INTESSAR SULTAN MD, MRCP PROF. OF MEDICINE @ TAIBAH UNIVERSITY Consultant endocrinologist, diabetologist @ KFH

1. Medical Nutrition
Therapy in Diabetes
Day
INTESSAR SULTAN
MD, MRCP
PROF. OF MEDICINE
@ TAIBAH UNIVERSITY
Consultant endocrinologist,
diabetologist @ KFH

2. Defining MNT
• American Dietician Association “a
supportive process to set priorities,
establish goals, and create
individualized action plans which
acknowledge and foster responsibility
for self-care.”

3. Clinical trials/outcome of
MNT
Day
• Lower A1C ∼1% in type 1
diabetes
• Lower A1C 1–2% in type 2
diabetes, depending on the
duration of diabetes.

4. Goals of MNT in diabetes
• Achieve and maintain Day
– BG levels in the normal or close to
normal & safe
– Bp levels in the normal or close to
normal & safe
– Lipid and lipoprotein profile at goal
• To prevent or slow chronic
complications
• To address nutrition needs, personal
and cultural preferences
• To maintain the pleasure of eating by
only limiting food choices when
indicated by scientific evidence

5. Goals of MNT: specific
situations
Day
• Youth with type 1 diabetes or type 2
diabetes
• Pregnant and lactating women
• Older adults with diabetes
• Insulin or insulin secretagogues Rx.
• During exercise: prevention and
treatment of hypoglycemia
• Acute illness.

6. MNT
• MNT consists of multiple, one-on-
one sessions between an RD and a
patient
• patients can receive
– 3 hours of individual counseling with an
RD during the first year of treatment
– 2 hours of counseling each year after
that RD evaluates
• nutrition diagnosis
• nutrition intervention
• nutrition monitoring
• Nutrition evaluation

9. ADA
Recommendatio
ns: overweight,
and obesity
with pre or
diabetes

10. • Weight loss is recommended . (A)
– low-carbohydrate or low-fat calorie-restricted diets
effective in short term (up to 1 year). (A)
• With low-carbohydrate diets, monitor lipid
profiles, renal function, and protein intake and Day
adjust hypoglycemic therapy . (E)
• Physical activity : components of weight loss
and maintenance (B)
• Weight loss medications in type 2 diabetes:
5–10% weight loss combined with lifestyle
modification. (B)
• Bariatric surgery if BMI ≥35 kg/m2: diabetes
resolved or improve But ?? long-term
outcome (B)

11. RDA for digestible CHO is 130
g/day
Day
• Provide glucose for CNS.
• sources of energy, fiber, vitamins
& minerals
• Low palatability.
• Manufactured Meal replacements:
defined amount of energy must
be continued to maintain wt loss.

12. ADA
Recommendation:
nutrition for primary
prevention of
DM 2 but not type 1.

13. • Moderate weight loss (7%) using low fat
diets, regular physical activity (150 min/
week), reduced calories and dietary fat.
(A)
• Dietary fiber (14 g fiber/1,000 kcal) and
Day
foods containing whole grains (one-half
of grain intake) improved insulin
sensitivity. (B)
• Moderate alcohol intake may reduce the
risk for diabetes, but not recommended.
(B)
• Nutritional needs for normal growth and
development are maintained for youth
predisposed to DM2. (E)
• No evidence to use low–glycemic load
diets only benefits are their rich fibers (E)

14. Low–glycemic load diets
Day
• CHO amount > type determine pp response.
• Glycemic index: the increase above fasting in BG
over 2 h after ingestion of 50-g carbohydrate portion
divided by the response to a reference glucose (100).
• If > 70 considered high and < 55 is considered is low
• Oats, barley, bulgur, beans, lentils, legumes, pasta,
coarse rye bread, apples, oranges, milk, yogurt, and
ice cream.
• Because of their content of Fiber, fructose,
lactose, and fat.
• Lower pp in pts consuming high–glycemic index diet.

15. ADA
Recommendation:
nutrition for
secondary
prevention of
DM 2.

16. CHO
• CHO from fruits, vegetables, Day
whole grains, legumes, and low-
fat milk . (B)
• Monitoring carbohydrate
– carbohydrate counting
– CHO exchanges
– Experienced-based estimation. (A)
• Low Glycemic index and load
diets may be used to lower pp. (B)

17. • Sucrose-containing foods can
– substituted for other carbohydrates in
meal plan
– added to meal plan covered with RX Day
– avoid excess energy intake. (A)
 Dietary sucrose does not increase
glycemia >isocaloric amounts of
starch .
 Thus, sucrose-containing foods are
not restricted.
 Intake of fats ingested with sucrose is
better avoided (excess energy
intake).

18. Recommendation:
Fiber (14 g/1,000 kcal). Day
• Intake as general population (B)
• legumes, fiber-rich cereals (≥5 g
fiber/serving), fruits, vegetables,
and whole grain products
• reduces glycemia in type 1 and
glycemia, hyperinsulinemia, and
lipemia in type 2 diabetes
• Palatability, limited food choices,
and gastrointestinal side effects
are potential barriers.

19. Recommendation
Sweeteners.
Day
• Fructose lowers PP response if replaces
sucrose or starch but adversely affect
plasma lipids.
• Use of added fructose sweetening
agent is not recommended but not
the naturally occurring sources

20. • Sugar alcohols (with calories ) and non-
nutritive sweeteners (without calories ) are
safe if consumed within FDA intakes (A)
• Approved: sorbitol, acesulfame Day
potassium, aspartame, neotame,
saccharin, sucralose.
• Lower pp response < sucrose or glucose
• Lower energy: 2 calories/g (1/2 sucrose).
• reduces the risk of dental caries.
• Safe but diarrhea, especially in children.
• no evidence of lowering
glycemia, energy, or weight.

21. ADA
Recommendation:
Intake of fats in
diabetics.

22. Dietary goals for fat
and cholesterol in D
Healt hy Hear t Diet Th er apeu t ic Lif est yle
Ch ange Diet ( TLC)
8-10% calories from < 7% calories from
saturated fat saturated fat
20 - 35% calories from fat 20-35% calories
from fat
< 300 mg. cholesterol < 200 mg. cholesterol
5-10% of energy from 5-10% of energy from PUFA
PUFA
Up to 20% MUFA Up to 20% MUFA
Calories to maintain I BW Calories to maintain I BW

24. Plant sterol and
stanol esters
Day
• block the intestinal absorption of dietary
and biliary cholesterol.
• intake of ∼2 g/day
• lowers plasma TC and LDLc.
• they should displace, rather than be added to,
the diet to avoid weight gain.
• Diets, drinks and Soft gel capsules containing
plant sterols are available.

25. ADA
Recommendation:
Protein intake in
diabetics.

26. • usual protein intake (15–20% of energy) If
normal renal function. (E) : 0.8 g good-
quality protein /kg /day ( ∼10% of calories) Day
• Protein intake increases insulin response
without increasing plasma glucose so,
protein should not be used to treat acute
or prevent nighttime hypoglycemia. (A)
• High-protein diets >20% of calories are not
recommended for weight loss. short-term
weight loss and improved glycemia, but ?
long-term effects of protein intake on kidney
function. (E)

27. Good-quality protein sources
• High protein digestibility–corrected Day
amino acid scoring pattern and
provide all 9 indispensable amino
acids.
• meat, poultry, fish, eggs, milk,
cheese, and soy.
• Not good category: cereals,
grains, nuts, and vegetables.
• protein intake >0.8 g/ kg/day to
account for mixed protein quality.

28. ADA
Recommendation:
Micronutrients
intake in diabetics.

29. • There is no clear evidence of benefit from
vitamin or mineral supplementation in
people with diabetes who do not have
underlying deficiencies. (A) Day
• Routine supplementation with antioxidants,
such as vitamins E and C and carotene, is
not advised. No evidence and ? long-term
safety. (A)
• Benefit from chromium supplementation in
individuals with diabetes or obesity has not
been clearly demonstrated and therefore
can not be recommended. (E)

30. • Nutrition counseling: daily vitamin
and mineral requirements from
natural food sources and a Day
balanced diet.
• Multivitamin supplement for :
– Elderly
– Pregnant
– Lactating women
– Strict vegetarians
– Those on calorie-restricted diets.

31. ADA
Recommendation:
Nutrition
interventions for
type 1 diabetes

32. • Insulin therapy should be integrated into
an individual’s dietary and physical
activity pattern. (E)
Day
• Individuals using rapid-acting insulin by
injection or an insulin pump should
adjust the meal and snack insulin doses
based on the carbohydrate content of
the meals and snacks. (A)
• For individuals using fixed daily insulin
doses, carbohydrate intake on a day-to-
day basis should be kept consistent with
respect to time and amount. (C)

33. • For planned exercise, insulin
doses can be adjusted.
• For unplanned exercise, extra
carbohydrate may be needed. (E) Day
• Moderate-intensity exercise
increases glucose utilization by 2–
3 mg / kg/ min above usual
requirements.
• For a 70-kg person, ∼10–15 g
additional carbohydrate per hour of
moderate intensity physical activity
is needed .

34. ADA
Recommendation:
Nutrition
interventions for
pregnancy and
lactation with
diabetes

35. • Adequate energy intake that provides
appropriate weight gain is recommended
during pregnancy.
• Weight loss is not recommended
• for overweight and obese women with Day
GDM, modest energy and carbohydrate
restriction may be appropriate. (E)
• Ketonemia from ketoacidosis or starvation
ketosis should be avoided. (C)
• MNT for GDM focuses on food choices for
appropriate weight gain, normoglycemia,
and absence of ketones. (E)
• Because GDM is a risk factor for
subsequent type 2 diabetes, after delivery,
lifestyle modifications are recommended.
(A)

36. • 175 g carbohydrate/day should be provided
distributed in 3 moderate-sized meals and
2-4 snacks.
•
• Evening snack to prevent overnight ketosis
Day
• Hypocaloric diets in obese result in
ketonemia .
• Moderate caloric restriction (30%) in
obese
• Food records, weight, and ketone
testing detect undereating to avoid
insulin therapy.

37. Day
• Breast-feeding is recommended .
• Nursing require less insulin requiring a
CHO snack before breast-feeding .

38. ADA
Recommendation:
for elder adults with
diabetes

39. Day
• Modest energy restriction and physical
activity for obese older adults for modest
weight loss of 5–10% (E)
• daily multivitamin supplement (C)
• involuntary gain or loss of > 10% of body
weight in <6 months should be addressed in
the MNT evaluation .
• Exercise is risky: cardiac ischemia,
musculoskeletal injuries, and hypoglycemia

40. ADA
Recommendation:
for diabetics with
microvascular
complications
(3ry prevention)

41. • protein intake to 0.8/ kg/day in
earlier stages of CKD and to <0.8
g later. (B) Day
• MNT that favorably affects CVD
risk factors have a favorable effect
on microvascular complications.
(C) as Dyslipidemia increases
albumin excretion and progression
of nephropathy

42. ADA
Recommendation:
for diabetics with
macrovascular
complications
CVD
(3ry prevention)

43. • Increase fruits, vegetables, whole grains,
and nuts. (C)
• dietary sodium intake of <2 g/day may Day
reduce symptoms if heart failure. (C)
• In normotensive and hypertensive
individuals, a reduced sodium intake (2.3
g/day) with a diet high in fruits,
vegetables, and low-fat dairy products
lowers blood pressure (DASH). (A)
• In most individuals, a modest amount of
weight loss beneficially affects blood
pressure. (C)

44. ADA
Recommendation:
for hypoglycemia in
diabetes

45. Recommendations for
Hypoglycemia <70 mg/dl
• Ingestion of 15–20 g glucose (A)
Day
(carbonated beverages, jelly beans, jelly
babies, Honey and fruit juice)
• The response within 10–20 min
• Check plasma glucose in ∼60 min for
additional treatment (B) as BG begin to
fall after that
• +Fat prolong the acute glycemic
response.
• +Protein does not help hypoglycemia.

46. ADA
Recommendation:
for acute illness in
diabetes

47. • Continue antidiabetic treatrment
• Test plasma glucose and ketones Day
• Drink adequate amounts of fluids
• Ingest CHO especially if BG <100
(B)
• 150–200 g carbohydrate daily is
sufficient to prevent starvation
ketosis.

48. Special nutrition:
Day
• Liquids containing sugar ∼200 g
CHO/day divided at meal and snacks.
• tube feedings: enteral formula (50%
CHO) or a lower–CHO formula (40%)
Calorie needs: 25–35 kcal/kg/D.
• AVOID overfeeding.
• After surgery, food intake should be
initiated as quickly as possible.

49. Source:
Day
• American Diabetes Association,
Nutrition recommendations and
interventions for diabetes: a position
statement of the American Diabetes
Association. Diabetes Care.
2008;31(suppl 1):S61-S78

50. ‫وأخر دعوانا أن الحمد لله رب‬
‫العالمين‬