11 - Diabetes Lifestyle

Question 1

Medical Nutrition Therapy

MNT

Answer 1

Recommended for ALL patients w/ DM

0.5-2% reduction in A1C for T2DM

Nutrition plan + weight management

Provided by a registered dietitian or nutritional professional

Evidence based nutritional assessment / diagnostic / therapy / Counseling

Question 2

Clinical Effects of Metformin

Answer 2

Reduces HbA1c 1-2%

Reduces Fasting Blood Glucose (FBG) 50-70mg/dl

Question 3

Physical Activity Recommendations

for Children w/ DM or Pre-DM

Answer 3

>60 min / day

of moderate to vigorous Physical activity

Question 4

Metformin Side Effects

biguanide

Answer 4

•Diarrhea (IR >50%; ER 10%)

•Nausea, vomiting (IR~25%; ER 7%)

•Flatulence, Abdominal bloating

•Heartburn

•Taste disturbance

•Weakness/lack of energy (asthenia)

•Lactic acidosis (RARE)

Question 5

AADE7 Self-Care Behaviors

DIABETES EDUCATION

Answer 5

Healthy Eating

being Active

Monitering BG + other labs

Taking Medication

Problem Solving / Healthy Coping / Reducing Risks

Question 6

How many servings of CARBOHYDRATES per meal?

1 serving = ? grams of carbs?

Answer 6

Most persons w/ DM need

3-4 carb servings per MEAL

for adequate blood glucose control

lower for WEIGHT LOSS, Men > women

1 choice/serving/portion = 15 grams of total carbs

(1/2 cup in general = 1 CUPPED HAND)

Question 7

Food Insecurity

FI

Answer 7

• Unreliable availability of nutritious food and the inability to consistantly obtain food without resorting to socially unacceptable practices.
• 1 in 7 adults are food insecure
• 2 fold risk of T2DM
• Language Barriers

Question 8

Metformin DRUG INTERACTIONS?

Pregnancy / Lactation?

Answer 8

No evidence of risk in Pregnancy in animal studies

IS EXCRETED IN BREAST MILK

Cationic drugs / Cimetidine / Contrast material (Iodine) / ALCOHOL

Ranolazine / Dolutegravir (Tivicay)

Question 9

Glycemic Index

GI

Answer 9

Ranking of carbohydrates on a scale from 0 - 100 according to the extent to which they RAISE BLOOD SUGAR LEVELS after EATING

Low GI = GOOD = wheat bread / oatmeal / non-starchy veggies

• *Fat & Fiber** tend to lower the GI
  ex. WHOLE FRUIT (juice has more sugar, less fiber)

Question 10

Metformin FDA Recommendations

Answer 10

Contraindicated if eGFR < 30

Do not initiate therapy if eGFR 30-45

if drops below 45ml/min/1.73m², assess benefits and risk

Monitor eGFR at least anually

D/C if iodinated contract imaging if eGFR is between 30-50

also with pts with liver disease / alcoholism

Question 11

Metformin MoA / Class

Answer 11

• Insulin Sensitizer: Biguanide Class
  
  • ​​​Decreases hepatic glucose production
  • Decreases intestinal absorption of glucose
  • ​​Increases insulin sensitivity
    
    • increases peripheral glucose uptake & utilization

Question 12

Tools to count CARBOHYDRATES

Answer 12

• *PLATE METHOD**
• *1/2 of plate = non-starchy veggies**

1/4 protein 1/4 starch

Plastic Food Models / Measruing Cups

Question 13

Glycemic LOAD

GL

Answer 13

GL = (GI / 100) x Net Carbs
(net carbs = Total Carbs - Dietary Fiber)

Gives a relative indication of how much that serving of food is likely to increase your blood-sugar levels

Low GL food is <10

Question 14

When to start MONOTHERAPY?

Answer 14

A1C < 9%

Metformin + Lifestyle Management

after diagnosis lifestyle management comes FIRST along with AIC target

Monitor A1C every 3-6 months

Question 15

Metformin Indication

Answer 15

<9% HbA1C

Lifestyle management + Monotherapy for T2DM

in persons >10y/o

Question 16

Lactic Acidosis in Metformin

Answer 16

• FATAL in 50% of cases
• Risk increases in:
  
  • Sepsis / dehydration / ALCOHOL
  • Hepatic / Renal impairment
  • Acute / unstable CHF
  • >80 years of age
• ​Onset may be subtle w/ non-specific symptoms
  
  • ​Malaise / Myalgias / Respiratory distress
  • Somnolence
  • non-specific abdominal distress

Question 17

Metformin Starting Dose

Answer 17

Obtain GFR before initiation (<30 dnu)

500mg Qd
take with food

to reduce incidence of GI adverse Effects

may be titrated weekly depending on tolerability

Question 18

Equivilants of Portions of CARBOHYDRATES

= 1 serving

3-4 Carb Servings PER MEAL

Answer 18

15 grams of TOTAL CHO = 1 serving

Pasta/Rice = 1/3 cup

Milk = 1 cup

• *Low-starch Veggies = 1 & 1/2 cup**
• not beans / potatoes / corn / yams / peas*

1 Slice of Bread / 1 Small tortilla

3/4 cup cereal / 1/2 bun

1 small orange or apple

Question 19

Metformin Max Dose

Answer 19

Clinically Effective Max Dose = 2000mg / day

also the max dose for children from 1_0-16 y/o_

Maximum Approved dose = 2550mg / day

max doses not recommended in ELDERLY (esp >80 y/o)

Question 20

Physical Activity Recommendations

for ADULTS w/ DM

Answer 20

>150 min/week
of moderate to vigorous inseity AOEROBIC ACTIVITY

over at least 3 days / week

with NO MORE than 2 consecutive days WITHOUT EXERCISE

or

75 min/week of VIGOROUS activity

Question 21

Metformin Further Dosing

Answer 21

Start at 500mg due to GI upset

titrate to 500mg BID or

500mg XR or

850 mg once daily

Titrated WEEKLY

to BID or TID

Question 22

Physical Activity CONSIDERATIONS

for complications of DM

Answer 22

• *RETINOPATHY**
• VIGORous aerobic / resistance exercise may be CONTRAINDICATED*

risk of triggering hermorrhage / retinal detachment

• *NEUROPATHY**
• *Peripheral** - non-weight bearing activities if there is foot injury

Autonomic - decreased cardiac responsiveness / hypotention
gastoparesis, obtain cardiac evaluation b4 exercise

Question 23

Goals of NUTRITION THERAPY

in Diabetes

Answer 23

Promote & Support HEALTHFUL EATING PATTERNS

emphasise a VARIETY of nutrient-dense food

in APPROPRIATE PORTION SIZES

in order to improve overall health

Question 24

Metformin

CONTRAINDICATIONS?

Answer 24

• DNU if* eGFR <30
• Do not INITIATE if eGFR = 30-45*

Contrast Induced Nephropathy = high risk if <60ml/min

May impair absorption of Vitamin B12

Unstable / Acute CHF or Liver Disease