TPN

Next we will review treatment options for people with diabetes. Whether a patient has type 1 or type 2 diabetes, they will likely benefit from diet modifications and physical activity.

Dietary modification

Tailored diets

Weight control

Support for control of hypertension, high blood fats

Glycemic load and index

Lifestyle modification is an important first step in the treatment for both prediabetes and type 2 diabetes. There is strong evidence to support the inclusion of medical nutrition therapy, including tailoring diets and meal composition to individual needs in order to control weight, support medication regimens, and deal with complications of diabetes, such as hypertension and dyslipidemia. For meal composition, the strongest evidence supports the inclusion of 25-50 grams of fiber daily and the reduction of saturated fat to less than 10% of energy intake, or more severe restrictions in cases of elevated LDL-C cholesterol (>100 mg/dL). Recommendations have been made to include carbohydrates at a level of 45-65% of energy and standard dietary protein levels, but more research is required to strengthen the evidence to support these recommendations. Weight loss diets and tailored diets to achieve target levels of glucose, lipids, and blood pressure have good evidence to support this as a preventative strategy. Other recommendations, such as limits on alcohol intake and the use of multivitamins have weaker supporting evidence.

Of special note is the abandonment of terms such as “simple” or “complex” carbohydrates. The total amount and source of carbohydrate in the diet and carbohydrate counting has replaced the concept of avoiding simple sugars. For patients on insulin, it will be important to match insulin therapy to carbohydrate ingestion with consideration for the amount, source, and fiber content for better blood glucose control. An adjunctive tool to consider is the glycemic load and glycemic index of carbohydrate foods.

Treatment Strategies

Strategies in obese patients, such as weight and abdominal girth reduction, and dietary changes to reduce fat intake and increase fiber intake, can be developed with a registered dietitian. A decrease in weight of 5-10% with exercise may reduce the risk of developing diabetes in overweight patients by 58%.[iv][v] Weight reduction with the combination of high-fiber and lower-fat diet strategies are associated with sustained results in the prevention of type 2 diabetes.[i] Sustained weight loss trials have suggested that this intervention can significantly reduce the progression to diabetes, even during 3-6 years of follow-up.[ii] While these strategies can produce the desired results, it has been suggested that targeting several obesity-related health complications can reduce the risk for developing diabetes. However, results of such programs may vary according to other risk factors, such as smoking.[iv]

In patients with renal disease, dietary intervention will include typical recommendations for the restriction of sodium, phosphate, potassium, and protein intake. Patients with diabetes have a higher rate of wounds and non-healing wounds than non-diabetes patients, and dietary adequacy to support healing should be among the routine therapies applied.

Exercise

Diet plus exercise appear to have an advantage in the prevention of diabetes over diet alone.[iii]

Exercise is an important feature of both weight and blood glucose control.[v] Exercise can build endurance and improve peripheral insulin sensitivity,[vi] glycemic control,[vii] and blood lipid profiles. In addition, exercise can improve heart rate recovery after exertion, which may be predictive of mortality and cardiovascular events in patients with type 2 diabetes.[viii] The improvement in inflammatory levels through exercise may also be beneficial for patients with diabetes to prevent cardiovascular complications.[ix] More aggressive recommendations have suggested 150 minutes of physical activity weekly, distributed over at least 3 sessions each week. In addition, exercise patterns and other treatment regimens should be planned individually to assure optimal glucose control.

Improves effect of diet

Improves insulin sensitivity
and glucose control

Improves heart rate

Improves inflammatory levels

[i] Lindstrom J, Peltonen M, Eriksson JG, Louheranta A, FogelholmM, Uusitupa M, Tuomilehto J. High-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: the Finnish Diabetes Prevention Study. Diabetologia. 2006;49(5):912-920.

[ii] Norris SL, Zhang X, Avenell A, Gregg E, Bowman B, Schmid CH, Lau J. Long-term effectiveness of weight-loss interventions in adults with pre-diabetes: a review. Am J Prev Med. 2005;28(1):126-139.

[iii] Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, Hu ZX, Lin J, Xiao JZ, Cao HB, Liu PA, Jiang XG, Jiang YY, Wang JP, Zheng H, Zhang H, Bennett PH, Howard BV. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 1997;20(4):537-544.

[iv] Davey Smith G, Bracha Y, Svendsen KH, Neaton JD, Haffner SM, Kuller LH; Multiple Risk Factor Intervention Trial Research Group. Incidence of type 2 diabeted in the randomized multiple risk factor intervention trial. Ann Intern Med. 2005;142(5):313-322.

[v] Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29:1433-1438.

[vi] Winnick JJ, Sherman WM, Habash DL, Stout MB, Failla ML, Belury MA, Schuster DP. Short-term aerobic exercise training in obese humans with type 2 diabetes mellitus improves whole body insulin sensitivity through gains in peripheral, not hepatic insulin sensitivity. J Clin Endocrinol Metab. 2007; Available at: http://jcem.endojournals.org/cgi/rapidpdf/jc.2007-1524v1.

[vii] Nojima H, Watanabe H, Yamane K, Kitahara Y, Sekikawa K, Yamamoto H, Yokoyama A, Inamizu T, Asahara T, Kohno N. Effect of aerobic exercise training on oxidative stress in patients with type 2 diabetes mellitus. Metabolism. 2008;57(2):170-176.

[viii] Chacko KM, Bauer TA, Dale RA, Dixon JA, Schrier RW, Estacio RO. Heart rate recovery predicts mortality and cardiovascular events in patietns with type 2 diabetes. Med Sci Sports Exerc. 2008;40(2):288-295.

[ix] Kadoglou NP, Iliadis F, Angelopoulou N, Perrea D, Ampatzidis G, Liapis CD, Alevizos M. The anti-inflammatory effects of exercise training in patients with type 2 diabetes mellitus. Eur J Cardiovasc Prev Rehabil. 2007;14(6):837-843.