The document outlines medical nutrition therapy (MNT) for diabetes, emphasizing its role in individualized care and management of blood glucose levels, weight control, and prevention of complications. It includes recommendations for dietary interventions in different groups, such as youth, pregnant women, and older adults, highlighting the importance of individualized meal plans and monitoring carbohydrate intake. The guidelines also address nutrition for specific conditions like type 1 diabetes, gestational diabetes, and complications associated with diabetes.

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