DIABETES MEDICAL NUTRITION
THERAPY: CORE CONCEPTS
Anne Daly, MS, RDN, BC-ADM, CDE
Southern Illinois Univ School of Medicine
Center for Family & Community Medicine
OBJECTIVES OF TALK


To review the goals of medical
nutrition therapy (MNT), evidence
for effectiveness & key MNT
messages for PWD
To describe commonly used
nutrition interventions & discuss
challenges PWD face in the real
world to implement healthy
lifestyles
ABC’s of Diabetes Management
ABC’s
A-A1C
Significance
Average blood sugar level over the past
three months
Keeping A1C closer to normal reduces
the risk for long term complications
Performed 2-4 times per year
B-Blood Pressure Controlling BP decreases risk for strokes,
heart attacks, eye and kidney damage
Performed q visit
C-Cholesterol
High cholesterol adds to the risk of heart
disease
Performed at least once per year
MEETING DIABETES CARE GOALS
IN U.S.



30-50% not meet goals A1c, BP,
lipids
40-50% receive no DSME,
vaccinations or dental exams
20% continue smoking
Centers for Disease Control 2012
Diabetes Care 2013
NEJM 2013; 368:1613-1624
HUGE GAP BETWEEN PROMISE OF
QUALITY CARE VS. REALITY OF DB
CARE
HCP feel:
 Frustrated by
pts inability to
change behavior
and follow
prescribed
diabetes care
plans

Patients feel:



Overwhelmed
Guilty
Frustrated
Diabetes Education Underutilized

Few people with diabetes receive diabetes
education…
THE RESEARCH SHOWS:
People with Diabetes
Providers
• Don’t follow through
on referral
• Are emotional /
shocked at diagnosis
• End up relying on
family / friends
• Believe they know
enough / can handle
it on their own
• Know importance of
DE, but don’t
necessarily prescribe
– or don’t prescribe
definitively enough
• Sometimes forget to
follow up with
patients to encourage
attendance
DIABETES NUTRITION THERAPY




What to eat = most challenging part DB
treatment plans
“One size fits all” approaches do not work
Individualized medical nutrition therapy (MNT)
provided by RDN familiar with DB MNT
recommended all persons with T1, T2, pre-DB
All team members, including MDs, PAs, NPs,
PharmD, behavioralists, need be knowledgeable
about MNT, so can support its role, and ensure
pt has adequate access to therapy support
GOALS OF MEDICAL NUTRITION
THERAPY

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Healthful eating with variety nutrient
dense foods in appropriate portions to
attain target metabolic goals
Achieve and maintain body weight goals
Delay & prevent DB complications
Address individual nutr needs based on
personal & cultural preferences, health
literacy & numeracy, access to healthful
foods, willingness & ability to make
behavioral changes, barriers to change
GOALS OF MNT CONTINUED


Maintain pleasure of eating, promote
positive messages re: food choices,
limiting food choices only when based on
evidence
Provide practical tools for day-to-day
meal planning, rather than focusing on
individual macronutrients, micronutrients
or single foods
Diabetes Care 2014; 37 (Supp 1)S120-
EVIDENCE OF EFFECTIVENESS OF
MNT
Glycemic Control
 ~ 1% decrease A1c newly diagnosed T1D
 ~ 2% decrease A1c newly diagnosed T2D
 ~1% decrease A1c w average 4 yr duration
T2D
 50-100 mg/dl decrease FBG
 Outcomes known by 6 wks-3months
American Diabetes Association. Therapy for Diabetes
Mellitus (6th ed) 2014
EVIDENCE OF EFFECTIVENESS
MNT CONT
Lipids
 Decrease TC 24-32 mg/dl
 Decrease LDL 15-25 mg/dl
 Decrease TG 15-35 mg/dl
 Wo PA, HDL-C decreases; w PA, no
decrease
Hypertension
 5 mmHG decrease systolic BP, 2 mm
HG decrease (in pts with HTN)
Nutrition therapy changes as type 2 diabetes progresses
Insulin Resistance
Normal
insulin level
Insulin Deficiency
-15
-10
-5
0
5
10
15
20
25
30
Years
Early type 2 diabetes
Pre-diabetes
Later type 2 diabetes
Nutrition Therapy
Pre-diabetes
Early Type 2 Diabetes
Later Type 2 Diabetes
Nutrition (food)
focus
Healthy eating guidelines
Consistent carbohydrate intake*
Insulin-to-carbohydrate ratios
-- My Plate / DASH Diet/
Mediterranean Diet
-- Carb distributed throughout the day
-- Initially a consistent carb intake with
consistent insulin
-- 3 meals and 0-2 snacks/day
Per meal: 2-4 carb choices (30-60 gm carb)
Daily; at least 9 carb choices (130 gm carb)
Physical activity
Regular activity
Regular activity
-- To maximize therapy, when patient is
ready, advance from carb counting to
insulin-to-carb ratio
Regular activity
(30 minutes moderate activity; minimum 5 days a week)
Weight
management
Weight loss
Weight management
Weight management
(5-7% body weight)
(Prevent weight gain or aim for weight loss of 57% body weight)
(Prevent weight gain or aim for weight loss
of 5-7% body weight)
* Carbohydrate is in a wide variety of foods including grains, beans, starchy vegetables, fruits, juices, milk, yogurt, snacks and desserts
KEY MESSAGES FOR ALL PEOPLE
W DB

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Manage portion sizes to help meet carb
prescription, weight loss, and maintenance
Carbohydrate-containing foods/beverages and
endogenous insulin production=greatest
determinant pp BG; need know which foods
contain carbs—whole grains, starchy veg, nonstarchy veg, fruits, milk & milk products,
sweets/desserts
Choose nutrient dense, high fiber foods when
possible vs processed foods without added
sodium, fat and sugars
KEY MESSAGES ALL PEOPLE WITH
DB CONT



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Avoid sugar sweetened beverages,
ie soda pop, sweet tea, juices,
punches
Select leaner protein sources and
meat alternatives
Limit alcohol to one drink/day for
women, two drinks or less for adult
men
Add 30 minutes of physical activity
each day
NUTRITION THERAPY PRINCIPLES
FOR T1D AND INSULIN-REQUIRING
T2D


Learn how to count carbohydrates to
be able to “match” mealtime insulin to
carbohydrate consumed
If on multiple daily injections (MDI) or
pump:



Take mealtime insulin before eating
Meals can be consumed +/- 1 hour usual
eating time
If do PA within 1-2 hrs of mealtime insulin
injection, dose may be decreased to
decrease risk hypo
NUTRITION THERAPY PRINCIPLES
FOR T1D AND INSULIN-REQUIRING
T2 D CONT
If on a premixed insulin plan:
 Insulin needs be taken before eating
 Meals need be eaten at similar times each day
 Do not skip meals to reduce risk of
hypoglycemia
 Physical activity may result in hypo, depending
on when performed; always carry quick-acting
carbohydrate to reduce risk of hypoglycemia
If on a fixed insulin plan:
 Eat similar amounts of carbohydrate each day
to match set insulin doses
NUTRITION THERAPY PRINCIPLES
FOR T2D

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Avoid excess intake of carbs at any one time; aim
for consistent intake of carbs at similar times each
day; use SBGM to evaluate distribution carbs
Limit saturated fat and trans fatty acids, cholesterol.
Avoid excess intake of sodium
If overweight or obese, modify calorie intake, using
portion control & other strategies
Increase physical activity to reach 30 min 5 days/wk
Monitor BG to determine whether food adjustments
sufficient, or if medications need be added
Add and advanced diabetes medications, as needed
Healthy Eating
Manage Glucose
Timing of meals
1. Eat at least 3 times daily
2. Be consistent
3. Do not skip meals
4. Eat breakfast
How much food
1. Smaller portions
2. Small plate
3. One serving
4. Eat slowly
5. Bad foods out of site
6. Gradually cut down size
What type of food
1. Reduce amount of carbs
2. Increase fiber
http://www.ndep.nih.gov/diabetes/MealPlanner/pyramid.htm
Carb (CHO) Counting:
~15 g carb = 1 Carb choice
For detailed list
of “carb” exchanges,
see 
Now published as:
 Choose Your Foods:
Exchange Lists for
Diabetes
 Published by the
Academy of Nutrition
and Dietetics and the
American Diabetes
Association

DIABETES MEAL PLANNING TOPICS
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What is healthy eating—how to create the plate
Food groups--# servings recommended/day
Reading nutrition facts label—focus on serving size
Estimating/checking portion sizes
Carbohydrate consistency/carbohydrate counting
Calorie counting/weight loss strategies
Understanding dietary fats
Eating away from home
Recipe modifications
Sick days
Special occasions/holidays
MNT AND MEDICATIONS MUST BE
WELL MATCHED TO PHYSIOLOGY
OF DB

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
PWD can eat their way thru any
pills/meds we give them
Medication adherence overestimated;
barriers include side effects, lack
perceived effectiveness, cost,
misunderstanding how take correctly
Use BG monitoring to see effects
food and activity/sitting
SUMMARY

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

Diabetes care in U.S. remains
challenge
Referring PWD for both DSMT and
MNT first step
Using multidisciplinary team
approach recommended
PWD need ongoing support to
manage daily self-care behaviors