Total Fat 20-35% calories from fat Average of total calories consumed over a one week period. Saturated fatty acid Intake is the strongest dietary determinant of LDL-C Recommendation: 8-10% calories Help to thin blood and prevent blood platelets from clotting and sticking to artery walls. Food Sources: fatty fish, such as salmon, sardines, trout, swordfish, herring, albacore tuna, mackerel and, soy, canola and flaxseed oil. Consumption of 2 servings (~8ounces)per week of fish high in α -linolenic acid Monounsaturated fatty acids If equal amounts of MUFAs are substituted for saturated fatty acids, LDL-C decreases MUFAs do not lower HDL-C Recommended intakes: up to 20% of total calories
Diet intessar 2012 final ppt
Medical Nutrition Therapy in Diabetes Day INTESSAR SULTAN MD, MRCP PROF. OF MEDICINE @ TAIBAH UNIVERSITYConsultant endocrinologist, diabetologist @ KFH
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.”
Clinical trials/outcome ofMNT Day• Lower A1C ∼1% in type 1 diabetes• Lower A1C 1–2% in type 2 diabetes, depending on the duration of diabetes.
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
Goals of MNT: specificsituations 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.
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
ADARecommendations: overweight, and obesity with pre or diabetes
• 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)
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.
ADARecommendation:nutrition for primary prevention ofDM 2 but not type 1.
• 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)
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.
ADARecommendation: nutrition for secondary prevention of DM 2.
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)
• 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).
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.
RecommendationSweeteners. 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
• 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.
ADARecommendation: Intake of fats in diabetics.
Dietary goals for fatand cholesterol in DHealt hy Hear t Diet Th er apeu t ic Lif est yle Ch ange Diet ( TLC)8-10% calories from < 7% calories fromsaturated fat saturated fat20 - 35% calories from fat 20-35% calories from fat< 300 mg. cholesterol < 200 mg. cholesterol5-10% of energy from 5-10% of energy from PUFAPUFAUp to 20% MUFA Up to 20% MUFACalories to maintain I BW Calories to maintain I BW
Plant sterol andstanol 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.
ADARecommendation: Protein intake in diabetics.
• 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)
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.
ADARecommendation: Micronutrientsintake in diabetics.
• 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)
• 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.
ADARecommendation: Nutritioninterventions for type 1 diabetes
• 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)
• 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 .
ADARecommendation: Nutritioninterventions for pregnancy and lactation with diabetes
• 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)
• 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.
Day• Breast-feeding is recommended .• Nursing require less insulin requiring a CHO snack before breast-feeding .
ADARecommendation:for elder adults with diabetes
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
ADARecommendation: for diabetics with microvascular complications (3ry prevention)
• 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
ADARecommendation: for diabetics with macrovascular complications CVD (3ry prevention)
• 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)
ADARecommendation:for hypoglycemia in diabetes
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.
ADARecommendation:for acute illness in diabetes
• 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.
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.
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