Nutrition Therapy for Diabetes Complications

Postgraduate Diploma in Diabetes Education (PDDE

Nutrition therapy: Dietary advice in case of
complications

Lec 4 nutrition therapy that apply to
specific situations
Prepared by;
Dr. Siham M.O. Gritly
Dr. Siham Mohamed Osman Gritly

1

Heart and blood vessels
Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing
Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning

• atherosclerosis tends to develop early, progress
rapidly, and be more severe in people with diabetes.
• The interrelationships among insulin
resistance, obesity, hypertension, and atherosclerosis
help explain why about 75 percent of people with
diabetes die as a consequence of cardiovascular
diseases, especially heart attacks.
• Intensive diabetes treatment that keeps blood glucose
levels tightly controlled can reduce the risk of
cardiovascular disease among those with type 1
diabetes

2

Atherosclerosis : a type of artery disease characterized
by plaques (accumulations of lipid-containing material)
on the inner walls of the arteries

As atherosclerosis
progresses, plaque
thickens over
time, causing
arteries to
harden, narrow, and
become less elastic


3

Diabetes and Hypertension
• Advise overweight persons to lose weight.
• Reduce salt consumption to less than 6 g daily.
• Replace processed foods, which are mostly high
in salt, with fruits and vegetables, which are rich
in potassium and aid in reducing blood pressure.
• Avoid sustained excessive alcohol
consumption, as it has a deleterious effect on
blood pressure.

4

• Physical Activity
• Physical activity helps with weight control to
reduce hypertension,
• moderate aerobic activity, such as 30 to 60
minutes of brisk walking most days, also helps
to lower blood pressure directly.
• Or Regular exercise (30-45 minutes) on 4-5
days/week is beneficial

5

Dietary Strategies;- Hypertension
• The following dietary plans based on;• USDA (United States Department of
Agriculture)
• the American Heart Association Dietary
Strategies to Stop Hypertension (DASH) ,


6

• The Dietary Strategies to Stop Hypertension
(DASH) recommended that;-

• diet rich in fruits, vegetables, nuts, and lowfat milk products and low in total fat and
saturated fat have positive effect on blood
pressure.


7

The DASH Eating Plan
and the USDA Food Guide
These diet plans are based on 2000 kcalories per day
Food Group

DASH

USDA

Grains
Vegetables
Fruits
Milk (fat-free/lowfat
Lean meats, poultry,
fish
Nuts, seeds,
legumes

6–8 oz
2–2 c
2–2 c
2–3 c

6 oz
2c
3c
2 c

6 oz or less

5. oz

4–5 oz per week

combines nuts,
seeds, and legumes
with meat, poultry,
and fish.
8


Diabetic Dyslipidemia
• is an abnormal amount of lipids (e.g.
cholesterol and/or fat) in the blood.
• Dyslipidemia is one of the major risk factors
for cardiovascular disease in diabetes mellitus.
• In many persons with type 2, and overweight
persons with type 1 diabetes, dyslipidaemia is
associated with insulin resistance.
• This is characterised by raised triglycerides
and small dense LDL cholesterol.

9

The characteristic features of
diabetic dyslipidemia
• a high plasma triglyceride concentration,
• low HDL cholesterol concentration
• increased concentration of small dense LDLcholesterol particles.
• The lipid changes associated with diabetes
mellitus are attributed to increased free fatty
acid flux secondary to insulin resistance.


10

• As suggested by some researchers that the
abnormal lipid profile, Lifestyle
changes, including increased physical activity
and dietary modifications, are the
cornerstones of management


11

Major lipoproteins in the blood


12

The body makes four main types of
lipoproteins, distinguished by their size and density.
Each type contains different kinds and amounts of
lipids and proteins


13

• VLDL; in the liver the most active site of lipid
synthesis—cells are making;• cholesterol,
• fatty acids,
• and other lipid compounds.
• the lipids made in the liver and those collected from
chylomicron remnants are packaged with proteins as
VLDL (very-low-density lipoproteins) and shipped to
other parts of the body

14

• As the VLDL travel through the body, cells
remove triglycerides, causing the VLDL to shrink.
• As VLDL lose triglycerides, Cholesterol becomes
the predominant lipid, and the lipoprotein density
increases. The VLDL becomes LDL (low-density
lipoprotein).
• * This transformation explains why LDL
contain few triglycerides but are loaded with
cholesterol

15

• The LDL circulate throughout the body, making their
contents available to the cells of all tissues—muscles
(including the heart muscle), fat stores, the mammary
glands, and others.
• The cells take triglycerides, cholesterol, and
phospholipids to build new membranes, make
hormones or other compounds, or store for later use.
• Special LDL receptors on the liver cells play a crucial
role in the control of blood cholesterol concentrations
by removing LDL from circulation.


16

• The liver makes HDL to remove cholesterol
from the cells and carry it back to the liver for
recycling or disposal.

• In addition, HDL have anti-inflammatory
properties that seem to keep atherosclerotic
plaque from breaking apart and causing heart
attacks.

17

Dietary Management of dyslipidemia in
people with diabetes mellitus
• The primary goal in individuals with diabetes
is to limit saturated fatty acids, trans fatty
acids, and cholesterol intakes so as to reduce
risk for CVD.
• Saturated and trans fatty acids are the principal
dietary determinants of plasma LDL
cholesterol

18

recommendations
Energy: Balance energy intake and physical activity to
prevent weight gain and to achieve or maintain a
healthy body weight.
Saturated fat, trans fat, and cholesterol: Choose lean
meats, vegetables, and low-fat milk products; minimize
intake of hydrogenated fats. Limit saturated fats to less
than 7 percent of total kcalories, trans fat to less than 1
percent of total kcalories, and cholesterol to less than
<200 mg/day
Two or more servings of fish per week (with the
exception of commercially fried fish filets) provide n-3
polyunsaturated fatty acids and are recommended

19

• Plant sterols and stanols have been shown to
lower LDL cholesterol:
• An intake of 2 g/day – LDL reduction of 10-15%.
• fat-derived products, e.g. yoghurt, semiskimmed milk, cereal bars, soft cheese, to other
dietary methods for reducing LDL cholesterol.
• Hypertriglyceridaemia is also associated with
alcohol consumption.

20

Soluble fibers:
a diet rich in vegetables, fruits, whole
grains, and other foods high in soluble fibers.
Potassium and sodium:
a diet high in potassium-rich fruits and
vegetables, low-fat milk products, nuts, and
whole grains.
• with little or no salt (limit sodium intake to
2300 milligrams per day).

21

Added sugars: Minimize intake of beverages and foods with
added sugars.
Fish and omega-3 fatty acids: Consume fatty fish rich in
omega-3 fatty acids (salmon, tuna, sardines) at least twice a
week.
Soy: Consume soy foods to replace animal and dairy products
that contain saturated fat and cholesterol.
Alcohol: If alcohol is consumed, limit it to one drink daily for
women and two drinks daily for men

22

Dietary advice in case of complications
children and adolescents
• Nutritional or energy requirements change
throughout childhood and adolescence, e.g.:
• < 5 years – need a relatively energy-dense
diet.
• 6-12 years – energy intake doubles, protein
intake per kg body weight decreases.

23

• Recommendations
• Regular dietetic review every 3-4 months
during growth and puberty.

• Monitor height and weight.
• Review changes in lifestyle and physical
activity.

24

• Motivated adolescents benefit from a more
flexible approach to diet and insulin.
• Use and intensive management approach in
order to permit variability inherent in normal
• Nutrient requirements for children and
adolescents with type 1 or 2 diabetes are
similar to other children/adults of similar age

25

Pregnancy
Pregnancy in pre-gestational diabetes
• Good control of diabetes before/during
pregnancy is vital to reduce risks to the
mother and the child.

• Folate supplementation (5 mg daily) should be
taken to prevent neural tube defects in the
baby.


26

• Vitamin/mineral supplements should be given
if deemed necessary.
• Women whose body weight exceeds 120% of
the ideal should be advised to lose weight
before pregnancy


27

• During pregnancy
• Regular dietary follow up is necessary to maintain
near-normal glycaemia and provide
nutritional demands for pregnancy.
• A stable meal pattern that is composed of smaller
frequent meals is vital.
• Food choices should focus on the need for
micronutrient-rich foods (fruits, vegetables, low fat
dairy products, lean meat, fish or alternatives) rather
than energy-dense fat rich foods.
• Greater consumption of low glycaemic index foods is
advisable.

28

• Alcohol should be avoided.
• Tight glycaemic control increases hypoglycaemic risk and people
with diabetes need to be advised on symptoms and measures to
take.
• Measures to cope with nausea and vomiting should be given.
• Weight gain must be monitored. For a pre-pregnancy BMI of 20-26
kg/m2, recommended total gain is 11.5-16 kg.
• If weight is gained too rapidly, try to replace energy-dense food
with nutrient-rich, lower energy alternatives. The aim is to stabilise
weight/reduce the rate of weight gain. Active weight reduction is
not advisable as it may compromise nutritional intake/foetal
development.
• Energy consumption should be sufficient to prevent ketonaemia.


29

• If weight is gained too rapidly, try to replace
energy-dense food with nutrient-rich, lower
energy alternatives. The aim is to stabilise
weight/reduce the rate of weight gain. Active
weight reduction is not advisable as it may
compromise nutritional intake/foetal
development.
• Energy consumption should be sufficient to
prevent ketonaemia.

30

• Pregnancy
– Adequate caloric intake and nutrients needed to provide
appropriate weight gain for mother and fetus
– Focus on food choices for a healthy and steady weight
gain, glycemic control, and absence of ketones
– Aim to develop healthy habits and lifestyle modifications
(diet and exercise) for after delivery


31

• Lactation
• Breast feeding should be encouraged unless the
infant requires specialist care in a neonatal unit.
• The high energy costs of lactation means the
mother may require an additional 40-50 g of
carbohydrates/day compared with her pregnancy
state.
• Extra carbohydrates may be required before
going to bed while the infant is still having
nocturnal feeds.

32

• Gestational diabetes
• Provide advice on healthy food choices.
• Emphasise low glycaemic index foods and
carbohydrate distribution throughout the day.


33

• Modest dietary restriction 24-30 kcal/kg in
obese women may be advised.
•
• Postpartum advice on healthy eating and
weight management is vital as these women
are prone to type 2 diabetes.
•


34

The elderly person
• nutrient-dense foods needs to be
encouraged.
•
• Overweight persons: weight reduction is
beneficial as long as micronutrient intake is
not compromised.
•


35

• Zinc deficiency is more common in
elderly, hence, a need for supplements or zincrich diet.
•
• Calcium intake: at least 1200 mg; multivitamin
supplementation is advisable especially if low
appetite.
•

36

• Dietary guidelines:
• Meals should be balanced to meet clinical
needs of diabetes without diminishing older
person’s ability to enjoy meals.
• Avoid hypoglycaemia (relax targets): to
reduce falls with associated fractures.
• Physical activity/exercise is beneficial and
should be encouraged.

37

• Institutional care
• • In Africa, this is an emerging concept, i.e. homes for the
elderly. However, we have children in boarding
schools, residential homes, and juveniles or adults in
prison.
• • Residents have no control over the time of their meals
and medications, or type and amount of food provided; as
well as no access to facilities for food preparation and
storage.
• • Undernutrition is common in elderly people in
residential care.
• • It is recommended that such elderly residents be given
regular meals, with less restrictive
• diets for better nutritional status and quality of life

38

• In prisons, problems include inappropriate
foods and or meal times, and limited
• opportunities to exercise. Diabetes
management must thus be provided by a
multidisciplinary
• team, who are fully aware of the realities of
prison life.


39

• Ethnic considerations
• The dietician must be familiar with
customs, food habits and cooking practices of
various ethnic groups,
• Language barriers are also obstacles, but a
translator or a relative may help.


40

Eating disorders
• Eating disorders, such as anorexia and bulimia, are very
common in adolescent females.
• This is because of their concern about body
weight/shape since they (type 1 females) tend to be
heavier than their non-diabetic peers.
• It may involve omission of insulin, reduced food
consumption, or outright starvation.
• Success rates for treating eating disorders are lower in
persons with diabetes than in those without diabetes.
• The following events should arouse suspicion
regarding possible eating disorders:

41

• The three most common eating disorders found
in athletes are:
• 1-Anorexia Nervosa,
• 2-Bulimia,
• 3-Compulsive Exercise


42

Anorexia nervosa
lose 15 to 60 percent of their normal body weight by severely
restricting their food intake or exercising excessively.

Signs and Symptoms of
Anorexia
Excessive weight loss Always
thinking about food, calories, and
body weight Wearing layered
clothing Mood swings or
depression Inappropriate use of
laxatives, or diuretics in order to
lose weight
Avoiding activities that involve
food

43

Bulimia
Bulimia is one such eating disorder
that describes a cycle of binging
and purging.
Bulimia can begin when restrictive diets
fail, or the feeling of hunger associated with
reduced calorie intake leads to reduce
eating.
Like the person with anorexia nervosa, the
person with bulimia nervosa spends much
time thinking about body weight and food

44

References
• American Diabetes Association. Standards of medical
care in diabetes--2011. Diabetes Care. 2011 Jan;34
Suppl 1:S11-61
• American Diabetes Association. Nutrition
recommendations and interventions for diabetes: a
position statement of the American Diabetes
Association. Diabetes Care. 2008;31:S61-S78.
• American Diabetes Association. Carbohydrate
counting. Available at http://www.diabetes.org/foodand-fitness/food/planning-meals/carbcounting. Accessed December 8, 2012.

45

• American Diabetes Association (2002). Clinical Practice
Recommendations:2002. Diabetes Care 25 (suppl. 1):S64-S68.
• Sareen Gropper, Jack Smith and James Groff, Advanced Nutrition and
Human Metabolism, fifth ed. WADSWORTH
• Melvin H Williams 2010; Nutrition for Health, Fitness and Sport. 9th
ed, McGraw Hill
• Heymsfield, SB.; Baumgartner N.; Richard and Sheau-Fang P. 1999.
Modern Nutrition in Health and Disease; Shils E Maurice, Olson A.
James, Shike Moshe and Ross A. Catharine eds. 9th edition
• Guyton, C. Arthur. 1985. Textbook of Medical Physiology. 6th
edition, W.B. Company


46

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