Selected Summaries of a Diabetes Nutrition RoundtableOctober 21-22, 2010

Columbus, Ohio, USA

The Role of Nutrition in Diabetes Management

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Table of Contents

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A message from Refaat Hegazi, MD, PhD Abbott Nutrition, Columbus, OH, USA . . . . . . . . . . . . . . . . . . . . . . . . . . . 4–5

Diabetes and Glycemic Management: New Advances . . . . . . . . . . 6–7 Glycemic management of subjects with prediabetes RobertKushner,MD,Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

Nutritional Issues in Subjects with Diabetes Is diabetes a nutritional disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9 CarolynM.Apovian,MD,FACP,FACN,Boston University School of Medicine, Boston, Massachusetts, USA

Protein requirements of subjects with diabetes . . . . . . . . . . . . . . . . . . . . . . . . . 10-11 OsamaHamdy,MD,PhD,Harvard Medical School, Boston, Massachusetts, USA

Effects of Nutrition on Cardiovascular Disease in Diabetes and Prediabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–13 IshwarlalJialal,MD,PhD,Departments of Medicine and Pathology, University of California, Davis, California, USA

Management of Tube Feeding-associated Hyperglycemia Medical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14–15 GordonS.Sacks,PHARM.D.,BCNSP,FCCP,Auburn University School of Pharmacy, Auburn, Alabama, USA

Nutritional management of enteral nutrition-associated hyperglycemia . . . . . 16–17 JenniferWooley,MS,RD,CNSD,University of Michigan Health System, Ann Arbor, Michigan, USA

Diabetes-specific Formulas: Science and Technology . . . . . . . . . . 18–19 VikkiMustad,PhD,Abbott Nutrition, Columbus, Ohio, USA

Diabetes-specific Nutrition in the Outpatient Setting Diabetes-specific nutrition in subjects with diabetes mellitus . . . . . . . . . . . . . . 20–21 W.TimothyGarvey,MD,Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama, USA

Diabetes-specific nutrition for subjects with co-morbidities . . . . . . . . . . . . . . . 22–23 JosephBass,MD,PhD,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

Diabetes-specific Nutrition in the Inpatient Setting . . . . . . . . . . . . 24–25 JoséRaimundodeAzevedo,MD,Intensive Care Units of Hospital São Domingos and Hospital Dr Clementino Moura, São Luis, Maranhão, Brazil

Diabetes-specific Nutrition in Subjects with Stress Hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26–27 PasqualeDiBiase,MD,Regional Center for Home Care & Clinical Nutrition, Regional Hospital A. Cardarelli, Campobasso, Italy

A closing message from Refaat Hegazi . . . . . . . . . . . . . . . . . . . . . . . . 28–29

In2010,guestspeakersandinvitedattendeesmetinColumbus,Ohio,todiscusswhatprovedtobeaparticularlyengagingtopic:The role of nutrition in diabetes management.AsChairmanofthismeeting,Iampleasedtointroduceselectedsummariesfromthisroundtablediscussionasawaytospreadthewordaboutthenewestconceptsindiabetesnutrition.

Hearingallthelatestnewsaboutresearchonnutritionindiabetesisveryexciting.Increasingly,studiesshowthatwecanactuallypreventdevelopmentoftype2diabetesthroughlifestylefactorssuchaspropernutrition,physicalactivityandweightmanagement.Manyotherrecentstudiesshowthatcontrolofbloodglucoseinpatientswhoarehospitalizedcanlowerriskforinfections,shortenlengthofstay,andevenreduceriskofdeath.

Iinvitereaderseverywheretotakeadvantageofthesereviewsofrecentresearchfindings,expertopinions,andprovokingdiscussionsasawaytostimulatestudyandconversationamongyourowncolleagues.Ihopethatthismeetinganditsselectedsummarieswillultimatelyleadthewaytohelpingimprovequalityoflifefortheever-growingpopulationofpeoplewithdiabetesandat-riskfordiabetesaroundtheworld.

Why is diabetes nutrition “hot”?

Herearethenumbers,andtheyarestriking.IthasbeenestimatedthatoneinthreeAmericansbornin2000willdevelopdiabetesintheirlifetime;amajorityofthesecaseswillbeattributed,atleastinpart,toobesity.1AlmostonethirdofUSchildrenover2yearsofagearealreadyoverweightorobese.2Therearealready24millionpeoplewithdiagnoseddiabetes,andmorethantwicethatnumberhaveprediabetes,withbloodglucoselevelshigherthannormal,butnothighenoughforadiagnosisofdiabetes.3Withdiabetes,risksforheartdiseaseandstrokesare2to4timeshigherthaninadultswithoutdiabetes.

A message from Refaat Hegazi, MD, PhD, Abbott Nutrition, Columbus, OH, USA

Butnutritionalstrategies,togetherwithexercise,areacknowledgedaseffectivewaystoprevent,delay,ortreatdiabetes.Somesolutionscanbefoundintheformofnewnutritionalingredientsandsupplements,whileotherstrategiesinvolveconsumptionofusualfoodinbalanceandinproperamounts.

What’s next?

It’suptoyou.IinviteyoutoperusetheselectedsummariesofThe Role of Nutrition in Diabetes Management,digintosomeofthereferencescited,andstartdiscussionsorholdmeetingsatyourownsite.Helpfillaknowledgegapbyconductingaresearchstudy.Thepossibilitiesareendless.Withyoursharedinterest,wecanworktogethertomakearealdifferenceinthelivesofmillionsofpeople.

RefaatHegazi,MD,PhDMedicalDirector,AbbottNutrition

References

1. NarayanKM,BoyleJP,ThompsonTJ,SorensenSW,WilliamsonDF.LifetimeriskfordiabetesmellitusintheUnitedStates.JAMA.Oct82003;290(14):1884-1890.

2. WojcickiJM,HeymanMB.Let’sMove–childhoodobesitypreventionfrompregnancyandinfancyonward.N Engl J Med.Apr222010;362(16):1457-1459.

3. www.diabetes.org/diabetes-basics/diabetes-statistics/.Diabetesstatistics.2010.AccessedOct31,2010.

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Obesity,withitsinherentriskfordiabetes,isaleadingpublichealthchallengetoday.Inpreparingtoadvisepatientsaboutloweringriskfordevelopingdiabetes,physiciansbenefitfromunderstandingbiomarkersofriskandrecognizingdietaryandlifestylepatternsthatareharmful.Excessweightincreasesriskfordiabetes,asdoessedentarylifestyleandintakeofausualWesterndiet.

Assummarizedbelow,thesemodifiableriskfactorscanbeaddressedtopreventordelayonsetoftype2diabetes.

•Weight and waist circumference.Formorethanadecade, weightchangehasbeenassociatedwithincidenceoftype2 diabetes.Weightloss≥5kgdecreasesriskby20%,while weightgainof5to8kgmorethandoublesrisk,andweight gain>20kgnearlyquadruplesrisk.1Further,largewaist circumferenceservesasapracticalandreliablepredic- torofdiabetes—withbetterpredictivevaluethanBMIor othercardiometricriskfactors(bloodpressure,triglycerides, serumlipoproteinandbloodglucoselevels).2Cutoffpoints forincreasedriskare88cm(35inches)forwomenand 92cm(36inches)formen.3

•Physical activity.Moderatephysicalactivitywas supportedbyasystematicreviewof10studiesinvolving morethan9000incidentcasesofdiabetes.4Takentogether, individualswhoregularlyengagedinphysicalactivityof moderateintensityhad~30%lowerriskoftype2 diabetescomparedwithsedentaryindividuals.

•Western diet.Foodgroupssuchasredmeat,low-fiber breadandcereal,friedpotatoes,eggs,andcheeseare prominentintheso-calledWesterndiet,whichalso commonlyincludessweetenedbeverages,highglycemic indexfoods,andfoodshighinsaturatedfats.5Lowintake offreshfruitsandvegetablesisalsocommon.

Thereissubstantialevidenceinthemedicalliteratureaboutusingspecificstrategiestopreventdiabetesonset.Forexample,areviewofdietaryadvicebytheCochraneGroupfoundsupportincommonforreducedintakeofenergyandsimplesugars,alongwithincreasedintakeoffreshfruitsandvegetables.6Otherprotectivefactorsarephysicalactivity,neversmoking,moderatedalcoholuse,BMI<25,anddecreasingwaistcircumference(<88cmforwomen,<92cmformen).Importantly,MozaffarianandcolleaguesfortheCardiovascularHealthStudydeterminedthatcombiningprotectivestrategiescanprovidecumulativebenefitfordiabetesprevention.Asexpected,increasingthenumberoflow-riskfactorsyieldsagreaterbenefit.3

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Diabetes and Glycemic ManagementGlycemic management of subjects with prediabetesRobertKushner,MD,Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

To advise patients about lower-ing risk for developing diabetes, physicians benefit from under-standing biomarkers of risk and recognizing dietary and lifestyle patterns that are harmful.

Numerousstudiessupportthebenefitsofhealthydiet,regularexercise,andweightlosswhenneededtodecreaseriskfordiabetesincidence.7,10Roumenandcolleaguesreviewedstudiesinordertocompileandquantifylifestylefactorsassociatedwithdiabetesriskreduction(Table).Inpeoplewithprediabetes

(impairedglucosetolerance)theriskofprogressiontodiabetescouldbereducedbyonehalfwhenmultipleformsoflifestyleinterventionwerepooled,asshownbyameta-analysisof17studiesinvolving>8000patients.10Manypharmacologicalinterventionshelpedpreventdiabetes,butlifestyleinterventionswereatleastaseffectiveasuseofadrug.10

References1. FordES,WilliamsonDF,LiuS.Weightchangeanddiabetesincidence:findingsfromanationalcohortofUSadults.

Am J Epidemiol.Aug11997;146(3):214-222.

2. JaniszewskiPM,JanssenI,RossR.Doeswaistcircumferencepredictdiabetesandcardiovasculardiseasebeyondcommonlyevaluatedcardiometabolicriskfactors?Diabetes Care.Dec2007;30(12):3105-3109.

3. MozaffarianD,KamineniA,CarnethonM,DjousseL,MukamalKJ,SiscovickD.Lifestyleriskfactorsandnew-onsetdiabetesmellitusinolderadults:thecardiovascularhealthstudy.Arch Intern Med.Apr272009;169(8):798-807.

4. JeonCY,LokkenRP,HuFB,vanDamRM.Physicalactivityofmoderateintensityandriskoftype2diabetes:asystematicreview.Diabetes Care.Mar2007;30(3):744-752.

5. LieseAD,WeisKE,SchulzM,ToozeJA.Foodintakepatternsassociatedwithincidenttype2diabetes:theInsulinResistanceAtherosclerosisStudy.Diabetes Care.Feb2009;32(2):263-268.

6. NieldL,SummerbellCD,HooperL,WhittakerV,MooreH.Dietaryadviceforthepreventionoftype2diabetesmellitusinadults.Cochrane Database Syst Rev.2008(3):CD005102.

7. RoumenC,BlaakEE,CorpeleijnE.Lifestyleinterventionforpreventionofdiabetes:determinantsofsuccessforfutureimplementation.Nutr Rev.Mar2009;67(3):132-146.

8. BantleJP,Wylie-RosettJ,AlbrightAL,etal.Nutritionrecommendationsandinterventionsfordiabetes:apositionstatementoftheAmericanDiabetesAssociation.Diabetes Care.Jan2008;31Suppl1:S61-S78.

9. JoslinDiabetesCenter.Clinicalnutritionguidelineforoverweightandobeseadultswithtype2diabetes,prediabetesorthoseathighriskfordevelopingtype2diabetes.2007.http://www.joslin.org/info/joslin-clinical-guidelines.html.Accessed11/11/10.

10.GilliesCL,AbramsKR,LambertPC,etal.Pharmacologicalandlifestyleinterventionstopreventordelaytype2diabetesinpeoplewithimpairedglucosetolerance:systematicreviewandmeta-analysis.Br Med J.Feb102007;334(7588):299.

Take-home messages

• Lifestylemodification,includinglosing5-10%ofinitialweightandengagingin30minutesofmoderately intensivephysicalactivityeveryday,canprovidesignificantreductionindiabetesriskandshouldbe implementedforallat-riskindividuals.• Dietarycomponentsshouldincluderecommendedamountsoflow-glycemiccarbohydratesandfiber,andlow levelsofsaturatedfat.

OtherguidelinesareavailablefromsourcessuchastheAmericanDiabetesAssociation8andtheJoslinDiabetesCenter.9

Table. Recommendations for reduction of diabetes risk7

Features of intervention Recommendation

Body weight loss ≥5%

Dietary guidelines

Carbohydrates ~55%ofenergy

Totalfat <30%ofenergy

Saturatedfat ≤10%ofenergy

Cholesterol <138mg/1000kcal

Protein 10–15%ofenergy

Fiber 12.5g/1000kcal/day

Exercise 30minofmoderatephysical activity/day,atleast5days/wk

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Thechronicdiseaseofobesitytakesmanytolls.Itsgreatestisitsassociationwithdiabetesincidence,1whichisincreasinglyprevalentintheUSandaroundtheworld.

Thelinkbetweenobesityanddiabetesiscomplex.Scientificevidencesuggestsakeyroleforthebraininthecontrolofbothbodyfatcontentandglucosemetabolism.2Neuronalsystemsrespondtoinputfromhormonalandnutrient-relatedsignalsconveyinginformationregardingbothbodyenergystoresandcurrentenergyavailability.Inresponsetothisinput,thebrainnormallyregulatesenergyintake,energyexpenditure,andendogenousglucoseproductiontomaintainenergyhomeostasisandbloodglucoselevelsinthenormalrange.Thelinkbetweenobesityandtype2diabetesisthoughttoresultfromdefectsinthiscontrolsystem,eg,changesinreleaseofhormonessuchasleptinandadipsinfromadiposetissue.

Sinceobesityisusuallyassociatedwithabundantfoodintake,itmaybesurprisingthatpeoplewithdiabetesexperiencenutritionaldeficiencies.However,deficienciesofmicronutrients—magnesium,zinc,andchromium—arecommon.3Proteininadequacyisanotherimportantshortfall,especiallyforolderpeoplewithdiabetes.Thenetresultisdeclineofskeletalmusclefunction.Thisconditionhasrecentlybeenrecognizedassarcopenia,orsarcopenicobesitywhenitoccursinpeopleofexcessweight.4

Sarcopeniaisthelossofmusclemassand/orstrength,alongwithadeclineinfunctionality.5Suchchangesareoftenassociatedwithobesityandinsulinresistance,whichpredisposeindividualstodevelopmentoftype2diabetes.Withsarcopenicobesity,thequalityofmuscleisfurthercompromisedbyinfiltrationoffat.This“marbling”furtherdiminishesmusclefunction.Peoplewithsarcopeniahavedifficultywalkingandclimbingstairsandhavetroubleperformingtasksofdailyliving.Theyareatincreasedriskforfallsandhipfracture,andevenfordeath.Theunderlyingpathologyisthoughttoberelatedtodeficitsinmitochondrialfunction,especiallythefunctionofmusclemitochondria.6

Asarcopeniadiagnosisshouldbeconsideredinallolderpatientswhopresentwithobserveddeclinesinphysicalfunction,strength,oroverallhealth.5Sarcopeniacanbesuspectedinpatientswhoarebedridden,cannotriseindependentlyfromachair,orhaveameasuredgaitspeed<1.0meterpersecond.PatientswhomeettheseinitialcriteriashouldfurtherundergobodycompositionassessmentusingdualenergyX-rayabsorptiometry.Sarcopeniaisdefinedaslean/fatratiomorethan2standarddeviationsbelowthatofanaverageyoungadult.

Managementofsarcopeniainolderpeoplewithdiabetesdependslargelyontwostrategies:exerciseanddiet.Sincelossoffunctionalabilitieshasamarkedeffectonlifestyleandindependenceofanolderperson,exerciseisimportanttorestoreleanbodymass.7Resistancetraininghasprovenhighlyeffectivetohelpolderindividualsbuildmuscleandimprovetheirabilitytoperformactivitiesofdailylivingsuchaswalking,bathing,dressing,andchangingfromasittingtoastandingposition.7,8

Proteinintakeisakeyconsiderationfordietarymanagementofsarcopeniainolderpeople,includingtheamountandqualityofproteinandthetimingofitsintake.WhiletheUSInstituteofMedicinerecommends0.8gproteinperkgbodyweighteachdayforalladults,geriatricclinicianshavedeterminedthathigherlevelsofdietaryproteinmaybeappropriateforolderindividuals—upto1.8gprotein/kg/day.9Furthermore,thetimingofthisproteinintakecanalsobeafactor.Paddon-Jonesandcolleaguesrecentlyadvisedintakeof25-30gproteinateachof3mealsperday,incontrasttocustomaryintakethatisweightedmoreheavilytoproteinintakeattheeveningmeal(60gdinner,10-20gatbreakfastandlunch).10

Animportantrolealsohasbeenrecognizedforintakeofleucine,anessential,branched-chainaminoacidthatactsasasignaltoenhanceproteinsynthesis.11However,beta-hydroxy-beta-methylbutyrate(HMB),astable,highlyactivemetaboliteofleucine,hasrecentlyemergedasabeneficialdietarysupplementthatstimulatesproteinsynthesisandinhibitsbreakdownofproteins.12

Nutritional Issues in Subjects with DiabetesIs diabetes a nutritional disease?CarolynM.Apovian,MD,FACP,FACN,Boston University School of Medicine, Boston, Massachusetts, USA

Inaddition,aroleforsupplementaltestosteroneisnowbeinginvestigatedasawaytobuildandmaintainmuscleinolderpeople.8

Obesityanddiabetesareindeednutritionaldiseases.Managementrequiresattentiontodiet,withfocusonintakeofprotein.However,

dietaloneisnotenough.Physicalactivity,particularlyresistanceexercise,playsakeyroleinbuildingandmaintainingleanbodymassinolderindividualswithdiabetes.Sustainedmusclefunctionisvitaltocontinuingwithactivitiesofdailyliving,therebymaintainingqualityoflife.

References1. ApovianCM.Thecauses,prevalence,andtreatmentofobesityrevisitedin2009:whathavewelearnedsofar?

Am J Clin Nutr.Jan2010;91(1):277S-279S.

2. SchwartzMW,PorteD,Jr.Diabetes,obesity,andthebrain.Science.Jan212005;307(5708):375-379.

3. WalkerAF.Potentialmicronutrientdeficiencylacksrecognitionindiabetes.Br J Gen Pract.Jan2007;57(534):3-4.

4. VillarealDT,BanksM,SienerC,SinacoreDR,KleinS.Physicalfrailtyandbodycompositioninobeseelderlymenandwomen.Obes Res.Jun2004;12(6):913-920.

5. EvansWJ.Skeletalmuscleloss:cachexia,sarcopenia,andinactivity.Am J Clin Nutr.Apr2010;91(4):1123S-1127S.

6. LanzaIR,NairKS.Musclemitochondrialchangeswithagingandexercise.Am J Clin Nutr.Jan2009;89(1):467S-471S.

7. GillTM,BakerDI,GottschalkM,PeduzziPN,AlloreH,ByersA.Aprogramtopreventfunctionaldeclineinphysicallyfrail,elderlypersonswholiveathome.N Engl J Med.Oct32002;347(14):1068-1074.

8. KoopmanR,vanLoonLJ.Aging,exercise,andmuscleproteinmetabolism.J Appl Physiol.Jun2009;106(6):2040-2048.

9. WolfeRR.Theunderappreciatedroleofmuscleinhealthanddisease.Am J Clin Nutr.Sep2006;84(3):475-482.

10.Paddon-JonesD,RasmussenBB.Dietaryproteinrecommendationsandthepreventionofsarcopenia.Curr Opin Clin Nutr Metab Care.Jan2009;12(1):86-90.

11.NicastroH,ArtioliGG,DosSantosCostaA,etal.Anoverviewofthetherapeuticeffectsofleucinesupplementationonskeletalmuscleunderatrophicconditions.Amino Acids. Jun12010.

12.WilsonGJ,WilsonJM,ManninenAH.Effectsofbeta-hydroxy-beta-methylbutyrate(HMB)onexerciseperformanceandbodycompositionacrossvaryinglevelsofage,sex,andtrainingexperience:Areview.Nutr Metab (Lond).2008;5:1.

Take-home messages

• Obesepeoplewithdiabetesoftensufferfrommalnutritionandsarcopeniaastheygetolder,aconditionknown assarcopenicobesity.• Sarcopenicobesitymanifestsasmitochondrialdysfunctionandreducedmusclefunction.• Clinicalstudiesoftreatmentstrategiessuggestthatfocusonquantity,quality,andtimingofdietaryprotein maybeimportanttoincreasemusclemassandstrength.• Nutritionthatincludesaminoacidsormetabolites(HMB)isapromisingstrategyforimprovedmanagementof sarcopenicobesity.Useofanabolicenhancersalsoneedsfurtherexploration.

Protein Quality(ie,supplementationwithleucineorHMB)

Protein Quantity(ie,1.6-1.8g/kg/day)

Exercise and/or Testosterone

Debatecontinuesaboutoptimaldietaryproteinintakeamongpeoplewithdiabetes.TheAmericanDiabetesAssociationhasdevelopedrecommendationsformedicalnutritiontherapy(MNT),whichincludeguidancefordietaryproteinintake.1Forpeoplewithdiabetes,adietaryintakeofproteinrepresenting15-20%oftotalenergyisrecommended(levelE,expertrecommendation).Body-weight-basedintakeforproteinissuggestedas0.8-1.0g/kg/dayforpeoplewithnormalkidneyfunctionbutlessforthoseinlaterstagesofchronickidneydisease(CKD;levelB).SelectionofMNTthatbenefitsloweringofcardiovascularriskfactorsisrecommended(levelC),butahigh-proteindietisnotrecognizedasamethodforweightlossatthistime.

However,clinicalstudyresultssupportedbenefitsofahigh-proteindiet(ascomparedtoahigh-carbohydratediet)forobesewomenwhowereinsulinresistant.2Thehigh-proteindietcontained34%carbohydrateand30%protein,whilethehigh-carbohydratedietcontained49%carbohydrateand21%protein.Overthe24-weektreatmentinterval,patientsonthehigh-proteindietshowedsignificantlybetterBMI-lowering;significantreductionofweight,waistcircumference,andtriglyceridelevels;andmoreindividualsexperiencedloweringoflow-densitylipoproteinlevels.2

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Hamdy’s Top 10 Reasons for People with Diabetes and Normal Kidney Function to Increase Protein Intake:

1. Proteindoesnotincreaseplasmaglucose.

2. Proteinincreasesinsulinresponse.

3. Higherproteinreducestheneedtoincreasecarbohy- dratesorfat,whichcancauseothernegativeeffects.

4. Proteinreducesappetiteandincreasessatiety.

5. Proteinincreasesthermogenesis.

6. Higherproteinenhancesweightlossandmaintains leanmass.

7. Moredietaryproteinisassociatedwithreductionin totalcholesterol,LDLandtriglyceridelevels.

8. Higherproteinintakeisassociatedwithreductionin bloodpressure.

9. Higherproteinintakeisassociatedwithreductionin inflammationmarkers.

10.High-proteindietislinkedwithfewercardiovascularevents.

Nutritional Issues in Subjects with DiabetesProtein requirements of subjects with diabetesOsamaHamdy,MD,PhD,Harvard Medical School, Boston, Massachusetts, USA

References1. BantleJP,Wylie-RosettJ,AlbrightAL,etal.Nutritionrecommendationsandinterventionsfordiabetes:apositionstatementofthe

AmericanDiabetesAssociation.Diabetes Care.Jan2008;31Suppl1:S61-78.

2. McAuleyKA,HopkinsCM,SmithKJ,etal.Comparisonofhigh-fatandhigh-proteindietswithahigh-carbohydratedietininsulin-resistantobesewomen.Diabetologia.Jan2005;48(1):8-16.

3. BrinkworthGD,NoakesM,KeoghJB,LuscombeND,WittertGA,CliftonPM.Long-termeffectsofahigh-protein,low-carbohydratedietonweightcontrolandcardiovascularriskmarkersinobesehyperinsulinemicsubjects.Int J Obes Relat Metab Disord.May2004;28(5):661-670.

4. GannonMC,NuttallFQ,SaeedA,JordanK,HooverH.Anincreaseindietaryproteinimprovesthebloodglucoseresponseinpersonswithtype2diabetes.Am J Clin Nutr.Oct2003;78(4):734-741.

5. RileyMD,DwyerT.Microalbuminuriaispositivelyassociatedwithusualdietarysaturatedfatintakeandnegativelyassociatedwithusualdietaryproteinintakeinpeoplewithinsulin-dependentdiabetesmellitus.Am J Clin Nutr.Jan1998;67(1):50-57.

6. HuFB,StampferMJ,MansonJE,etal.Dietaryproteinandriskofischemicheartdiseaseinwomen.Am J Clin Nutr.Aug1999;70(2):221-227.

Take-home messages

• Forpeoplewithtype2diabetes,increasingproteinintaketo1.5-2g/kg(or20-30%oftotalcaloricintake) mayenhanceweightloss,reducebloodpressure,improvelipidprofile,andreduceA1c.• Increasingproteinintaketo1.5-2g/kg/day(or20-30%oftotalcaloricintake)wasnotassociatedwith deteriorationofrenalfunctionindiabeticpatientswithnormalrenalfunction.• Currently,nodatasupportincreasingproteinintakeabove2g/kgbodyweightperdayorhigherthan30%oftotal energyintake.

ADA 2008 dietary protein recommendations for people with diabetes1:

• Protein as 15-20% of total energy for people with normal renal function (level E)

• With normal kidney function or early-stage CKD, protein as 0.8-1.0 g/kg/day (level B)

• With later-stage CKD, protein as 0.8 g/kg/day (level B)

• MNT that favorably affects cardiovascular risk factors is preferred (level C)

• High protein diet not recommended as a method for weight loss at this time (level E)

Additionalstudiesprovidedevidencetosupportbenefitsofhigher-proteindietsforpeoplewithdiabetes,especiallythosewhowereobeseandinsulinresistant.Brinkworthandcolleaguesfoundthatahigh-proteindiet(proteinas30%ofenergy)causedsignificantlygreaterweightlossthandidalow-proteindiet(proteinas15%ofenergy).3Gannonandcolleaguesfoundthatahigh-proteindietcausedsignificantlygreaterloweringofhemoglobinA1ccomparedtoalow-proteindiet.4Nevertheless,somecliniciansdonotrecommendhigh-proteindietsforpatientswithdiabetesbecauseofconcernsaboutincreasingrisksforkidneydisease.Doesahigh-protein

dietactuallypredisposepeoplewithdiabetestodevelopingkidneydisease?No,ahigh-proteindietdoesnotraisemicroalbuminuria,butadiethighinfatdoes.5Further,ahigh-proteindietimprovedcardiovascularoutcomesinwomencomparedtoadietwithlowerproteinintake.6

Irecommendtheuseofmoderateproteindietsforpeoplewithdiabetesandprediabetesforweightlossandglycemicmanagement.Seepage10formytop10reasonsforpeoplewithdiabetes(andnormalkidneyfunction)toincreaseintakeofprotein.

Nearly8%oftheUSpopulationhasbeendiagnosedwithdiabetes.Doublethatpercentagehaveprediabetes,orbloodglucoselevelshigherthannormalbutnothighenoughforadiagnosisofdiabetes.1Asincreasingnumbersofpeopleliveasedentarylifestyleandareoverweightorobese,thenumberofnewcasesofdiabetesisgrowing—atleast1.6millionnewcasesarediagnosedeachyear.Thepricetagforthesenewcasesisreflectedindollars(thedirectcostofhealthcareforpeoplewithdiabeteshasbeenestimatedat$116billionperyear2)andinco-morbidities:diabetesistheleadingcauseofend-stagerenaldiseaseandthemostcommoncauseofblindnessinworking-agedadults;themostprominentcauseoflower-extremityamputationsfornon-traumaticcause;andisassociatedwitha2-to4-foldincreaseinriskforcardiovasculardisease.1

Dyslipidemiaandhypertensionareriskfactorscommontocardiovasculardiseaseandtodiabetes.Incombinationwithhyperglycemia,thesemodifiableriskfactorsaretargetedformanagementofdiabetes.TargetlevelsfordiabetescontrolarehemoglobinA1clevellowerthan7.0%;bloodpressurelessthan130/80mmHg;andlow-densitylipoprotein(LDL)cholesterolbelow100mg/dL.1ArecentUSreportfoundthatonly12%ofAmericanswithdiabeteshavebeenabletomeetallthreeofthesetargets.3

Therapeuticlifestylechanges(TLC)areadvisedtolowerrisksforheartdisease.Changesincludeincreasedphysicalactivity,weightreduction,andaTLCdiet(Table).4Recommendationslimitintake

offatto25-35%oftotalenergy,withemphasisoninclusionofhealthiermonounsaturatedfattyacids(MUFA)oversaturatedandpolyunsaturatedfats.TheTLCdietalsorecommendsanintakethatishighinfiberandincludesmoderateamountsofproteinandlowamountsofcholesterol.Importantly,thisdietrecommendsbalancingcaloricintakewithenergyoutputinphysicalactivitiesinordertopreventweightgain.

Evidencesupportstheinclusionofsomespecificdietarycomponentsforhearthealth—plantstanols,solublefiber,omega-3fattyacids(suchasfishoil),andMUFA(asincanolaandoliveoil)whileminimizingintakeoftransfattyacidsandotherwiselimitingconsumptionofpolyunsaturatedfattyacids(PUFA).ClinicalstudiessupportconsumptionofMUFAtohelpmaintainlowLDLandtriglyceridelevels,whileincreasinghigh-densitylipoprotein(HDL)levels.5Dietshighinmarine

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To lower risk for heart disease, therapeutic lifestyle changes (TLC) are recommended— increased physical activity, weight reduction, and a TLC diet.

Effects of Nutrition on Cardiovascular Disease in Diabetes and PrediabetesIshwarlalJialal,MD,PhD,Departments of Medicine and Pathology, University of California, Davis, USA

Take-home messages

• IntheUS,diabetesisacommonandcostlydiseasethattakesahightolloncardiovascularhealth.• Therapeuticlifestylechanges(healthylow-fatdiet,exercise,andweightreduction)arerecommendedto lessenriskforcardiovasculardisease.• Specificheart-healthydietarynutrientsincludesolublefiber,omega-3fattyacids,andplantstanols/sterols.

oils(richineicosapentaenoicacid,orEPA)havebeenshowntoprotectagainstincidenceofcoronaryarterydiseaseandmajorcoronaryevents.6,7

Forheartbenefits,low-glycemiccarbohydratesarerecommendedintheformofwholegrains,vegetablesandfruit,withdietaryfibertotalingmorethan25g/day.5,8Soluble

References1. AmericanDiabetesAssociation.Executivesummary:standardsofmedicalcareindiabetes—2010.Diabetes Care.2010;33:S4-S11.

2. http://www.diabetes.org/diabetes-basics/diabetes-statistics.AccessedJanuary6,2011.

3. CheungBM,OngKL,ChernySS,ShamPC,TsoAW,LamKS.DiabetesprevalenceandtherapeutictargetachievementintheUnitedStates,1999to2006.Am J Med.May2009;122(5):443-453.

4. SmithSC,Jr.,AllenJ,BlairSN,etal.AHA/ACCguidelinesforsecondarypreventionforpatientswithcoronaryandotheratheroscleroticvasculardisease:2006update:endorsedbytheNationalHeart,Lung,andBloodInstitute.Circulation.May162006;113(19):2363-2372.

5. GrundySM,BeckerD,ClarkLT,etal.NationalCholesterolEducationProgramExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults(AdultTreatmentPanelIII):NationalHeartLungandBloodInstitute;2002.

6. OikawaS,YokoyamaM,OrigasaH,etal.SuppressiveeffectofEPAontheincidenceofcoronaryeventsinhypercholesterolemiawithimpairedglucosemetabolism:Sub-analysisoftheJapanEPALipidInterventionStudy(JELIS).Atherosclerosis.Oct2009;206(2):535-539.

7. SaravananP,DavidsonNC,SchmidtEB,CalderPC.Cardiovasculareffectsofmarineomega-3fattyacids.Lancet. Aug142010;376(9740):540-550.

8. GrundySM,CleemanJI,MerzCN,etal.ImplicationsofrecentclinicaltrialsfortheNationalCholesterolEducationProgramAdultTreatmentPanelIIIguidelines.Circulation.Jul132004;110(2):227-239.

Table. Nutrient composition of TLC diet

Dietary component Recommended intake

Saturated fat <7%oftotalcalories

Polyunsaturated fat Upto10%oftotalcalories

Monounsaturated fat Upto20%oftotalcalories

Total fat 25-35%ofcalories

Carbohydrate 50-60%ofcalories

Fiber 20-30g/day

Protein ~15%oftotalcalories

Cholesterol <200mg/day

Total calories Balance intake and output to prevent weight gain

fibers(eg,oatproducts,beans,psyllium,guargum,soyproducts,pectin)arerecognizedtolowerLDLlevels.Whentakenatadoseof2g/day,plantsterolandstanolestersareeffectiveinloweringLDLcholesterolby6-15%.5

Dietaryrecommendationssuchasthesehaveallowedmypatientstoreducetheirriskfactorsforcardiovasculardisease.

Hyperglycemiaisacommonsideeffectforpatientsreceivingenteralfeeding.1Hyperglycemiarequiresaggressive,coordinatedtreatmentinthehospitalsetting.Thistreatmentshouldbeginatadmissionwiththepatienthistory,aswellasanassessmentofbloodglucoselevelandglycatedhemoglobin(hemoglobinA1c).Thesedataallowcaregiverstoestablishappropriatedeliverymethodsandlevelsofglucosecontrolduringthehospitalizationandtodevelopdismissalplanswithrecommendationsforfollow-uptestingandcare.

ForenteralnutritionpatientswithstabletypeIIdiabetesandnormalrenalandkidneyfunction,oraldiabeticagentsmaybeprovidedviathefeedingtube;however,metforminshouldnotbeusedinthehospital.Patientstreatedwithinsulinpriortoadmissionorwithbloodglucoselevelsconsistently>150mg/dLneedinsulin,andmaybebrokenintothreecategories2:

•Mostpatientsrequire0.5-0.7unitsofinsulin/kg/day.

•PatientswithtypeIdiabetes,leanbodyweight,renal dysfunction,hepaticdysfunction,oranagegreaterthan 65yearsusuallyrequirealowertotaldailydoseofinsulin (ie,0.3-0.5units/kg/day).

•PatientswithtypeIIdiabetes,aBMI>30,post-myocardial infarction,aninfection,orarereceivingcorticosteroids usuallyrequireahighertotaldailydoseofinsulin (ie,0.5-1.5units/kg/day).

Patientswhoarereceivingcombinationinsulinpreparations(mixturesofintermediateandrapidorshort-actinginsulin)onadmissionneedtobeconvertedtobasal/bolustherapywherealong-actingbasalinsulinissupplementedwitharapidorshort-actinginsulinformealsorbloodglucoselevelcorrection

14 15

Hyperglycemia is a common side effect of patients with enteral feeding. Managing hyperglycemia starts at admission and ends with appropriate dismissal plans for follow-up testing and care.

duringhospitalization(Table).Theprovisionofonlyslidingscaleinsulin(SSI)isareactiveratherthanproactiveresponsetohyperglycemia;SSIhasbeenshowninnon-criticallyillpatientstobethreetimesmorelikelytocausehyperglycemicevents.

Inadditiontotheabovecriteria,bloodglucosemanagementinenteralnutritionpatientsrequiresadaptationunderthefollowingspecialconditions:

• Iffeedingisinfusedduringtheday,initiallyadminister½of thepreadmissionmorninginsulindoseasanintermediate- actinginsulin.

•Twicedailyintermediate-actinginsulin(eg,NPH)isoften needediffeedingiscontinuous.

• Iffeedingisinfusedovernight,intermediate-actinginsulin shouldbeadministeredintheevening.

•Short-actinginsulinshouldbeaddedifglucosegoalsare notachieved.

•Forgravityadministration,checkglucoselevelspriorto feedingsandnosoonerthan4hoursafterendofpriorfeeding.

•Thefeedingrateshouldnotbeadvanceduntilglucose controlisadequate.Ifthefeedingrateisincreased,the doseofintermediate-actinginsulinshouldbeincreased.

• Inpatientswithunsatisfactoryglucosecontrolorunstable course,anintravenousinsulininfusionshouldbestarted. Finally,theestablishmentofbloodglucoselevelgoalsiscrucialtothemanagementofhyperglycemiaforhospitalpatientsreceivingenteralnutrition.Thesegoalswillvaryaccordingtothestatusofthepatient3:

•Forcriticallyillpatients(thoseinIntensiveCare)ablood glucoselevelof100-120mg/dL.

•Fornon-criticallyillpatientsabloodglucoselevelof 120-180mg/dL.

Management of Tube Feeding-associated HyperglycemiaMedical managementGordonS.Sacks,PHARM.D.,BCNSP,FCCP,Auburn University School of Pharmacy, Auburn, Alabama, USA

References1. AmericanDiabetesAssociation.Standardsofmedicalcare–2010.Diabetes Care.2010;33:S11-S61.

2. ArnoldL,KellerD.Hyperglycemiamanagementinnon-criticallyillhospitalizedpatients.J Pharm Pract.2009;22:467-477.

3. MoghissiES,KorytkowskiMT,DiNardoM,etal.AmericanAssociationofClinicalEndocrinologistsandAmericanDiabetesAssociationconsensusstatementoninpatientglycemiccontrol. Diabetes Care.2009;32:1119-1131.

Take-home messages

• Effectivemanagementoftubefeeding-associatedhyperglycemiainvolvesaggressivetreatmentevenforthose patientswithoutaknownhistoryofdiabetes.Theestablishmentofbloodglucoselevelgoalsisprimary.

• Insulinisthepreferredtreatmentbecauseofitseasytitrationandrapidachievementofglycemiccontrol. Basal/bolustherapy—long-actingbasalinsulincombinedwithshort-actingbolusinsulin—shouldbeused duringhospitalization.

• Forenteralnutritionpatients,establishingbloodglucoselevelgoalsiscriticalformanaginghyperglycemia. Bloodglucosemanagementalsomayrequireadaptationundersomespecialconditions.

Table. Selected insulin preparations with their onset, peak and duration2

Rapid & Short-acting Insulins Onset Peak Duration

Lispro 5-15minutes 1-2hours 4-6hours

Aspart 5-15minutes 1-2hours 4-6hours

Glulisine 5-15minutes 1-2hours 4-6hours

Regular 30-60minutes 2-4hours 6-10hours

Intermediate & Long-acting Insulins Onset Peak Duration

NPH 2-4hours 6-12hours 12-18hours

Glargine 2-4hours None 24hours

Detemir 2-4hours None 24hours

Hyperglycemiaiscommoninhospitalsettings.InastudyofpatientsadmittedtoaUScommunityhospital,about1ofevery3patientshadhyperglycemia.1Numerousguidelinesandstandardssetgoalsforclinicalmanagementofdiabetesinoutpatients,butevidence-basedstandardsofcareforinpatientshaveonlyrecentlybecomeavailable.Hospitalizedpatientscanexperiencehyperglycemiaduetounderlyingdiabetesortothemetabolicstressesofillness.2,3

Hospitalizedpatientswithpoorlycontrolledglucoselevelsfaceseriousconsequences,includingincreasedriskofinfections,impairmentofwoundhealing,gastroparesis,hypercatabolismandmusclewasting,increasedlengthofICUorhospitalstay,andincreasedmortalityrates.Regardlessofthecauseofhyperglycemia,studiesinhospitalizedpatientshaveshownimprovedoutcomeswhenthehyperglycemiaistreated.4

TheSocietyofCriticalCareMedicine(SCCM)andtheAmericanSocietyforParenteralandEnteralNutrition(A.S.P.E.N.)recentlyupdatednutritionguidelinesforcriticallyillpatients.5Withregardtocontrolofglycemicstatus,theguidelinesrecommend:

•Useprotocolstopromotemoderatelystrictglycemiccontrol inpatientsreceivingenteralnutrition-supporttherapy. (GradeB)

•Targetserumglucoseintherangeof110-150mg/dL. (GradeE)

Nutrition-supportdietitiansplayimportantrolesinthecareofhospitalizedpatientswithpoorglucosecontrol.6Toachievebestresults,dietitiansneedto(1)knowwhatfactorsaffectglycemiccontrolandtherationaleforminimizingglycemicvariability,(2)understandcurrentrecommendationsforgainingoptimalglycemiccontrol,and(3)implementnutritiontherapythatwillsafelyachieveandmaintainglycemiccontrolwithoutinducinghyper-orhypoglycemia.

Whenenteralnutrition(EN)isprescribed,thefirstconsiderationistheaccesspoint—shouldthepatientbetube-fedviathestomachorjejunum?Whatstrategiescanbeemployedtoachieveandmaintainglucosecontrol?IscontinuousorintermittentENinfusionpreferred?Shouldthepatientreceiveastandardformula,ahigh-fiberformula,oradiabetes-specificformula?

Withtube-fedEN,theoverallgoalistopreventhyperglycemiaandhypertriglyceridemia,whichareassociatedwithnegativeoutcomes.Itisthusimportanttoavoidcarbohydrateoverfeedingthatcandrivede novofatsynthesisintheliver.Inhospitalizedpatients,insulintreatmentisoftenpreferredoveranti-diabeticagents.ToaverthypoglycemiawhenENisinterruptedduringintensiveinsulintherapy,ourprocedureadviseshanging5%dextroseinwater(D5W)at1.5timesthehourlytube-feedingrateor10%dextroseinwater(D10W)atthetube-feedingrate.

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In hospitalized patients, adverse consequences of poor glucose control include:

• Increased risk of infections

• Impairment of wound healing

• Gastroparesis

• Hypercatabolism and muscle wasting

• Increased length of ICU or hospital stay

• Increased mortality rates

Management of Tube Feeding-associated HyperglycemiaNutritional management of enteral nutrition-associated hyperglycemia JenniferWooley,MS,RD,CNSD, University of Michigan Health System, Ann Arbor, Michigan, USA

Tomoderateriskforglucosevariability,alargebodyofresearchsupportstheuseofdiabetes-specificenteralnutrition.7-9Suchformulascontainslowlyabsorbedcarbohydratesandhealthymonounsaturatedfatsasenergysourcesthathelpbluntpostprandialrisesinbloodglucose.

Therearesound,evidence-basedjustificationsforcontrolofbloodglucoselevelsinhospitalizedpatients,withbettercontrol

yieldingbetteroutcomes.Especiallywhenintensiveinsulintherapyisusedforcontrol,itisimportanttoavertepisodesofhypoglycemia.Nutritioncanplayanimportantroleinhelpinglimitglucosevariability.Diabetes-specificnutritionalformulasarewell-supportedaspartofsafeandeffectiveglucosemanagementinhospitalizedpatients.

References1. UmpierrezGE,IsaacsSD,BazarganN,YouX,ThalerLM,KitabchiAE.Hyperglycemia:anindependentmarkerofin-hospitalmortalityinpatientswith

undiagnoseddiabetes.J Clin Endocrinol Metab.Mar2002;87(3):978-982.

2. Wylie-RosettJ.Thediabetesepidemic:whatcanwedo?J Am Diet Assoc.Jul2009;109(7):1160-1162.

3. McMahonMM,MilesJM.Glycemiccontrolandnutritionintheintensivecareunit.Curr Opin Clin Nutr Metab Care. Mar2006;9(2):120-123.

4. MoghissiES,KorytkowskiMT,DiNardoM,etal.AmericanAssociationofClinicalEndocrinologistsandAmericanDiabetesAssociationconsensusstatementoninpatientglycemiccontrol.Diabetes Care.2009;32:1119-1131.

5. McClaveSA,MartindaleRG,VanekVW,etal.GuidelinesfortheProvisionandAssessmentofNutritionSupportTherapyintheAdultCriticallyIllPatient:SocietyofCriticalCareMedicine(SCCM)andAmericanSocietyforParenteralandEnteralNutrition(A.S.P.E.N.).JPEN J Parenter Enteral Nutr.May-Jun2009;33(3):277-316.

6. BoucherJL,SwiftCS,FranzMJ,etal.Inpatientmanagementofdiabetesandhyperglycemia:implicationsfornutritionpracticeandthefoodandnutritionprofessional.J Am Diet Assoc.Jan2007;107(1):105-111.

7. deAzevedoJR,deAraujoLO,daSilvaWS,deAzevedoRP.Acarbohydrate-restrictivestrategyissaferandasefficientasintensiveinsulintherapyincriticallyillpatients.J Crit Care.Mar2010;25(1):84-89.

8. AlishCJ,GarveyWT,MakiKC,etal.Adiabetes-specificenteralformulaimprovesglycemicvariabilityinpatientswithtype2diabetes.Diabetes Technol Ther.Jun2010;12(6):419-425.

9. EliaM,CerielloA,LaubeH,SinclairAJ,EngferM,StrattonRJ.Enteralnutritionalsupportanduseofdiabetes-specificformulasforpatientswithdiabetes.Diabetes Care.2005;28(9):2267-2279.

Take-home messages

• ManagementofEN-associatedhyperglycemiainhospitalizedpatientscanbechallenging.

• ThereiscompellingevidenceforbenefitsofminimizingglycemicvariabilityinallEN-fedpatients.

• Toachievetheoptimalnutritionstatusforeachpatient,thenutrition-supportclinicianneedstoconsiderthe route,timing,quantity,andcompositionofthefeeding.

• Alargebodyofresearchsupportstheuseofdiabetes-specificENformulasinthemanagementof hospitalizedpatients.

Forpeoplewithdiabetes,medicalnutritiontherapyisanimportantcomponentofglycemiccontrol—alongwithmedicalmanagementofthediseaseandregularmonitoringofglycemicstatus.Managementofglycemiainthehospitalsettingisparticularlyimportantbecausehyperglycemiaisassociatedwithincreasedmorbidityandmortalityinpatientswithandwithoutdiabetes.1Specifically,hyperglycemiaimpairsimmunefunction,delayswoundhealing,increasessusceptibilitytoinfection,andincreaseslengthofhospitalstay.

Diabetes-specificnutritionformulasaredesignedtoprovidequalitynutritionandtheyincludefeaturestohelpimproveglucosecontrol.2Examplesofsuchfeaturesare:(1)carbohydratesthataremodifiedtobedigestedandabsorbedslowly(basedonuniqueglucose-glucoseorglucose-fructoselinkages),(2)inclusionofhealthymonounsaturatedfatstohelplowerplasmatriglyceridesandincreaseHDLcholesterollevels,3and(3)highfibercontentforguthealthandglucosecontrol.Forpeoplewithhyperglycemia,diabetes-specificnutritioncanreducetheneedforadditionalinsulintomaintainglycemiccontrol,whilestandardformulasoftennecessitatemoretimeandmedicationstocontrolbloodglucose.2

Herearethekeystudiesthatunderscorebenefitstousingdiabetes-specificnutrition.

Elia and colleagues2reviewedandconductedametaanalysison23studiescomparingdiabetes-specificnutritionwithstandardnutrition.Theyfoundthattheuseofdiabetes-specificformulassignificantlyloweredpostprandialbloodglucose,peakglucose,andareaunderthecurveforglucose.Theseimprovementswere

demonstratedwithshort-andlong-termuse.Long-termusemayhaveimplicationsforreducingchroniccomplicationsofdiabetes.Additionally,severalstudiesshowedsignificantreductionininsulinrequirements(26%to71%).

Voss et al4conductedaclinicalresearchstudytocomparediabetes-specificnutritionformulasandastandardnutritionformula.Participantswhofastedovernightconsumedaservingofformula,andwerethenmonitoredforeffectsonbloodglucose,insulin,andglucagon-likepeptide-1(GLP-1)responses.Resultsshowedsignificantlylowerpost-mealglucoseandinsulinlevelswithdiabetes-specificnutrition,andsignificantlyhigherlevelsofGLP-1.

The LOOK Ahead Study5wasdesignedtodeterminetheeffectivenessofintentionalweightlossforreducingcardiovasculareventsinpeoplewithtype2diabetes.Morethan5000peopleparticipatedinthisstudy,andtheinterventionincluded:(1)portion-controlleddietthatincludesliquidmealreplacement,(2)multi-componentapproachtointervention,(3)ongoingregularcontactwithparticipantsthroughoutthefollow-upperiod,and(4)weight-lossmedicationsandadvancedbehavioralstrategiesinlatermonthsofstudy,asneeded.Afterjust1year,beneficialresultswerealreadyapparent—withdecreasesinbodyweightandloweredA1clevels,fastingglucoselevels,andtriglyceridelevelsinintensive-lifestyle-managedpatientscomparedtostandard-carepatients.

AstudybySun and colleagues6usedastructuredintegrationmanagementprogramtoassessdiabetescontrolinoverweight

18 19

peoplewithtype2diabetes.Thestudyincluded150patientswithtype2diabeteswhowererandomizedtoeitherthetreatmentgrouporcontrolgroup.Patientsinbothgroupsreceiveddietaryandexercisecounselinganddiabeteseducation.Thepatientsinthetreatmentgroupalsoreplacedpartoftheirbreakfastwiththediabetes-specificproduct.Bytheendofthe6-monthstudy,haemoglobinA1clevelsweresignificantlyreducedintheinterventiongroupondiabetes-specificnutritioncomparedtothecontrolgroup.

Alish and colleagues7conductedastudytocomparethe24-hourglucoseresponsesinpatientswithtype2diabeteswhoweretube-fedastandardformulaversusadiabetes-specificformulaassole-sourcenutritionfor16h/dayover4days.Glycemicvariability,measuredwithacontinuousglucosemonitorandexpressedasmeanamplitudeofglucoseexcursions,wassignificantlylowerwithfeedingofdiabetes-specificnutrition.Therewasalsoa28.4%reductionintheamountofshort-actinginsulinneededtomanagebloodglucoselevels.

References1. JunejaR.Hyperglycemiamanagementinthehospital:aboutglucosetargetsandprocessimprovements.Postgrad Med.Nov2008;120(4):38-50.

2. EliaM,CerielloA,LaubeH,SinclairAJ,EngferM,StrattonRJ.Enteralnutritionalsupportanduseofdiabetes-specificformulasforpatientswithdiabetes.Diabetes Care.2005;28(9):2267-2279.

3. LichtensteinAH,AppelLJ,BrandsM,etal.Dietandlifestylerecommendationsrevision2006:ascientificstatementfromtheAmericanHeartAssociationNutritionCommittee.Circulation.Jul42006;114(1):82-96.

4. VossAC,MakiKC,GarveyWT,etal.Effectoftwocarbohydrate-modifiedtube-feedingformulasonmetabolicresponsesinpatientswithtype2diabetes.Nutrition.Oct2008;24(10):990-997.

5. Pi-SunyerX,BlackburnG,BrancatiFL,etal.Reductioninweightandcardiovasculardiseaseriskfactorsinindividualswithtype2diabetes:one-yearresultsofthelookAHEADtrial.Diabetes Care.Jun2007;30(6):1374-1383.

6. SunJ,WangY,ChenX,etal.AnintegratedinterventionprogramtocontroldiabetesinoverweightChinesewomenandmenwithtype2diabetes.Asia Pac J Clin Nutr.2008;17(3):514-524.

7. AlishCJ,GarveyWT,MakiKC,etal.Adiabetes-specificenteralformulaimprovesglycemicvariabilityinpatientswithtype2diabetes.Diabetes Technol Ther. Jun2010;12(6):419-425.

Diabetes-specific Formulas: Science and TechnologyVikkiMustad,PhD,Abbott Nutrition, Columbus, Ohio, USA

Take-home messages

Inclinicalstudies,diabetes-specificnutritionformulashavebeenshownto:

• Improvepost-mealresponses,asmeasuredbyloweredglucoseandinsulinandincreasedGLP-1responses.

• Improveweightmanagement,asintheLOOKAheadstudyofpeoplewithtype2diabetes.

• ImprovehemoglobinA1clevelswhenusedaspartofanintegrateddiabetesinterventionprogram.

• Lessenglycemicvariabilityandreducetheamountofshort-actinginsulinneededtomanagebloodglucose levelsintube-fedpatientswithdiabetes.

Diabetes-specific nutrition formulas Standard nutrition formulas

Modifiedcarbohydrateisdigestedandabsorbedslowly, Rapidlydigestedcarbohydratepredisposestohighabenefittopeoplewithpoorglucosecontrol postprandialglucoseriseinpeoplewithpoorglucosecontrol

Healthymonounsaturatedfatsused Lowinfat

Highinfiber Lowinfiber

Enablebetterglycemiccontrol,includingcontrolofpostprandialrise Maycompromiseglycemiccontrol

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Theimportanceofdiethaslongbeenrecognizedasakeyelementindiabetesmanagement.Specificgoalsofdietarymanagementaretopromoteglycemiccontrol(inconcertwithmedicationsandexercise),toimprovethelipoproteinprofileandpreventvasculardiseasecomplications,andtofacilitateweightlossinthosewhoareoverweightorobese.Asnewstrategiesemergefordiabetesmanagement,thedietarycomponentoftreatmentremainsthemainstayforfulleffectiveness.

Thispresentationprovidedanoverviewofwhatthefutureofdiabetestherapymaylooklike.

Diabetes Prevention.Itisnolongersufficienttowaituntildiabetesisoverttobegintreatment.Thereisnowanationalmandatefordiabetesprevention.Themandatecallsforcombinedrecommendationofdietandincreasedphysicalactivityaslifestyleinterventionstopromoteweightlossandlowerriskforcardiometabolicdisease.1,2Thisapproachrecognizesobesity,

insulinresistance,metabolicsyndrome,andprediabetes(impairedfastingglucose,impairedglucosetolerance)asconditionsalongthecontinuousspectrumtowardfull-blowndiabetes.Assuch,recognitionandmanagementoftheprecursorconditionsareessentialtopreventordelaytheonsetofdiabetes.Dietsrichinfreshfruitsandvegetablesalongwithcalorie-controlledmealreplacementsareusefulinthisstrategy—alongwithincreasedexercise.

New Obesity Medications. Awiderangeofobesitymedicationsarenowinphases2or3oftestingorundergoingreviewbytheUSFoodandDrugAdministration.Theseincludeserotoninagonists(eg,lorcaserin);multipleaminereuptakeinhibitors(eg,tesofensine);glucagon-likepeptide-1agonists(eg,liraglutide);combinedphentermine+topiramate(eg,Qnexa®);combinedbupropion+naltrexone(eg,Contrave®);andcombinedamylin+leptin(eg,metreleptin+pramlintide).Despitethepromisingeffectsofthesedrugs,allwillneedtobeusedtogetherwithdietandexercise.

Bariatric Surgery. Atthepresenttime,bariatricsurgeryissignificantlyandconclusivelymoreeffectiveatproducingsustainableweightlossandcontrollingcomorbiditiesthanavailablemedicaltreatments.3,4However,dietarystrategiesarestillneededtoenhanceoutcomesforbariatricsurgery,includingpre-andpostoperativeweightloss,aswellaspostoperativenutrition.Dietarystrategiesarealsoimportanttoreversemicronutrientdeficienciesthatcanresultfromthegastrointestinalalterationsofsurgery.

The Incretin Axis.Incretinsphysiologicallyregulateglucosebymodulatinginsulinsecretioninaglucose-dependentmanner.IncretinsincludeGIP,GLP-1,andDPP-4inhibitor.5,6Dietaryintervention,ie,mealreplacementbeverages,havebeenshowntoactsynergisticallywithincretinaxisdrugs.7Therearemanynewoptionsthatofferpromiseforbettercontrol

ofweightandloweringofriskfordiabetesandcardiovasculardisease.Theroleofdiet(includingmealreplacement)isforemost.Activelifestyle,obesitymedications,incretin-axisdrugs,and

References1. KnowlerWC,FowlerSE,HammanRF,etal.10-yearfollow-upofdiabetesincidenceandweightlossintheDiabetesPreventionProgramOutcomes

Study.Lancet.Nov142009;374(9702):1677-1686.

2. WillettWC,DietzWH,ColditzGA.Guidelinesforhealthyweight.N Engl J Med.Aug51999;341(6):427-434.

3. JaunooSS,SouthallPJ.Bariatricsurgery.Int J Surg.2010;8(2):86-89.

4. KarraE,YousseifA,BatterhamRL.Mechanismsfacilitatingweightlossandresolutionoftype2diabetesfollowingbariatricsurgery.Trends Endocrinol Metab.Jun2010;21(6):337-344.

5. HollanderPA,KushnerP.Type2diabetescomorbiditiesandtreatmentchallenges:rationaleforDPP-4inhibitors.Postgrad Med. May2010;122(3):71-80.

6. SzmitkoPE,LeiterLA,VermaS.Theincretinsystemandcardiometabolicdisease.Can J Cardiol. Feb2010;26(2):87-95.

7. VossAC,MakiKC,GarveyWT,etal.Effectoftwocarbohydrate-modifiedtube-feedingformulasonmetabolicresponsesinpatientswithtype2diabetes.Nutrition.Oct2008;24(10):990-997.

ContraveandQnexaarenottrademarksofAbbottLaboratories.

bariatricsurgerycanbeintegratedintothemanagementprogramasneeded.

Diabetes-specific Nutrition in the Outpatient SettingDiabetes-specific nutrition in subjects with diabetes mellitusW.TimothyGarvey,MD,Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama, USA

Take-home messages

Usedietarystrategiesincombinationwithotherapproachesformanagementofweightanddiabetes.

• Diet,includinguseofmealreplacements,isakeycomponentofacomprehensiveweightlossprogramfor preventionandtreatmentofdiabetes.

• Dietisanimportantadjuncttonewweightlossmedications.Inthefuture,therewilllikelybenewusesfor incretin-axisdrugsasstrategiesformanagementofbodyweightandloweringriskfordiabetes.

• Beforeandafterbariatricsurgery,anappropriatediethelpstoachieveweightloss,maintainhealthybodyweight, andreversemicronutrientdeficiencies.

• Anintegrationofmultiplestrategies,withdietplayingakeyrole,willbeimportanttofacilitateweightlossand managediabetes.

Goals of dietary management for diabetes:

• To promote glycemic control (in concert with medications and exercise)

• To improve lipoprotein profile and prevent vascular disease complications

• To facilitate weight loss in those who are overweight or obese

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Diabetesisachronic,multisystemdiseasethatrequiresattentiontoco-morbiditiesforoptimalmanagement.1Manyoftheco-morbiditiesofdiabetesarecommontotheoverlappingconditionsofinsulinresistanceandobesity.Theseincluderenaldisease,cardiovasculardisease,neuropathy,gastroparesis,myopathy,dyslipidemia,andinflammation.

Dietarystrategiesareprominentlyusedtoaddresstheseco-morbidities.Thefollowingsummarydescribeshowdietcanbetailoredtoaddressproblemscharacteristicofvariousco-morbidities:

Renal Disease. Kidneydiseaseisacommoncomplicationofdiabetes,andthisconditionincreasesriskforprotein-energy wasting (PEW).2Kidneydisease-associatedPEWisrootedinabnormalenergymetabolismthatisassociatedwithchangesincentralandperipheralcontrolsignals.Suchchangesimpairnutrientintakeandutilizationbywayofmanycontributingfactors—inflammation,catabolism,oxidativestress,uremia,anorexia,nutrientlossbydialysisormedicationeffects,andphysicalinactivity.TheendresultofPEWislossofphysical

function,lowerqualityoflife,andhigherriskofdeath.Specializednutrition,includinghighenergywithorwithouthighprotein,isnecessarytohelpovercomenutritionaldeficitsinpatientswithchronickidneydisease.Inearlystagesofdisease,itisnecessarytolimitproteinintaketohelpslowdeclineofkidneyfunctioninpre-dialysispatients.Oncedialysisbegins,proteinintakecanbeincreasedtocompensateforlosses.

Cardiovascular Disease. Medicaltreatmentisusedcommonlytohelpcorrectalteredlipidstatesthatincreaseriskforcardiovasculardisease(elevatedtriglyceridesandlow-densitylipoproteins,loweredhigh-densitylipoproteins),butdietisalsoimportant.TheAmericanHeartAssociationrecommendslimitingdietarysaturatedfatintaketo<7%oftotalcalories,transfatsto<1%ofcalories,andcholesterolto<300mg/day.3Likewise,consumptionoffish(richinomega-3eicosapentaenoicacid,EPA;docohexaenoicacid,DHA)isrecommendedtolowercardiovascularrisk.3

Neuropathy.Glycemicvariability(GV)isdefinedasthevariationsinglucoselevelsfrompeaktovalley.IthasrecentlybeenacknowledgedthatGVmaybemoredeleteriousthanconstantexposuretohighglucose,especiallyduetoescalatedlikelihoodofincreasingoxidativestress,whichcandamagetheendothelialtissues.4Itisthoughtthatkidneydamageandothercomplicationscanbelessenedbyusingdietarystrategiesthatstabilizeglycemicvariability.

Myopathy. Musclemyopathyorweakeningcanaffectbothskeletalandcardiacmuscles.Onewaytolimittheseeffectsistobalancedietaryprovisionsofglycolyticandoxidative(non-ketotic)fuels.

Inflammation.Inflammation(associatedwithinflammatorycytokinesandothermediators)isassociatedwithobesityandrecognizedasapossiblecauseofitsmorbidities.5Dietaryadvicetoreduceinflammationincludesincreasingintakeofomega-3fattyacidssuchasEPAandemployingdietarystrategiesthatwillreducevisceraladiposity.

Diabetes-specific Nutrition in the Outpatient SettingDiabetes-specific nutrition for subjects with co-morbidities JosephBass,MD,PhD,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

Co-morbidities associated with diabetes, insulin resistance, and obesity:

• Renal disease

• Cardiovascular disease

• Neuropathy

• Gastroparesis

• Myopathy: skeletal and heart

• Inflammation

References1. GrantP.Theperfectdiabetesreview.Prim Care Diabetes.Jul2010;4(2):69-72.

2. FouqueD,Kalantar-ZadehK,KoppleJ,etal.Aproposednomenclatureanddiagnosticcriteriaforprotein-energywastinginacuteandchronickidneydisease.Kidney Int.Feb2008;73(4):391-398.

3. LichtensteinAH,AppelLJ,BrandsM,etal.Dietandlifestylerecommendationsrevision2006:ascientificstatementfromtheAmericanHeartAssociationNutritionCommittee.Circulation.Jul42006;114(1):82-96.

4. ColetteC,MonnierL.Acuteglucosefluctuationsandchronicsustainedhyperglycemiaasriskfactorsforcardiovasculardiseasesinpatientswithtype2diabetes.Horm Metab Res.Sep2007;39(9):683-686.

5. GualilloO.Mediatorsofinflammationinobesityanditscomorbidities.Mediators Inflamm.2010;2010.

Take-home messages

Dietarychangesarestrategictoloweringriskforco-morbiditiesofdiabetes,insulinresistance,andobesity.

• Inpatientswithchronickidneydisease,specializednutrition,includinghighenergywithorwithouthighprotein,is necessarytohelpovercomenutritionaldeficits.Dietaryproteinisdeterminedbythecapacityofthekidneys. • Riskofcardiovasculardiseasecanbereducedbylimitingintakeofsaturatedfatto<7%oftotalcalories, transfatsto<1%ofcalories,andcholesterolto<300mg/day.

• Complicationscanbeavertedorlessenedbyusingdietarystrategiestostabilizeglycemicvariability.

• Dietaryadvicetoreduceinflammationincludesincreasingintakeofomega-3fattyacidssuchasEPAand employingdietarystrategiesthatwillreducevisceraladiposity.

Numerousstudieshaveshownthathyperglycemiaiscommonamonghospitalizedpatients—notonlyinthosewithdiabetesbutalsointhosewithout.Infact,hyperglycemiaispresentin50–85%ofcriticallyillpatients.Ofthese,about25%havediabetesandothersareexperiencingstresshyperglycemia.1Inpatientswithcriticalillnesses,hyperglycemiaisassociatedwithsignificantlyincreasedriskforinfectionsanddeath.2,3Theconverseisalsotrue:improvedglycemiccontrolcanleadtoimprovedoutcomes.

ThemostinfluentialinterventionalstudyofglucosemanagementwasthatofVandenBerghepublishedin2001—astudyofsurgicalICUpatientsinasinglecenter(theLeuven-IstudyfromBelgium).Thisrandomized,controlledstudycomparedintensiveinsulintherapy(bloodglucoselevelsat80-110mg/dL)withconventionaltreatment(maintenancegoalof180-200mg/dL).Leuven-Iresultsshowedthatintensivetreatmentledtoasignificantanddramatic34%reductioninmortality,andtheauthorsconcludedthataggressiveinsulintreatmentcouldimprovesurvivalinavarietyofcriticallyillpatients.4Theresultsweresodramaticthatadoptionwaswidespread.

However,asubsequentstudybyVandenBergheandcolleagues(Leuven-II)didnotconfirmthemortalitybenefitofintensiveinsulintherapyforpatientsinthemedicalICU.5Infact,ratesofhypoglycemiaweresignificantlygreaterinpatientsonintensiveinsulintherapycomparedtoconventionaltreatment(18.7%vs3.1%).Astightglucosecontrolpracticesbecamemorewidespread,accumulatingmedicalevidencebegantoshowthatsuchmanagementhadattendantrisksforincreasedhypoglycemia,whichcanitselfbelife-threatening.6-8

MycolleaguesandIrecentlypublishedresultsofastudyonrestrictionofcarbohydrateasawaytomanageglycemia

incriticallyillpatients.9Inthisstudy,patients(n=337)wererandomizedtoreceivecarbohydrate-restrictiveenteralformula(33.3%carbohydrate,16.7%proteinand50.0%lipid;alsocalleddiabetes-specificnutrition),glucose-freehydration,andinsulintherapywithmoderateglycemictargets(below180mg/dL;<150mg/dLinstablepatients)ortoastandarddiet(45%carbohydrate,17%protein,and38%lipid),glucose-salinehydration,andintensiveinsulintherapywithtight-controlglucosetargets(below180mg/dL;80-120mg/dLinstablepatients).Resultsshowedthatpatientsonthecarbohydrate-restrictivedietrequiredsignificantlylessinsulineachday(mean2Uregularinsulinvs52U;P<0.001).Meanbloodglucosewas144mg/dLinthecarbohydrate-restrictivegroupand133.6mg/dLinthecontrolgroup.Hypoglycemiaoccurredsignificantlymorefrequentlyinthecontrolgroupthaninthecarbohydrate-restrictivegroup(16%vs3.5%,P<0.001)andwasanindependentriskfactorforneurologicaldysfunctionandmortality.

Thus,carbohydrate-restrictivetherapyissaferandisaseffectiveasintensiveinsulintherapyformanagingglycemiaincriticallyillpatients.Ourstudyextendedthesefindingstoshowthattherewasnodifferenceinincidenceofacutekidneyinjuryinpatientswhoreceivedcarbohydrate-restrictivenutritioncomparedtointensiveinsulintherapy.10

Iadvisethefollowingtoachievetargetbloodglucoselevelsincriticallyillpatients:(1)minimizeuseofintravenousfluidsthatcontainglucose,(2)administerinsulinonlywhennecessary,(3)introduceenteralnutritionearly,anduseaformulathatislowincarbohydrate.

Carbohydrate-restrictive enteral nutrition is as effective as intensive insulin therapy for managing glycemia in critically ill patients, and it is safer.

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Diabetes-specific Nutrition in the Inpatient SettingJoséRaimundodeAzevedo,MD,Intensive Care Units of Hospital São Domingos and Hospital Dr Clementino Moura, São Luis, Maranhão, Brazil

In patients with critical illnesses, hyperglycemia is associated with significantly increased risk for infections and death. References

1. UmpierrezGE,IsaacsSD,BazarganN,YouX,ThalerLM,KitabchiAE.Hyperglycemia:anindependentmarkerofin-hospitalmortalityinpatientswithundiagnoseddiabetes.J Clin Endocrinol Metab.Mar2002;87(3):978-982.

2. JunejaR.Hyperglycemiamanagementinthehospital:aboutglucosetargetsandprocessimprovements.Postgrad Med.Nov2008;120(4):38-50.

3. CapesSE,HuntD,MalmbergK,PathakP,GersteinHC.Stresshyperglycemiaandprognosisofstrokeinnondiabeticanddiabeticpatients:asystematicoverview.Stroke.Oct2001;32(10):2426-2432.

4. VandenBergheG,WoutersP,WeekersF,etal.Intensiveinsulintherapyincriticallyillpatients.N Engl J Med.Nov82001;345(19):1359-1367.

5. VandenBergheG,WilmerA,MilantsI,etal.Intensiveinsulintherapyinmixedmedical/surgicalintensivecareunits:benefitversusharm.Diabetes.Nov2006;55(11):3151-3159.

6. FinferS,HeritierS.TheNICE-SUGAR(NormoglycaemiainIntensiveCareEvaluationandSurvivalUsingGlucoseAlgorithmRegulation)Study:statisticalanalysisplan.Crit Care Resusc.Mar2009;11(1):46-57.

7. BrunkhorstFM,EngelC,BloosF,etal.Intensiveinsulintherapyandpentastarchresuscitationinseveresepsis.N Engl J Med.Jan102008;358(2):125-139.

8. GriesdaleDE,deSouzaRJ,vanDamRM,etal.Intensiveinsulintherapyandmortalityamongcriticallyillpatients:ameta-analysisincludingNICE-SUGARstudydata.Can Med Assoc J.Apr142009;180(8):821-827.

9. deAzevedoJR,deAraujoLO,daSilvaWS,deAzevedoRP.Acarbohydrate-restrictivestrategyissaferandasefficientasintensiveinsulintherapyincriticallyillpatients.J Crit Care.Mar2010;25(1):84-89.

10.deAzevedoJR,deAzevedoRP,deLucenaLC,daCostaNdeN,daSilvaWS.Impactofglycemiccontrolontheincidenceofacutekidney injuryincriticallyillpatients:acomparisonoftwostrategiesusingtheRIFLEcriteria.Clinics (Sao Paulo).Jun2010;65(8):769-773.

Take-home messages

• Inhospitalizedpatientswithcriticalillness,hyperglycemiaisassociatedwithincreasedriskforinfections andmortality.

• Leuven-Istudyresultsindicatedthataggressiveinsulintreatmentcouldimprovesurvivalinsurgical ICUpatients.Subsequentstudiesshowedthatintensiveinsulintherapyhadattendantrisksforincreased hypoglycemia,whichcanitselfbelife-threatening.

• NewstudiesbydeAzevedoandcolleaguesshowedthatdiabetes-specificnutritiontherapyisaseffectiveas intensiveinsulintherapyformanagingglycemiaincriticallyillpatients,anditissafer.

Hyperglycemiaisanindependentmarkerforin-hospitalmortality.1Itcanresultfromunderlyingdiabetesorfromthemetabolicstressofillness2,3andisassociatedwithincreasedcomplicationsandincreasedlengthofstay(ICUandhospital).

Theadverseconsequencesofstresshyperglycemiamaybeevenworsethanthoseassociatedwithdiabetichyperglycemia—glucoselevelsofstressedpatientscanbehighlyelevatedandhaveextremefluctuationsfrompeaktonadir.Likehyperglycemia,severehypoglycemiaisalsoamarkerofpooroutcomes.IntheICU,hypoglycemiahasbeenlinkedtoincreasedmortality,seizures,andcoma.4,5

Diabetes-specificnutrition(DSN)isaneffectivestrategytocontrolhyperglycemiawithoutriskforhypoglycemiainhospitalizedpatients.ADSNformulahasbeendesignedwithdigestion-resistantstarchandhighcontentofmonounsaturatedfattyacids(MUFA).Inclinicaltesting,thisformulationbluntedthepost-mealglucoseresponseandreducedinsulinrequirementsinpatientswithdiabetes.6PatientswhoreceivedthisDSNalsoshowedevidenceofincreasedproductionoftheincretinhormoneglucagon-likepeptide-1(GLP-1).6GLP-1isreleasedfromthedigestivetract,inturnincreasingpancreaticsecretionofinsulininresponsetoglucoseoracarbohydrate-containingmeal.Suchamechanismisthoughttorepresentforward-regulationofinsulininanticipationoftheriseinbloodglucosethatnormallyfollowsingestionofcarbohydrates.

Recently,anewconceptcalledglycemicvariabilityhasbeenintroduced.Glycemicvariabilitymaybeanevenmoreimportantpredictorofmortalityinthecriticallyillpatientthanthemeanglucoselevel.Highvariabilityofbloodglucoselevelscanresultinincreasedmortalityandpermanentneurologicaldisabilities.Asaresult,glycemicvariabilityhasbecomeanimportanttargetforin-hospitalregulation.Glycemicvariability,whichismeasuredbycontinuousglucosemonitoringtechnology,canbeusedtomeasureMeanAmplitudeofGlycemicExcursions(MAGE),whereamplitudeisthedifferencebetweenpeakandnadirvalues.ArecentstudyusedMAGEtocompareeffectsofDSNandstandardenteralformulafedcontinuouslyfor5days(16h/day)inhospitalizedpatients.7ResultsshowedthatDSNfeedingsignificantlyreducedglycemicvariability(MAGE),postprandialglycemiaandinsulinemia,meanglucoselevels,andinsulinuse.

WerecentlyextendedtheobservationofimprovedglucosecontrolwithDSNinastudyofpatientswithstresshyperglycemia.8WecompareduseofaDSNformulawithdigestion-resistantstarchtoaDSNformulawithoutthisfeature.Bothformulasloweredmeanglucoselevelsinthestudypatients,buttheformulawithdigestion-resistantstarchwasmoreeffective.

Thesefindingsshowthatdiabetes-specificnutritioncanbeusedtohelpmaintainglucosehomeostasisinhospitalizedpatientswithorwithoutdiabetes.DSNeffectivelybluntspost-mealglucoseandinsulinrises,increasespost-mealGLP-1levels,andreducesglycemicvariability.Sucheffectsareexpectedtoreducerisksforin-hospitalmorbiditiesandmortality.

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Diabetes-specific Nutrition in Subjects with Stress HyperglycemiaPasqualeDiBiase,MD,Regional Center for Home Care & Clinical Nutrition, Regional Hospital A. Cardarelli, Campobasso, Italy

The adverse consequences of stress hyperglycemia may be even worse than those associated with diabetic hyperglycemia.

References1. UmpierrezGE,IsaacsSD,BazarganN,YouX,ThalerLM,KitabchiAE.Hyperglycemia:anindependentmarkerofin-hospitalmortalityinpatients

withundiagnoseddiabetes.J Clin Endocrinol Metab.Mar2002;87(3):978-982.

2. Wylie-RosettJ.Thediabetesepidemic:whatcanwedo?J Am Diet Assoc.Jul2009;109(7):1160-1162.

3. McMahonMM,MilesJM.Glycemiccontrolandnutritionintheintensivecareunit.Curr Opin Clin Nutr Metab Care.Mar2006;9(2):120-123.

4. MoghissiES,KorytkowskiMT,DiNardoM,etal.AmericanAssociationofClinicalEndocrinologistsandAmericanDiabetesAssociationconsensusstatementoninpatientglycemiccontrol.Endocr Pract.Jul-Aug2009;15(4):353-369.

5. KrinsleyJS,GroverA.Severehypoglycemiaincriticallyillpatients:riskfactorsandoutcomes.Crit Care Med.Oct2007;35(10):2262-2267.

6. VossAC,MakiKC,GarveyWT,etal.Effectoftwocarbohydrate-modifiedtube-feedingformulasonmetabolicresponsesinpatientswithtype2diabetes.Nutrition.Oct2008;24(10):990-997.

7. AlishCJ,GarveyWT,MakiKC,etal.Adiabetes-specificenteralformulaimprovesglycemicvariabilityinpatientswithtype2diabetes.Diabetes Technol Ther.Jun2010;12(6):419-425.

8. DiBiaseP.Stresshyperglycemia:acomparisonbetweentwodiabetes-specificenteralformulasintheacutecriticallyill.Clin Nutr2009;suppl4(2):35.

Take-home messages

• Non-diabeticpatientswithcriticalillnesscanexperiencehyperglycemiaduetothemetabolicstresses ofillness.

• Theconsequencesofstresshyperglycemiamaybeevenworsethanthoseofdiabetes-associated hyperglycemia.

• Feedingadiabetes-specificenteralformulawithslowlydigestedcarbohydratecanreduceaverageblood glucoselevelandinsulinrequirementsinpatientswithstresshyperglycemia.

• Diabetes-specificnutritionalsoincreasesproductionofglucagon-likepeptide-1(GLP-1).GLP-1isanincretin hormonethatmodulatesglucosehomeostasis.Itsregulationmaybeakeytoimprovingglucosehomeostasis.

• Adiabetes-specificenteralformulahasalsobeenshowntoreduceglycemicvariabilityinhospitalizedpatients.

• Diabetes-specificnutritionformulasarenotallequallyeffective.

DearColleagues,AsourconferenceonThe Role of Nutrition in Diabetes Management comestoanend,Ifeelamixofemotions.

Iamdelightedthatwecouldgathersuchanoutstandingpanelofexpertsfromthefieldsofnutrition,endocrinology,pharmacy,gastroenterology,intensivecaremedicine,andbasicscienceforlively,informeddiscussions.Iamexcitedthatwehadanopportunitytohearstate-of-the-artsummariesfromrenownedspeakersinthefieldsofobesity,diabetes,exercise,andnutrition.AndIampleasedwecouldhostthiscongenialmeetinginthecomfortablesettingprovidedbyAbbottNutritioninColumbus,Ohio.

ButIamalsoconcerned.Ourdiscussionsraisedmanyquestionsaboutinformationgapsthatneedtobefilled.Wehavemuchworkaheadofusinoureffortstoachievenear-normalglycemiccontrolforpeoplebothinandoutofthehospital.Wemustgalvanizeoureffortstousenutritionasameanstohelpreversehyperglycemia,reversehypoglycemia,andlimitglycemicvariability.Wemustcombineourfreshknowledgeofnutritiontohelppreventordelaytheonsetofdiabetes.Andwemustworktogethertouseournewinsightstoachieveoptimalglucosecontrolinordertolessenshort-termconsequencesandlong-termtollsofglucoseabnormalities.

Nowthatthisroundtablediscussionisdone,wemustengageourclinicalandscientificcolleaguesaroundtheworld.Togetherwearechallengedtoturnourknowledgeintoactionsthatwillimprovethehealthandwell-beingofmillionsofpeoplewithorat-risk-fordiabetes.Followingthismessageisasummaryofkeyissuesandquestionsthatsurfacedduringthismeeting.

RefaatHegazi,MD,PhDMedicalDirector,AbbottNutrition

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A closing message from Refaat Hegazi

A closing message from Refaat Hegazi, MD, PhD

Nutrition and Diabetes: Challenges for the Near Future

Glycemic management in people with prediabetes and diabetes• Howcanwemotivateallpeopletocombinenutritionandexercisetopreventordelay theonsetofdiabetes?• Whataretheoptimalglycemictargetsforpeoplewithdiabetesinandoutofthehospital? Shouldtheybethesameordifferent,andwhy?

Nutritional considerations for people with diabetes• Whatistheroleofnutritioninavertingordiminishingadverseconsequencesofdiabetes oncardiovascularfunction?• Howdocertaindietaryingredients,eg,fishoilandantioxidantvitamins,playfunctional rolesinhealth?• Howandwhydoproteinrequirementsdifferinpeoplewithdiabetescomparedto thosewithoutdiabetes?

Stress hyperglycemia in hospitalized patients• Whatarethesafestandmosteffectivemedicalstrategiestomanagestresshyperglycemia?• Howcannutritionbeemployedasatoolformanagingstresshyperglycemia?

Science and technology in diabetes-specific nutritional formulations• Howaremodifiedcarbohydratesusedtolimitpostprandialglucoserisesinpeoplewithdiabetes?• Whatisthemostbeneficialfatblendtolimitcardiovascularcomplicationsofdiabetes?• Whatarethebenefitsofmicronutrientrepletion?• Whatamountsandtypesoffiberareoptimalforthedietofapersonwithdiabetes?

Use of diabetes-specific medical nutrition for people in and out of the hospital• Forpeoplewithdiabeteslivingathome,howcandiabetes-specificnutritionbeoptimized toimproveweightlossandglycemicstatus?• Whataretherolesfordiabetes-specificnutritioninhospitalizedpatientswithdiabetes?• Whataretherolesfordiabetes-specificnutritionalformulationsforhospitalizedpatientswho havestresshyperglycemia?

Selected Summaries of a Diabetes Nutrition RoundtableOctober 21-22, 2010Columbus, Ohio, USA

The Role of Nutrition in Diabetes Management

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