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Present e-learning systems

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My name is Doctor Jeffrey Mechanick and I will be presenting on nutrition and diabetes.

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Production of this present lecture was brought to you by a generous grant from Vital Remedy MD, medically directed vitamins and supplements. Have a healthy life.

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What is healthy eating? Well, healthy eating involves consuming total calories to obtain or maintain a normal body mass index of 18.5-24.9kg/M2 or generally in the 25-30kcal/kg/day range. Protein should be consumed in the 0.8-1.0g/kg/day range and be delivered from lean meats, eggs, poultry, fish, beans, lentils, nuts, and seeds. About 15-20% of total kilocalories per day and remember that there are 4kcal/g of protein.

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Carbohydrate is an important component of a healthy diet. Typically, carbohydrates account for 50-60% of total kilocalorie per day. Lower carbohydrate diets may be useful for overweight or obese patients. Carbohydrates should be derived primarily from unprocessed grains, fruits, and vegetables containing fiber and less from processed grains, starches, and sweets. Target carbohydrates in this form include 8-10 servings of fruit and vegetables per day. The target fiber consumption is 30g/day. Carbohydrates is 4cal/day.

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Fat is also an essential component of a healthy diet. It generally accounts for 20-35% of total kilocalories per day. Saturated fat should be less than 10% of total kilocalories per day or less than 7% if the LDL-cholesterol is greater than 100mg/dl in patients with diabetes. Polyunsaturated fat should account for up to 10% of total calories per day. Monounsaturated fat for up to 15-20% of total calories per day. Polyunsaturated fatty acids and monounsaturated fatty acid dietary sources include: olive oil, canola oil, nuts, seeds, and fish. In fish, the Omega-3 fatty acids are found in high concentrations in salmon, herring, trout, sardines, and fresh tuna. Avoid trans-fats! These are found in fast foods, some margarines, and commercially baked goods. Dietary cholesterol intake should be less than 300mg/day or less than 200mg/day if the LDL-cholesterol is greater than 100mg/dl in patients with diabetes. Limit egg yolks to 2-3 per week, red meat, whole fat dairy products, shellfish, and organ meats.

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Micronutrients are also an essential component of a healthy diet. Salt should be consumed at less than 2,300mg/day or approximately 1 teaspoon. At this amount, there is an association with a lower risk for hypertension. Calcium 1,000-1,500mg/day and vitamin D in the range of 400-800units/day should be supplemented in postmenopausal women to decrease the risks for fracture. However, this concept has recently been challenged in the medical literature. Routine supplementation of magnesium beyond physiological levels is not supports by the data. Phosphorus supplementation is usually harmful. Trace element supplementation should be done only for documented deficiency states. The same is true for vitamin supplementation, only for documented deficiency states.

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There are four broad categories of dietary reference intakes or DRI's. The first is the estimated average requirements. This is the nutrient intake value estimated to meet a requirement in 50% of individuals. This second is the recommended daily allowances or RDA. This is the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all 97-98% of healthy individuals within a specific lifestage and gender group. The third is adequate intakes. This is an observed or experimentally determined approximations of nutrient intakes for a group, or groups, of healthy people. And lastly, tolerable upper limits. This is the highest level of daily nutrient intake that is not likely to pose a risk of adverse health effects.

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I would like to now move on to aspects of nutrition and preventative medication. First, let's define some terms. Primary prevention is an action that does not allow a disease to develop. For example, by preventing initial weight gain, type II diabetes may not develop.

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For secondary prevention, detecting a disease and early asymptomatic stage so that effective treatment will delay symptoms. For example, lifestyle intervention trials once screening studies have detected type II diabetes.

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Lastly, tertiary prevention, this is the act of not allowing the complications of an established disease to develop. For example, achieving tight glycemic control to prevent retinopathy.

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Let’s now look at nutritional risk factors for type I diabetes. These include cow's milk protein, wheat gluten, vitamin D, vitamin E, nitrites and nitrates, and nicotinamide.

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And nutritional risk factors for type II diabetes include total calorie intake and whether weight loss can occur or not.

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Lifestyle intervention in secondary prevention of type II diabetes. This includes monitoring consumption of dietary fats, limiting consumption of dietary carbohydrates, consumption of specific foods, and certain micronutrients.

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another important concept is the synchronization of dietary carbohydrate with insulin in type I diabetes. Strategies include carbohydrate counting which includes recognizing carbohydrates in the diet, determining insulin and carbohydrate sensitivity. For instance, one unit of insulin covers 5-15 grams of carbohydrate. Determining the correction factor. For instance, one unit of insulin sub q will drop glucose by 18-20mg/dl. Another way to calculate the correction factor is taking 1500-1800 and dividing it by the total daily dose of insulin to arrive at the amount that glucose drops in response to one unit of insulin.

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Let’s look at the carbohydrate content of common foods. 8 ounces of milk has 12 grams, one slice of white bread 15 grams, 1/2 cup spaghetti sauce 20 grams, one medium apple 21 grams, 1/2 cup of cooked white rice 22 grams, one medium banana 27 grams, 12 ounces cola 38 grams, and 2 ounces spaghetti 41 grams.

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The glycemic index is a controversial topic. It is the system of classifying the glycemic response of different foods. It is compared with the responses over 120 minutes after a standard 50 grams dextrose or white bread load. Cooked foods generally have a higher glycemic index than raw foods. The pitfalls of using the glycemic index include: the problems with mixing foods, issues with food preparation, within subject variability, the fact that the glycemic index of one meal is influenced by the previous meal, and that the glycemic index is qualitative and not really a quantitative measure. The glycemic load is equal to the glycemic index times the amount eaten.

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Perhaps glycemic load is a better way to look at common foods. Here is a table looking at examples of glycemic index and glycemic load for different foods. For instance, ice cream has a glycemic index of 27 with a low glycemic load of three. Carrots have a higher glycemic index of 47 but the same glycemic load of three. Popcorn, an even higher glycemic index of 55 and still a relatively low glycemic load of six. Some other examples: corn with a glycemic index of 60 but a low glycemic load of 11, shredded wheat a glycemic index of 83, rather high, with a glycemic load of 17, a baked potato with a glycemic index of 85 and a glycemic load the 26, mashed potatoes have a glycemic index of 85 the same as a baked potato, but a lower glycemic load of 17 compared to baked potato, and cornflakes have a very high glycemic index of 92 with a glycemic load of only 24.

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Let’s examine the different types of dietary carbohydrates. Starches are found in rice, pasta, bread, cereals, and starchy vegetables. Sugars include lactose in milk or dairy products, fructose in fruits and juices, and sucrose in table sugar and of course desserts. Fiber is found in fruits, vegetables, whole grains, beans, cellulose, hemicellulose, lignin, gums, and pectins.

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A useful technique for a diabetic is to build a personal food database. This involves first, to generate a broad list of foods preferred and regularly consumed to inspect the pantry, refrigerator, and freezer for the foods usually consumed. Then to assign amounts usually consumed in each serving for each food, weigh and measure these amounts. Compute the amount of carbohydrate in each serving from the nutrition facts labels, books, and other useful resources. Compute the amount of carbohydrate for combinations of these foods in usual meals and record in a personal database, which could be a notebook. Finally, add information about labeled and unlabeled foods from experience. For instance, the patient may test glucose two hours after consumption of the food alone or with other foods.

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Calorie restriction is very important for type II diabetes. A very low calorie diet is defined as less than 800 calories per day. It improves glycemic control, which worsens when calories are liberalized greater than 1000 calories per day. Very low calorie diets have a relatively high percentage of carbohydrates. Low calorie diets are defined as 800-1500 calories per day or 500-1000 calorie deficit per day. This corresponds to a 1-2 pound weight loss per week. Meal replacements are useful. In the diabetes prevention program a low-fat, low-calorie diet plus 150 minutes per week of physical activity produced a 5-7% weight loss and is translated into a 58% type II diabetes risk reduction. Increased physical activity is therefore, necessary for long-term weight loss. This improves insulin sensitivity and lowers blood pressure also.

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The diabetes prevention program diet was able to maintain greater than a 7% loss in body weight and included a total fat composition less than 25% of total calories with total calories in the 1200-1800 calorie per day range. Patients exercise more than 150 minutes per week.

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Other factors that are important for type II diabetes nutritional management include: dietary fiber; dietary protein; dietary fat; alcohol, which should be limited to one drink per day for women or less than two per day for men; micronutrient intake; in the use of non-sucrose sweeteners. In addition, exchange lists are very useful.

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In an exchange list one food with a specified amount of carbohydrate can be exchanged for another food with the same amount of carbohydrate. However, there are some other subtle differences between the foods. For instance, in a starch that contains 15 grams of carbohydrate, there may be three grams of protein, very little fat, and 80 calories. If we compare that to a fruit that also contains 15 grams of carbohydrate, there is no protein at all, and no fat at all, and only 60 calories.

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Recently, the food pyramid has been revised to be personalized for each patient, rather than specifying a set amount for all patients. As you can see from this cartoon, the pyramid generally contains larger amounts of whole grain, fruits and vegetables, and dairy products and limits oil, meats, and beans.

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Here are some level one recommendations for nutrition in type II diabetes. Whole grains, fruits, vegetables, and low-fat milk should be included in the diet. One does not need to eliminate sucrose from the diet. Nonnutritive sweeteners are safe.

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Fad diets have been particularly popular lately in the management of various diseases. In diabetes, obesity, and metabolic syndrome, and any patient who wants to lose weight the Atkins diet has become very popular. Other diets include: the South Beach diet, the glycemic index diet, the zone diet, low fat/high complex carbohydrate diets and the United States Department of Agriculture conference on popular diets concluded that reduced calorie diets produce weight loss independent of macronutrient consumption. That means that the important aspect is balanced caloric restriction and not necessarily some fad composition of a diet that has to be popular or advertised.

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Mitochondrial diabetes is a rare type of diabetes. There are various syndromes which include: maturity onset diabetes of the young, atypical diabetes of African-Americans, Ballinger-Wallace syndrome, Wolfram syndrome, MELAS syndrome, and MERFF. In addition, Kearns-Sayre syndrome, which includes other aspects of diseases of the endocrin glands can present with diabetes.

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Nutritional strategies for mitochondrial diabetes are largely unproven but they include specified amounts of proteins and certain amino acids. Certain fatty acids that can affect mitochondrial function: coenzyme Q10,A-lipolic acid, creatine, thiamin, carnitine, riboflavin, niacin, biotin, zinc, copper, vitamin A, vitamin C, vitamin E, and vitamin K.

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The metabolic syndrome is a very important condition that afflicts many patients. It is defined by clustering of various features. These include: overweight or obese with a waist circumference, a body mass index, or waste-to-hip ratio that is abnormally high; hypertension; impaired glucose regulation, whether it's an impaired glucose or an impaired post challenge glucose; hypertriglyceridemia; low HDL-cholesterol; and microalbuminemia.

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Interventions for the metabolic syndrome include: decrease calories by 500 per day for a 1 pound weight loss per week; and for a 5-10% reduction in weight by six months; 30 minutes of moderate physical activity five days per week; no salt shaker at the table, no added salt when cooking; more than five servings of fruits and vegetables per day; two servings per day of skim milk or low-fat yogurt or cheese; unsalted almonds or walnuts to replace sweets; reduce soft drinks and juices, switch to seltzer or diet sodas; limit to one alcoholic beverage per day with a meal; fresh or canned fish more than twice a week; and eat more whole wheat grains and cereals, switch from white to brown grains.

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What is a therapeutic lifestyle changes diet? This includes saturated fat less than 7% of total calories, polyunsaturated fat less than 10% of total calories, monounsaturated fat less than 20% of total calories, total fat that's 25-35% of total calories, carbohydrate 50-60% of total calories, fiber 20-30 grams per day, protein 15% of total calories, cholesterol less than 200 milligrams per day, and total calories to achieve and then maintain a desirable weight.

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The Dash diet is very useful in managing patients with hypertension. In this diet, nutrients such as grains, grain products, vegetables, fruits, nuts, seeds, and dry beans are consumed in larger amounts in the diet. Fats, oils, meats, and poultry are consumed less. Sweets and sodium at very small amounts.

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Nutritional strategies for the patient with gestational diabetes include the following: first to provide necessary nutrients during pregnancy; prevent ketosis; normalize the blood sugar; allow for appropriate weight gain, 2-5 pounds during the first trimester and 1/2-1 pound per week thereafter. If the patient is underweight or less than 80% ideal body weight than the diet should be approximately 40 calories per kilogram. For a normal weight individual 30 calories per kilograms, overweight 24 calories per kilogram, and obese 12-15 calories per kilogram.

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In the euglycemic diet, used for gestational diabetes, there's less than about 40% calories as carbohydrates. And as you can see, the calories are divided up among seven different meals and snacks.

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Other guidelines for gestational diabetes include: avoid sugars and concentrated sweets; avoid convenience foods or fast foods; each small frequent meals with protein; eat a small breakfast with only one starch; choose high fiber foods; have a lower fat intake; and eat free foods: cabbage, cucumbers, green onions, mushrooms, zucchini, spinach, celery, green beans, radishes, and lettuce.

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Let’s turn to nutritional therapy for chronic kidney disease. We see here the various stages of chronic kidney disease based on the GFR, the sodium intake, the energy intake, fat intake and the use of therapeutic lifestyle changes, protein intake which is limited except in patients on hemodialysis and peritoneal dialysis, phosphate intake which is limited, and of course potassium intake.

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Let’s examine some of the evidence-based nutritional strategies for chronic kidney disease. High biological value protein has an evidence level two meaning there are perspective randomized controlled trials to support the use. Oral protein supplements in malnourished patients with chronic kidney disease is also, supported by level II evidence. Amino acid containing peritoneal dialysis fluid also, for malnourished. Intra-dialectic parenternal nutrition-based on some weaker experimental evidence total parenternal nutrition also based on weaker experimental evidence and then by consensus, multidisciplinary approach with a dietitian and the use of enteral tube feedings particularly in patients with chronic kidney disease and nutritional compromise.

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what are some of the nutritional goals to limit malnutrition and cardiac calcification with chronic kidney disease and diabetes? An albumin of four. In stages 3-4 a phosphate of 2.7-4.6. In stage 5 a phosphate of 3.5-5.5. And also to have a calcium phosphate cross product less than 55.

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Production of this present lecture was brought to you by a generous grant from Vital Remedy MD. Medically directed vitamins and supplements have a healthy life.

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I would like to thank you for your attention during this presentation of diabetes and nutrition.