Nutrición: Interacciones

con la salud
M.Sc. Daniel Silva Ochoa
Máster Universitario Europeo en
Alimentación, Nutrición y Metabolismo
 Key points
• Long-term clinical trials have documented the
importance of metabolic control of glucose, lipids,
and blood pressure in persons with diabetes.
• Although new oral medications and insulin
preparations are now available, nutrition therapy
continues to be essential if desired medical goals
are to be achieved.
• Successful nutrition therapy is an ongoing process
 Key points
• Clinical trials and outcomes studies have
documented the effectiveness of nutrition
therapy.
• In general, nutrition therapy provided by
registered dietitians can lower hemoglobin A1c
(A1C) by approximately 1–2%, depending on
the type and duration of diabetes, LDL
cholesterol by 19–25 mg/dL (0.46–0.65
mmol/L), and blood pressure by 5 mmHg.
 Key points
• Normal: less than 5.7%
• Prediabetes: 5.7 to 6.4%
• Diabetes: 6.5 or higher
• In general, nutrition therapy provided by
registered dietitians can lower hemoglobin A1c
(A1C) by approximately 1–2%, depending on the
type and duration of diabetes, LDL cholesterol by
19–25 mg/dL (0.46–0.65 mmol/L), and blood
pressure by 5 mmHg.
 Key points
• For persons with type 1 diabetes, the first priority is to
identify a food/meal plan that can be used to
integrate an insulin regimen into the person’s lifestyle.
• Physiological insulin regimens consisting of basal and
bolus insulins or insulin pumps provide flexibility in
timing and frequency of meals, amount of
carbohydrate eaten, and timing of physical activity.
Insulin-to carbohydrate ratios are used to adjust the
bolus insulin dose needed to cover the planned
carbohydrate intake.
 Key points
• Type 2 diabetes is a progressive disease beginning with
insulin resistance.
• However, glucose levels remain normal if adequate insulin
is available; it is not until insulin deficiency (b -cell failure)
develops that hyperglycemia occurs.
• Therefore, for persons with type 2 diabetes, nutrition
therapy progresses from improving insulin resistance and
preventing diabetes by modest weight loss and regular
physical activity to contributing to improved metabolic
control by carbohydrate counting and reduced energy
intake.
 What is basal and bolus insulin?

Bolus
insulin

Basal
insulin
 Introduction
• Diabetes mellitus is group of diseases characterized by
elevated glucose concentrations resulting from insulin
deficiency. Without sufficient insulin, hyperglycemia occurs
causing both the acute and long-term complications of
diabetes. A primary function of insulin, a hormone produced
by the b-cells of the pancreas, is the use or storage of body
fuels.
 Type 1 diabetes
• Immune-mediated type 1 diabetes accounts
for 5–10% of all diagnosed cases of diabetes.
• The primary defect is a cellular-mediated
autoimmune destruction of pancreatic b
-cells, usually leading to absolute insulin de fi
ciency and resulting in hyperglycemia,
polyuria, polydipsia, weight loss, dehydration,
electrolyte disturbance, and ketoacidosis.
 Type 1 diabetes
• The capacity of a healthy pancreas to secrete
insulin is far in excess of what is needed
normally; therefore, the clinical onset of
diabetes may be preceded by an extensive
asymptomatic period of months to years,
during which b -cells are undergoing gradual
destruction.
• Can occur at any age, most cases are diagnosed
< 30 years.
 Type 1 diabetes
• Antibodies identified as contributing to the destruction of b
-cells are as follows:
• Islet cell autoantibodies (ICAs).
• Insulin autoantibodies (IAAs), which may occur in persons
who have never received insulin therapy.
• Autoantibodies to glutamic acid decarboxylase
autoantibodies (GAD 65 ), a protein on the surface of b -cells
which appears to provoke an attack by the T cells (killer T
lymphocytes) and to destroy the b -cells.
• Autoantibodies to tyrosine phosphatases IA-2 and IA-2 b .
 Type 1 diabetes
• Antibodies identified as contributing to the destruction of b
-cells are as follows:
• Islet cell autoantibodies (ICAs).
• Insulin autoantibodies (IAAs), which may occur in persons
who have never received insulin therapy.
• Autoantibodies to glutamic acid decarboxylase
autoantibodies (GAD 65 ), a protein on the surface of b -cells
which appears to provoke an attack by the T cells (killer T
lymphocytes) and to destroy the b -cells.
• Autoantibodies to tyrosine phosphatases IA-2 and IA-2 b .
 Type 2 diabetes
• Type 2 diabetes accounts for 90–95% of all
diagnosed cases of diabetes and is a
progressive disease that is often present long
before it is diagnosed.
• Persons may or may not experience the classic
symptoms of uncontrolled diabetes and they
are not prone to develop ketoacidosis.
 Type 2 diabetes
• Risk factors include a strong genetic
predisposition and the risk increases with age,
obesity, and physical inactivity.
• Obesity alone causes some degree of insulin
resistance. Even persons who develop
diabetes and are not obese by traditional
weight criteria usually have an increased
percentage of intraabdominal body fat.
Impared glucose intolerance
 Type 2 diabetes
• Type 2 diabetes results from a combination of
insulin resistance and insulin deficiency ( b
-cell failure).
• Endogenous insulin levels may be normal,
depressed, or elevated; but they are
inadequate to overcome the concomitant
insulin resistance and as a result
hyperglycemia occurs.
 Gestational diabetes mellitus
• For many years gestational diabetes mellitus
(GDM) was defined as any degree of glucose
intolerance with onset or first recognition
during pregnancy.
• However, because of the increase in type 2
diabetes in women of childbearing age, the
number of women with undiagnosed type 2
diabetes has increased.
 Gestational diabetes mellitus
• The American Diabetes Association
recommended that high-risk women be
screened for diabetes at their initial prenatal
visit.
• Pregnant women not known to have diabetes
should be screened for GDM between 24 and
28 weeks of gestation, using a 75-g 2-h oral
glucose tolerance test (OGTT) and the diagnosis
criteria.
 Prediabetes
• Individuals with impaired glucose tolerance
(IGT), impaired fasting glucose (IFG), and/or
hemoglobin A1c (A1C) levels between 5.7 and
6.4% have prediabetes and have an increased
risk for diabetes.
 Prediabetes
• They are also at high risk for future
cardiovascular disease (CVD).
• Prediabetes is associated with obesity,
especially intraabdominal obesity,
dyslipidemia with high triglycerides and/or
low high-density lipoprotein (HDL) cholesterol,
and hypertension (often referred to as
metabolic syndrome).
 Medical nutrition therapy
• The goals of nutrition therapy emphasize
improving glucose control, lipid and
lipoprotein pro fi les, and blood pressure.
• However, because lifestyle modifications
impact almost immediately on glycemia,
glucose goals are often the first focus.
 Medical nutrition therapy
• Randomized controlled trials and observational
studies of diabetes nutrition therapy provided
by registered dietitians (RDs) have
demonstrated decreases in A1C of
approximately 1–2% (range = −0.5 to −2.6%),
depending on the type and duration of
diabetes .
• These outcomes are similar to those from
glucose-lowering medications.
 Medical nutrition therapy
• An example of the effectiveness of nutrition
therapy for type 1 diabetes is the Dose Adjusted
for Normal Eating (DAFNE) trial.
• Conventional insulin therapy in the United
Kingdom at the time of the study was to
determine the insulin regimen first.
• This required individuals with type 1 diabetes to
eat according to the times of action of the
insulin they had been prescribed.
 Medical nutrition therapy
• Although nutrition therapy has been shown to
be effective at any time in the type 2 disease
process, it appears to have its greatest impact
earlier in the course of the disease.
• In individuals with newly diagnosed type 2
diabetes, decreases in A1C of ~2% are reported,
whereas in individuals with an average duration
of diabetes of 4 years, average decreases in A1C
of ~1% are reported.
 Medical nutrition therapy
• A variety of nutrition interventions have been
shown to improve glycemic control.
• Interventions used included reduced
energy/fat intake, carbohydrate counting,
simplified meal plan, healthy food choices,
individualized meal-planning strategies,
exchange lists, insulin-to-carbohydrate ratios,
physical activity, and behavioral strategies
 Medical nutrition therapy
• Nutrition therapy is reported to lower LDL
cholesterol by 15–25 mg/dL or by 9–12%
compared to baseline values or to a Western
diet.
• Nutrition therapy for hypertension is reported
to decrease both systolic and diastolic blood
pressure ~5 mmHg.
Metabolic goals
Metabolic goals
 Evidence-Based Nutrition
Recommendations for Diabetes
 Carbohydrate
• Foods containing carbohydrate—grains, fruits,
vegetables, low-fat milk—are important
components of a healthful diet and should be
included in the food/meal plan of persons with
diabetes.
• Monitoring total grams of carbohydrate,
whether by carbohydrate counting, exchanges,
or experienced based estimation is a key
strategy for achieving glycemic control.
 Carbohydrate
• Numerous studies have reported that when
subjects are allowed to choose from a variety
of starch and sugars, the glycemic response is
similar, as long as the total amounts of
carbohydrate is kept constant.
• Diets containing 44–50 g/day fiber have been
shown to improve glycemia; however, more
usual fiber intake (up to 24 g/day) has not
shown bene ficial effects on glycemia.
 Carbohydrate
• However, consuming foods containing 25–30
g/day fiber, with special emphasis on soluble
fiber sources (7–13 g) is recommended as part
of cardioprotective nutrition therapy.
• Even though sucrose restriction cannot be justi
fi ed on the basis of its glycemic effect, people
with diabetes, as is the general public, are
advised to avoid foods containing large
amounts of sucrose.
 Carbohydrate
• Reduced calorie sweeteners approved by the US
Food and Drug Administration (FDA) include sugar
alcohols (erythritol, sorbitol, mannitol, xylitol,
isomalt, lactitol, and hydrogenated starch
hydrolysates) and tagatose.
• They produce a lower glycemic response and, on
average, 2 kcal/g. Although their use appears safe,
gastric discomfort and diarrhea, after ingestion of
large quantities is often a problem, especially in
children.
 Protein
• There is no evidence to suggest that usual intake of
protein (15–20% of energy intake) be changed in
people who do not have renal disease.
• In patients with diabetic nephropathy, a protein
intake of <1.0 g/kg/day is recommended. Energy and
protein intake must be monitored to ensure
adequate intake.
 Protein
• Usual protein intake has minimal acute effects on
glucose and no long-term effect on insulin
requirements.
• Although nonessential amino acids undergo
gluconeogenesis, in well-controlled diabetes, the
glucose produced does not enter into the general
circulation; however, ingested protein is just as
potent a stimulant of acute insulin release as dietary
carbohydrate.
 Protein
• Patients are often told that eating protein can slow
the absorption of carbohydrate. However, research
has clearly shown that ingested protein does not
slow the absorption of carbohydrates.
• Furthermore, patients are often told that adding
protein to the treatment of hypoglycemia will
prevent subsequent hypoglycemia but research has
also shown that this is not the case.
 Protein
• The long-term effects of a diet higher in protein and
lower in carbohydrate in persons with diabetes on
regulation of energy intake, satiety, and weight loss
have not been adequately studied.
 Dietary fat
• Limiting intake of saturated fats, trans fatty acids, and
dietary cholesterol is recommended, especially in
individuals with LDL cholesterol ≥ 100 mg/dL (2.6
mmol/L).
• Research in persons with diabetes supporting these
guidelines is limited. However, persons with diabetes are
considered to be at a CVD risk similar to persons with a
past history of CVD. Therefore, after focusing on glycemic
control, cardioprotective nutrition interventions should
be implemented in the initial education series.
 Dietary fat
• There is evidence from the general population that
foods containing n -3 polyunsaturated fatty acids are
beneficial and two to three servings of fish per week
are recommended.
• Studies in persons with diabetes using n -3 supplements
have shown beneficial effects on lowering triglycerides
and platelet reactivity, whether they also reduce blood
pressure, leukocyte reactivity, and arrhythmias in these
patients similarly to what occurs in other patient
groups remains to be established.