Medical Nutrition Therapy For Diabetes Mellitus

Dr: ola Al-wajeeh

 Diabetes mellitus
• Diabetes mellitus: is a group of metabolic diseases characterized by
prolonged high blood glucose concentrations. The cause of high blood
glucose—also known as hyperglycemia—is the result of defects in
insulin secretion, insulin action, or both
• Insulin: is a hormone produced by the β-cells of the pancreas, is
necessary for the use or storage of macronutrients (carbohydrate,
protein, and fat).
• Cause: is the result of defects in insulin secretion, insulin action, or
both
• Insulin and glucagon harmony

Glucagon Insulin
Low blood glucose stimulates High blood glucose stimulates insulin
glucagon secretion secretion
Glycogenolysis glycogenesis
+
Gluconeogenesis Uptake amino acid and increase
protein synthesis

Increase blood glucose level

Glucose +
homeostasis Lipogenesis

Hyperglycemia
Blood glucose level decrease

Inhibition release of glucagon

Hypoglycemia
Inhibition release of insulin
-Insulin anabolic hormone
Insulin action on CHO :
• Decrease breakdown and release of glucose from glycogen in the liver
• Facilities conversion of glucose to glycogen for storge in liver and muscles
• Activate the transport system of glucose into muscles and adipose cells

Insulin action on protein :

• Inhibit protein degradation, diminishes gluconeogenesis and stimulate protein
synthesis

Insulin action on fat :

• Inhibit lipolysis , prevent excessive production of ketones and ketoacidosis
• Stimulate lipogenesis
• Activate lipoprotein lipase , facelifting transport of triglyceride into adipose
tissues
 Criteria for diagnosis of DM

fasting Blood Glucose Random (non-fasting) Hemoglobin A1C

Blood Glucose
Normal: 70-99 mg/dL (3.9- Normal: Less than 140 Normal: Less than 5.7%
5.5 mmol/L) mg/dL (7.8 mmol/L) Prediabetes: 5.7-6.4%
Prediabetes: 100-125 Prediabetes: 140-199 Diabetes: 6.5% or higher
mg/dL (5.6-6.9 mmol/L) mg/dL (7.8-11.0 mmol/L)
Diabetes: 126 mg/dL (7.0 Diabetes: 200 mg/dL (11.1
mmol/L) or higher mmol/L) or higher
 Categories of glucose intolerance
Prediabetes
• Individuals with a stage of impaired glucose homeostasis that
includes impaired fasting glucose (IFG) and impaired glucose
tolerance (IGT) are referred to as having prediabetes, indicating their
relatively high risk for the development of diabetes and CVD.
Prediabetes is diagnosed with at least one of the following: IFG
(fasting plasma glucose [FPG] 100 to 125mg/dL), IGT (2-hour post
challenge glucose of 140 to 199mg/dL), both, or a hemoglobin
glycosylated hemoglobin (A1C) of 5.7% to 6.4%.
Type 1 Diabetes
• 10% of people with diabetes have type 1 diabetes . At diagnosis,
people with type 1 diabetes mellitus (T1DM) often experience
excessive thirst, frequent urination, and significant weight loss.
cause : people with T1DM experience destruction of the pancreatic β-
cells, which results in decreased insulin production and prolonged
Complications
Ketoacidosis Macrovascular diseases (Coronary heart disease ,
Peripheral vascular disease, Cerebrovascular disease) Microvascular
diseases( Retinopathy, Nephropathy Neuropathy)
 Type 1 Diabetes
• Medical Nutrition Therapy (MNT)
• Integrate insulin regimen into preferred eating and physical activity
schedule; consistency in timing and amount of carbohydrate eaten if
on fixed insulin doses
• Adjust premeal insulin dose based on insulin-to-carbohydrate ratio
• Adequate energy and nutrient intake to promote growth and
development in children
• Cardioprotective nutrition interventions
Self-monitoring of blood glucose, Lipids ,Blood pressure , Ketones
• Weight and growth in children
Insulin & diet
• Timing of meals and snacks important
• Quantity and quality of food important
• Eat snack if except meal will be delayed

• Type 1 should not miss insulin as illness often cause raise in blood
glucose
• Carry available source of CHO I .e glucose tablets or hard candy to
avoid hypoglycemic reaction
 type 2 Diabetes
Type 2 diabetes mellitus (T2DM) accounts for 90% to 95% of all diagnosed cases of
diabetes and is a progressive disease that, in many cases, is present long before it is
diagnosed . Hyperglycemia develops gradually and is often not severe enough in
the early stages for the person to notice any of the classic symptoms of diabetes
Most people with T2DM are obese (defined as body mass index [BMI] >30 kg/m2 )
Being at a higher weight may increase insulin resistance and can contribute to the
destruction of the pancreatic β-cells;. obesity combined with a genetic
predisposition may be necessary for T2DM to occur. Other risk factors include
genetic and environmental factors, including a family history of diabetes, older age,
physical inactivity, a prior history of gestational diabetes, prediabetes, hypertension
or dyslipidemia, and race or ethnicity
 type 2 Diabetes
• Hyperglycemia is first exhibited as an elevation of postprandial (after
a meal) blood glucose caused by insulin resistance at the cellular level
and is followed by an elevation in fasting glucose concentrations. As
insulin secretion decreases, hepatic glucose production increases,
causing the increase in pre-prandial (fasting/premeal) blood glucose
levels. The insulin response is also inadequate in suppressing α-cell
glucagon secretion, resulting in glucagon hypersecretion and
increased hepatic glucose Compounding the problem is glucotoxicity.
 type 2 Diabetes
Medical Nutrition Therapy (MNT)
• Lifestyle strategies (food/eating and physical activity) that improve
glycemia, dyslipidemia, and blood pressure
• Nutrition education (regular balanced meal pattern, carbohydrate
counting, fat modification) and counseling for health behavior change
• Blood glucose monitoring to determine adjustments in food or
medications
• Cardioprotective nutrition interventions
 Gestational Diabetes Mellitus
• Gestational diabetes mellitus (GDM) is a type of diabetes that occurs
during pregnancy.
• Gestational diabetes also increases the baby’s risk of premature labor
(causing breathing and other problems), having low blood sugar, and
developing diabetes later in life.
• For many women, blood sugar levels will revert to normal after
pregnancy. Others will end up developing diabete
 Differences between type 1 & 2 diabetes
Type 1 Type 2
Age group Childhood/ adolescent Middle aged
Weight Lean Overweight
Etiology Immune mediated DM Insulin resistance + insulin
deficiency
Risk factors Genetic autoimmune, or Family history, age, obesity
environmental (microbial) (central), sedentary life style ,
previous gestational diabetes
Insulin status Absolute insulin deficiency Partial insulin deficiency
Acute Ketoacidosis Hyperosmolar state
complication
Insulin Need insulin Need agent /insulin when beta cells
medication fail overtime
 What to do to cover when managing patient
with diabetes
Diabetes education Individual glycemic control Individual glycemic control

Pathophysiology MNT Dyslipidemia

Complication exercise Hypertension
Lifestyle change obesity
control heart disease
 Goals of Medical Nutrition Therapy
-goal : Mange diabetes and prevent complication
1- To promote and support healthful eating patterns, emphasizing a variety of nutrient-
dense foods in appropriate portion sizes, to improve overall diet and specifically to:
• attain individualized glucose, blood pressure, and lipids, achieve and maintain body
weight, and delay or prevent complications of diabetes.
2- To address individual nutrition needs based on personal and cultural preferences, health
literacy and numeracy, access to healthful food choices, and willingness and ability to make
behavioral changes.
3- To maintain the pleasure of eating by providing positive messages about food choices
while limiting food choices only when indicated by scientific evidence
4- To provide the individual with diabetes with practical tools for day-to-day meal planning
rather than focusing on individual macronutrients, micronutrients, or single food
 Energy Balance and Weight
• Children/Adolescents
• Historically, achieving and maintaining body weight goals has been a focus
of MNT for diabetes. This is particularly true for children with T1DM. The
provision of adequate calories for normal growth and development for
children and adolescents with T1DM is a key component of MNT. Therefore
height and weight should be measured at each visit and tracked via
appropriate height and weight growth. For youth with T2DM, traditional
nutrition therapy goals included the prevention of excessive weight gain
while encouraging normal linear growth. However, the 2016 American
Academy of Pediatrics (AAP) guidelines recommended shifting the focus
from weight to healthy lifestyle behaviors.
• Adults
Overweight and obesity are common in people both at risk for and with
T2DM. Some research suggests that reduced calorie intake can lead to
reductions in A1C of 0.3% to 2.0% in adults with T2DM. If appropriate
for the individual, a reduction in caloric intake may also lead to
improvements in medication doses and quality of life (ADA, 2021).
Similarly, weight-loss interventions implemented in people with
prediabetes and newly diagnosed with T2DM have been shown to be
effective in improving glycemic control
 • Macronutrient Percentages
Type1 Type 2 Not for type1
CHO 50-60% of need requirement prefer 45-60% Amount of CHO is more
complex Type low glycemic important than type
1 units of insulin /10-15g
CHO
Protein 15- 20 %need requirement 15-20 Vegetable & protein
source
Vegetable source is less
nephrotoxic
Fat <35 of need requirement <7% 25-35% MUFA up to 20 %
saturated fatty acid <7% SFA, 4-7 PUFA
10% polyunsaturated fatty acid 10-20% MUFA
>10% monounsaturated fatty acid Cholesterol<300mg
Cholesterol <300mg
Fiber Recommended to be around 14g/1000 20-30%g/d
kcal High intake fiber 50
grams may improve
glycemic control
• Note :Metformin is associated with vitamin B12 deficiency. Because
of this, a recent report from the Diabetes Prevention Program
Outcomes Study (DPPOS) suggests that periodic testing of vitamin
B12 levels should be considered in patients taking metformin,
especially if the individual has a history of anemia or peripheral
neuropathy
 Glycemic Index and Glycemic Load
• The glycemic index (GI) of food was developed to compare the
physiologic effects of carbohydrates on glucose. The GI ranks
carbohydrate foods according to how they affect blood glucose levels
(for example, the GI of glucose = 100; the GI of white bread = 70). The
estimated glycemic load (GL) of foods, meals, and dietary patterns is
calculated by multiplying the GI by the amount of available
carbohydrate (divided by 100) in each food and then totaling the
values for all foods in a meal or dietary pattern. For example, two
slices of white bread with a GI of 75 and 30 g of carbohydrate have a
GL of 22.5 (75 × 30/100 = 22.5)
• The key differences between GI and GL are:
1.GI focuses solely on the quality of the carbohydrates, while GL
considers both the quality and quantity.
2.GI is a relative measure, while GL is an absolute measure that takes
into account the portion size.
3.Foods with a similar GI can have different GLs depending on the
carbohydrate content per serving.
4.GL is generally considered a more useful tool for predicting the
glycemic response to a meal or food item.
Micronutrients and Herbal Supplements
• s certain supplements may be helpful in lowering blood sugar levels. These
include cinnamon, chromium, α-lipoic acid (ALA), and berberine
• Chromium is an essential trace mineral required by the body in small amounts.
Some research suggests that the mineral may be used to improve glycemic
control for diabetes (types 1 and 2), prediabetes, PCOS, reactive hypoglycemia,
metabolic syndrome, and other glucose regulation disorder
• berberine significantly lowered FBG, A1C, triglyceride, and insulin levels in
patients with T2DM. lowering effects of berberine were similar to those of
metformin and rosiglitazone. Liver function was improved greatly in these
patients by showing a reduction of liver enzymes
• Alpha-Lipoic Acid (ALA): is an antioxidant that has been shown to improve insulin
sensitivity and reduce oxidative stress in people with diabetes. It may also help
prevent or slow the progression of diabetic neuropathy (nerve damage).
 Physical Activity/Exercise
• Physical activity should be an integral part of the treatment plan for persons with
diabetes. Exercise helps improve insulin sensitivity, reduce cardiovascular risk
factors, control weight, and improve wellbeing. Given appropriate guidelines, the
majority of people with diabetes can exercise safely. Individual activity plans will
vary, depending on interest, age, general health, and level of physical fitness.
• There are two types of exercise: aerobic and anaerobic. Both are important in
people with diabetes. Aerobic exercise consists of rhythmic, repeated, and
continuous movements of the same large muscle groups for at least 10minutes at
a time. Examples include walking, bicycling, jogging, swimming, and many sports.
Anaerobic exercise, also known as resistance exercise, consists of activities that
use muscular strength to move a weight or work against a resistive load.
Examples include weight lifting and exercises using resistance-providing
machines.
 Exercise in patients on insulin
• Add 15g carbohydrate for every > 30 minuets of activity
• Ingesting carbohydrate after 40 –o 60 minutes of exercise is
important and may assist to prevent hypoglycemia
• Blood glucose between 150 /180mg /dl is aim before physical activity
• If blood glucose level below 150 mg /dl eat 10 -15g of carbohydrate
before sports
• Always keep CHO foods readily available during exercise
• Comparison MNT B/W type1 &type 2 diabetes

Type 1 Type2
Increase in energy intake reduction of energy intake for
obese
Diet and insulin necessary to Diet alone can control blood
control BS sugar
Equal distribution of CHO Equal distribution of CHO
through meal for insulin desirable, not essential, low fat
activity desirable
Consistency in daily intake – Consistency in daily intake –
control BS control weight
 Fasting and diabetes
• Patient must be educated to adjust :
• Their diet
• Their medication timing
• Dates can be taken up to 2 within their carbohydrate allowance
• Limit fried food and heavy sugary sweets e. g. sambosa , basbosa
 References

➢Books:
1. Krause's Nutrition Food Therapy.
2. Understanding normal and clinical nutrition.
➢Websites:
1. Healthline .