Alviar, Neil

Daniel, Pamela
Herrera, Katrina
Mandolang, Euclea
Panadero, Rechelle

Case #4:

Mr. Paran Noid is a diabetic man who is very much concerned on maintaining a good sugar
control through medications and proper diet. He comes to you for advice regarding the
proper nutrition of a diabetic. He is 55 tall and weighs 98 kgs.
Guide Questions:
1. How will you advice the patient on medical nutrition therapy?
2. How do you monitor the level of his glycemic control?

Medical Nutrition Therapy

Medical Nutrition Therapy (MNT) is a term used by the American Diabetes
Association (ADA) to describe the optimal coordination of caloric intake with other
aspects of diabetes therapy (insulin, exercise, weight loss)

Prevention Measures:
1. Primary: Directed at preventing or delaying the onset of type 2 DM in high-risk
individuals by promoting weight loss.
Structuredprogramsthatemphasizelifestylechangesthatincludemoderate
weightloss(7%bodyweight)andregularphysicalactivity(150min/week),with
dietarystrategiesincludingreducedcaloriesandreducedintakeofdietaryfat
AchieveUSDArecommendationofdietaryfiberof14gfiber/1,000kcaland
foodscontainingwholegrains(1/2grainintake)
2. Secondary: Directed at preventing or delaying diabetes-related complications in diabetic
individuals by improving glycemic control.
Carbohydrateincludecarbohydratefromfruits,vegetables,wholegrains,
legumes,andlowfatmilk;monitoringcarbohydrateintaketoachieveglycemic
control
Fatandcholesterollimitsaturatedfatto<7%oftotalcalories;minimizedintake
oftransfat;lowerdietarycholesterolto<200mg/day
Proteinhighproteindietsarenotrecommended;intype2DM,ingestedprotein
canincreaseinsulinresponse
3. Tertiary: Directed at managing diabetes-related complications in diabetic individuals.
Reductionofproteinintaketo0.81.0/kg/bodyweight/dayinindividualswith
CKD
Dietshighinfruits,vegetables,wholegrains,andnutsmayreduceriskofCVD
Dietarysodiumintakeof<2000mg/daymayreducesymptomsofheartfailure

Goal of MNT in Type 1 DM

 To coordinate and match the caloric intake with the appropriate amount of insulin.
Insulin-to-carbohydrate ratio determines the bolus insulin dose for a meal or
snack
MNT must be flexible enough to allow exercise, and
The insulin regimen must allow for deviations in caloric intake.
An important component of MNT in type 1 DM is to minimize the weight gain often
associated with intensive diabetes management

Goal of MNT in Type 2 DM

Focus on weight loss
Address the increased prevalence of cardiovascular risk factors (hypertension,
dyslipidemia, obesity) and diseases in this population
Hypocaloric diets and modest weight loss (5-7%) often result in rapid and
dramatic glucose lowering in individuals with new-onset type 2 DM.
Emphasize modest caloric reduction (low-carbohydrate) and
Increased physical activity

Exercise
Benefits:
Cardiovascular risk reduction
Reduced blood pressure, maintenance of muscle mass
Reduction in body fat, weight loss
For individuals with Type 1 or type 2 DM:
useful for lowering plasma glucose (during and following exercise)
Increasing insulin sensitivity
ADA recommendation:
150 min/week distributed over at least 3 days of moderate aerobic physical
activity with no gaps longer than 2 days.
The exercise regimen should also include resistance training

Calculation of Caloric Requirement

Hamwis Method:
Small Frame
For adult females, allow 100-lbs for 5 ft height. For each additional inch, add 5 lbs.
For adult males, use 106 lbs for 5 ft height and add 6 lbs for each additional inch
taller.
Medium Frame add 5 lbs for each additional inch taller
Large Frame
Add 10 lbs for each additional inch taller
Brocas Index (Tanhaussers Method)
DBW = Height (cm) 100
To adjust for Filipino standards:
If the height is between 5 ft. to 5ft. 6 inches, deduct 10% from the desirable weight
 If the height is below 5 ft. and above 5 ft. 6 inches, deduct 15% from the desirable
weight.

Diabetic Diet Prescription

Based on BMI:

BMI = = = 36.73 kg/m2 = Obesity

Desirable Body Weight:

Brocas Index:
165.1 cm 100 = 65.1 9.76 = 55 kg

Total Energy Requirement (TER)

UBW = 98 kg
Physical Activity = 30 kcal/kg (light)
TER = UBW x PA
= 98 x 30 kcal/kg
= 2,940 kcal

TER = 2,940 500 = 2,440 kcal

Protein = 20% x 2,440 = 488 kcal
= 488 : 4 = 122 g

Carbohydrates = 55% x 2,440 = 1,342 kcal

= 1,342 : 4 = 335.5 g

Fats = 25% x 2,440 = 610 kcal

= 610 : 9 = 68 g

Monitoring the Level of Glycemic Control

Optimal monitoring of glycemic control involves:
plasma glucose measurements by the patient and
an assessment of long-term control by the physician (measurement of HbA1c
) and review of the patient's self-measurements of plasma glucose)
These measurements are complementary: the patient's measurements provide a picture of
short-term glycemic control, whereas the HbA1c reflects average glycemic control over the
previous 2-3 months.

Self-monitoring Blood Glucose (SMBG)

is the standard of care in diabetes management and allows the patient to monitor
his or her blood glucose at any time.
 In this, a small drop of blood and an easily detectable enzymatic reaction allow
measurement of the capillary plasma glucose.
Many glucose monitors can rapidly and accurately measure glucose (calibrated to
provide plasma glucose value even though blood glucose is measured) in small
amounts of blood (3- 10 uL) obtained from the fingertip
The frequency of SMBG measurements must be individualized and adapted to
address the goals of diabetes care.
Individualswithtype1DMorindividualswithtype2DMtakingmultipleinsulin
injectionseachdayshouldroutinelymeasuretheirplasmaglucosethreeormoretimes
perdaytoestimateandselectmealtimebolusesofshortactinginsulinandtomodify
longactinginsulindoes.

Assessment of Long-term Glycemic Control

Measurement of glycated hemoglobin (HbA1c) is the standard method for assessing
long-term glycemic control.
When plasma glucose is consistently elevated, there is an increase in nonenzymatic
glycation of hemoglobin; this alteration reflects the glycemic history over the
previous 2-3 months, because erythrocytes have an average Iife span of 120 days
(glycemic level in the preceding month contributes about 50% to the HbA1c value)
Measurement of HbA1c at the "point of care allows for more rapid feedback and
may therefore assist in adjustment of therapy.
HbA1c should be measured in all individuals with DM during their initial evaluation
and as part of their comprehensive diabetes care.
HbA1c should mirror, to a certain extent, the short-term measurements of SMBG.
These two measurements are complementary in that recent intercurrent illnesses
may impact the SMBG measurements but not the HbA1c
Likewise, postprandial and nocturnal hyperglyemia may not be detected by the
SMBG of fasting and preprandial capillary plasma glucose but will be reflected in the
HbA1c
More frequent testing (every 3 months) is warranted when glycemic control is
inadequate or when therapy has changed.
Thefructosamineassay(measuringglycatedalbumin)reflectstheglycemicstatusover
theprior2weeks.

References:

Kasper, Dennis, L. MD, et al. Harrisons Principles of Internal Medicine, 2015.

McGraw Hill Education, Singapore, Chapter 418, 19th edition, 2015.
Nutrition Recommendations and Interventions for Diabetes: A position statement of
the American Diabetes Association. Diabetes Care, volume 31, Supplement 1,
January 2008
UniteforDiabetesPhilippines(CompendiumofPhilippineMedicine,p.2831.16th
edition,2014
 JamoraboRuiz,ClaudioandDeCastro.BasicNutritionforFilipinos6thEd.Chapter7.
MerriamWebster.2010.
JamoraboRuiz,ClaudioandDeCastro.MedicalNutritionTherapyforFilipinos6thEd.
Chapter8.MerriamWebster.2011.