutrition monitoring and evaluation

Follow-up
47
Acute Complications
Hypoglycemia
Autonomic or adrenergic symptoms: shakiness,
sweating, palpitations, anxiety, hunger
Neuroglycopenic symptoms: slow performance,
difficulty concentrating, confusion and
disorientation, slurred speech, irrational
behavior, extreme fatigue, seizures,
unconsciousness
Treatment
Hyperglycemia or diabetic ketoacidosis

(DKA)
DKA is life threatening but reversible
Dawn phenomenon
Somogyi effect
48
Common Causes of
Hypoglycemia
Inadvertent or deliberate errors in insulin doses
Excessive insulin or oral secretagogue medications
Improper timing of insulin in relation to food intake
Intensive insulin therapy
Inadequate food intake
Omitted or inadequate meals or snacks
Delayed meals or snacks
Unplanned or increased physical activities or exercise
Prolonged duration or increased intensity of exercise
Alcohol intake without food
Modified from American Diabetes Association: Medical management of type 1 diabetes, ed 4, Alexandria, VA, 2004,
American Diabetes Association.
49
Long-Term Complications
Macrovascular diseases
Dyslipidemia
Hypertension
Microvascular diseases
Nephropathy
Retinopathy
Neuropathy
Gastroparesis
50
Hypoglycemia of Nondiabetic
Origin
Symptoms usually with BG <65 mg/dL
Postprandial (reactive) hypoglycemia
Alimentary hyperinsulinemia
Idiopathic reactive hypoglycemia
Fasting (food-deprived) hypoglycemia
Factitious hypoglycemia
Management: five or six small meals a day
51
Focal Points
Nutrition therapy is a challenging but essential aspect of the

management of diabetes and hypoglycemia of nondiabetic
origin.
Attention to nutrition and food and meal-planning principles is

essential for metabolic (glucose, lipids, and blood pressure)
control and overall good health.
An RD who is knowledgeable and skilled in implementing

current nutrition principles and making recommendations for
patients with diabetes or hypoglycemia of nondiabetic origin
is the medical team member who should plan, implement,
and evaluate MNT and the nutrition care process.
Effective education and counseling of a person with diabetes

will lead to his or her becoming a team player in
management of his or her blood glucose.
The effectiveness of nutrition interventions need to be

continually monitored and documented to promote the best
possible outcomes.
52

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Chapter 31

Medical Nutrition Therapy

Diabetes and Prediabetes: Types

Prediabetes (Impaired Glucose

Symptoms: hyperglycemia, polyuria,

Gestational Diabetes Mellitus

Risk Factors for Type 2 Diabetes

Diagnosis of Diabetes Mellitus and

FPG 126 mg/dL (7.0 mmol/L)

FPG 100125 mg/dL (5.67.0 mmol/L)

2hPG 140199 mg/dL (7.811.0 mmol/L)

FPG <100 mg/dL (<5.6 mmol/L)

Algorithm for Type 1 Diabetes

Algorithm for Type 2 Diabetes

Diabetes prevention trials

Increase physical activity

Moderate weight loss

Reduced fat and energy intake

Regular participant follow-up

Whole grains and dietary fiber

Diabetes: Treatment Goals

Preprandial capillary plasma glucose

90130 mg/dL (5.0-7.2 mmol/L)

Peak postprandial capillary plasma

<180 mg/dL (<10.0 mmol/L)

Lipid and Blood Pressure Goals

<100 mg/dL (<2.6 mmol/L)

>40 mg/dL (>1.1 mmol/L)

>50 mg/dL (>1.4 mmol/L)

<150 mg/dL (<1.7 mmol/L)

Medical Nutrition Therapy

Goals of Medical Nutrition

Goals of Medical Nutrition

The Glycemic Index

Physical Activity and Exercise

Potential Problems with Exercise

Carbohydrate for Insulin or Insulin

Insulin Guidelines for Exercise

Enzyme inhibitors (a-glucosidase inhibitors)

Pramlintide (Symlin): synthetic form of

Action Times of Human Insulin

Insulin glargine (Lantus)

Insulin determir (Levemir)

Insulin lispro (Humalog)

70/30 (70% neutral protamine Hagedorn [NPH],

Medical Nutrition Therapy for

Medical Nutrition Therapy for

Medical Nutrition Therapy for

Medical Nutrition Therapy for

Medical Nutrition Therapy for

Medical Nutrition Therapy for

Medical Nutrition Therapy for

Nutrition Care Process

Nutrition monitoring and evaluation

Hyperglycemia or diabetic ketoacidosis

Nutrition therapy is a challenging but essential aspect of the

Attention to nutrition and food and meal-planning principles is

An RD who is knowledgeable and skilled in implementing

Effective education and counseling of a person with diabetes

The effectiveness of nutrition interventions need to be

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