Nutritional Interventions in Diabetes Management

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Nutritional Interventions in Diabetes Management

• Tinsika Riggs, RD, CDE
• LT, MSC, USN
• Head, Combined Food Services/Wellness
• Naval Hospital Lemoore
• 559-998-4429
• tinsika.riggs_at_med.navy.mil

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Objectives

• (1) Describe effective nutritional interventions
  in the management of persons with diabetes
• (2) Describe the micro and macro nutrition needs
  of persons with diabetes
• (3) Describe the prevalence of dietary
  supplement use by persons with diabetes
• (4) Discuss safety and efficacy of listed
  dietary supplements

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Source ADA Diabetes 1 and 2 Evidenced-Based
Nutrition Practice Guidelines for Adults

• Recommendations based on research described
  below.
• Franz MJ, Bantle JP, Beebe CA, Brunzell JD,
  Chiasson J-L, Garg A, Holzmeister LA, Hoogwerf B,
  Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler
  M Evidence-based nutrition principles and
  recommendations for the treatment and prevention
  of diabetes and related complications (Technical
  Review). Diabetes Care 25 S136S138, 2002

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Goals of medical nutrition therapy that apply to
all persons with diabetes are as follows

• 1. Attain and maintain optimal metabolic outcomes
  including
• Blood glucose levels in the normal range or as
  close to normal as is safely possible to prevent
  or reduce the risk for complications of diabetes.
  
• A lipid and lipoprotein profile that reduces the
  risk for macrovascular disease.
• Blood pressure levels that reduce the risk for
  vascular disease

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MNT Goals (cont)

• 2. Prevent and treat the chronic complications of
  diabetes. Modify nutrient intake and lifestyle as
  appropriate for the prevention and treatment of
  obesity, dyslipidemia, cardiovascular disease,
  hypertension, and nephropathy.
• 3. Improve health through healthy food choices
  and physical activity.

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MNT Goals (cont)

• 4. Address individual nutritional needs taking
  into consideration personal and cultural
  preferences and lifestyle while respecting the
  individuals wishes and willingness to change.

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Macronutrients

• Encourage consumption of macronutrients based on
  the Daily Recommended Intakes (DRI)
• DRI for CHO
• Adult 130 g/day (min)
• Pregnancy 175 g/day (min)
• Lactation 210 g /day (min)
• These are minimum requirements. Levels will
  vary depending on activity, needs for weight
  reduction or weight gain needs

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Source ADA Diabetes 1 and 2 Evidenced-Based
Nutrition Practice Guidelines for Adults

• Research does not support any ideal percentage
  from macronutrients for persons with diabetes

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Carbohydrate Consistency

• Consistency of CHO intake results in improved
  glycemic response.

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Typical Carbs per Meal

• 45- 60 g/meal for Women
• 60-75 g/meal for Men
• 15-30g/snack
• Eating every 4-5 hours assists with glycemic
  control and reduced binge eating.

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Sucrose containing foods

• Sucrose containing foods should be substituted
  for other CHO foods. Sucrose intakes of 10-35 of
  total energy intake do not have a negative effect
  on glycemic or lipid responses when substituted
  for isocaloric amounts of starch.

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10-15 jelly beans1 slice bread15 g CHO
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Non-nutritive sweeteners

• Need to tell patients products made with these
  may still have CHOs
• Research on these products reports no change in
  glycemic response

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Non-nutritive sweeteners (cont)

• Acceptable Daily Intake (ADI)
• Equal (aspartame)
• ADI50 mg/kg/day
• 200 mg/12 oz diet soda
• 35 mg/ packet
• A Person weighing 185 would have to drink 21
  (12 oz) diet sodas to exceed the recommended
  level of aspartame.

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Non-nutritive sweeteners (cont)

• Splenda (sucralose)
• ADI 5 mg/kg/day
• 70 mg/ 12 oz diet soda
• 5 mg/packet
• Ingestion of gt6 diet sodas sweetened with
  sucralose would exceed recommended levels.

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The Glycemic Index

• A system of ranking CHO-containing foods (0-100)
  based on their impact on blood glucose.
• Low 0-55
• Moderate 56-69
• High 70 or higher

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The Glycemic Index

• Used as a tool for meal planning
• Conflicting evidence on the effectiveness of this
  strategy
• Studies comparing high vs- low GI diet report
  mixed effects on glucose response

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Fiber Intake and Glycemia

• Fiber intake for people with DM similar to
  general population
• 14 g/1000 kcals
• Diets containing 44-50g fiber daily are reported
  to improve glycemia

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Fiber Intake and Glycemia

• It is unknown if free-living individuals can
  daily consume the amount of fiber needed to
  improve glycemia.

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Fiber Intake and Cholesterol

• Include foods containing 25-30g fiber per day.
• Special emphasis on soluble fiber fruit, beans,
  oats (7-13 g /day)
• Diets high in SF can reduce total cholesterol by
  2-3 and
• and LDL cholesterol by 7

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Protein Intake

• Normal renal fxn
• Recommend the usual protein intake of 15-20 of
  daily energy intake
• With nephropathy
• 1 g or less per kg body weight recommended.
• improvements in albuminuria seen, no
  significant effects on GFR

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Protein Intake (cont)

• For Chronic Kidney Disease (CKD)
• Stages 3-5
• With 0.7g/kg hypoalbuminemia seen
• With 0.9 g /kg no hypoalbuminemia

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Micronutrients

• Micronutrient recommendations for people with DM
  are the same as the general population (DRI)
• People with DM should be educated on the
  importance of obtaining the DRI from natural food
  sources
• Discuss potential toxicity of megadoses of
  vitamin and mineral supplementation

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Do you take any herbal or dietary supplements?
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Complimentary and Alternative Medicine Use (CAM)

• Less than 40 of patients tell their healthcare
  provider they use these treatments.
• Asking patients if they have any questions about
  herbal or dietary supplements may assist with
  disclosure.

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Complimentary and Alternative Medicine Use (CAM)

• One recent survey revealed that 17-57 of
  diabetes patients use CAM
• Another survey found that 31 of DM patients used
  supplements.
• CAM use among ethnic groups with DM Navaho 39,
  Hispanics 49, Vietnamese, 66

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Popular CAM Products for Diabetes

• Aloe vera
• Banaba
• Bitter melon
• Chromium
• Cinnamon
• Fenugreek

• Ginseng
• Gymnema sylvestra
• Magnesium
• Milk thistle
• Nopal

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Cinnamon

• Side effects
• Topical allergic reactions (contact dematitis)
• Drug interactions
• May lower BG if combined with BG lowering agents
• A coumarin type component warrants caution

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Cinnamon Summary of Research

• Cinnamon decreases fasting BG and lipids but meta
  analysis show no significant benefit
• Side effects are benign and there are no known
  interactions
• Caution with anticoagulant therapy

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Salacia

• Native of India and Sri Lanka
• Used in traditional Ayurveda for DM
• Used for DM, weight loss, asthma, menstrual
  problems
• Inhibits CHO breakdown into absorbable
  monosaccharides
• Decreases PPG

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Salacia

• Side effects
• Flatulence, distention, belching, abdominal pain,
  nausea, diarrhea
• Possible hypoglycemia with secretagogues or
  insulin

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Salacia Summary of Research

• Main benefit is reduction of PPG
• Side effects similar to acarbose, miglitol
• Doses have ranged from 240-1000 mg/day

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Bitter melon (Momordica charantia)

• Cultivated in tropical areas
• Adverse events include hypoglycemia, potential
  uterine bleeding and contractions may occur
• Should not be used by children
• Mostly poorly designed studies
• Insufficient information to recommend a reliable
  dose

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Ginseng

• 3 types
• Panax ginseng CA Meyer (Asian or Korean)
• Panax quinquefolius (American)
• Eleuutherococcus senticosus (Siberian)

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Ginseng

• Only Korean and American Ginseng have been
  studied in diabetes
• Side effect include hypertension, estrogenic
  effects, hepatitis, insomnia, nervousness,
  neurologic effects
• Drug interactions may occur with diuretics,
  estrogens, warfarin, phenelzine

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Ginseng

• Combining Ginseng with DM agents may cause
  hypoglycemia
• Patients may lose hypertension control.
• In a double-blind crossover trial, Korean red
  ginseng has been shown to improve erectile
  dysfunction
• Typical doses are 200-600 mg/day

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Conclusion (dietary)

• People will and do eat through their medication
  and/or insulin
• Food logs help patients and providers obtain the
  big picture of diabetes control
• Simple, individualized and realistic goals can
  help improve outcomes

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Conclusion (supplements)

• Do you have any questions about supplements?
• Counsel patients
• -Dont assume natural means safe
• -Side effects
• -Take only one new product at a time
• -Dont throw out your medication
• -Cinnabons will never be health food

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Questions?