Lifestyle Management

What does MNT stand for?

medical nutrition therapy

What is the purpose of MNT?

an individualized MNT program as needed to achieve treatment goals, preferably provided by a registered dietitian, is recommended for all people with T1 and T2DM, prediabetes, and gestational diabetes mellitus

What did the PREDIMED trial show?

following the mediterranean diet decreased MI, stroke, or CV death vs a low fat diet

What food is included in MNT for diabetics?

non-starchy vegetables, whole fruits, legumes, lean proteins, whole grains, nuts and seeds, and low-fat dairy or nondairy alternatives

What food should be minimized in MNT?

red meat, sugar-sweetened beverages, sweets, refined grains, processed and ultra-processed foods

What should diabetics do with their carbohydrate intake?

reduce overall

What should diabetics do in terms of beta-carotene?

avoid; we should counsel against

What is the alcohol limit that diabetics should follow?

men: 2 drinks/day

women: 1 drink/day

What is the recommended sodium consumption limit for diabetics?

limit < 2300 mg/day

What should diabetics drink?

water!! better than non-nutritive sweetened drinks

Why diabetic patients in particular should avoid a ketogenic eating?

those treated with SGLT-2i

When using fixed insulin doses, what should we educate patients on?

consistent pattern of carbohydrate intake

True or False: recommend more pant-based protein sources

true

What is religious fasting?

fixed duration and timing, high levels of intrinsic motivation, risk of hyperglycemia at end of fasting hours, dehydration is possible in some types

What is intermittent fasting?

flexible duration and timing, varying levels of intrinsic and extrinsic motivation, hyperglycemia is unlikely as motive is health related, no added risk of dehydration

What do religious fasting and intermittent fasting have in common?

hypoglycemia risk, risk assessment and education is essential prefasting, treatment adjustment is required

How should you adjust sulfonylureas during fasting?

reduce dose if glucose levels are within individualized goal range

How should you adjust prandial insulin during fasting?

reduce dose of insulin for the meal following fasting; match insulin to carbohydrate intake

What is the plate method for MNT?

half the plate with non-starchy veggies, ¼ of the plate with carbs, ¼ of the plate with proteins

Why is carb counting important for T1DM?

method to assure insulin doses are well matched with meals

Why is carb counting important for T2DM?

helpful tool for portion management

What are examples of complex carbs?

potatoes, whole wheat bread, pasta, oatmeal

What are examples of simple carbs?

donuts, candy, French fries, juice

What is insulin dosed on for T1DM?

carbohydrate content of meal, current BG level, level of physical activity and exercise

What is the risk with acute alcohol consumptoion?

hypoglycemia

What is the exercise recommendation for diabetics?

150 mins or more per week of moderate intensity aerobic activity, 2-3 sessions of resistance training, and 2-3 sessions of flexibility training a week

Why is exercise so important?

it opens up the glucose transporters to allow as much glucose into the muscle cells and out of the blood stream

What are goals for pediatric T1DM for management of other diseases?

only treat BP if >130/80

treat LDL if > 130

screen for retinopathy, neuropathy, and nephropathy once 10 years old

MNT and exercise 60mins 3x a week

What is the indication for teplizumab-mzwv?

monoclonal antibody indicated to delay the onset of stage 3 type 1 diabetes in adults and pediatric patients aged 8 years and older with stage 2 T1DM

What is the MOA of teplizumab-mzwv?

anti-CD3 monoclonal antibody that binds to CD3 antigens on the surface of T cells; may involve the partial agonistic signaling and deactivation of autoreactive T cells that target pancreatic beta cells

What is the brand name of teplizumab-mzwv?

Tzieled

How is teplizumab dosed?

IV once a day for 14 days

What are the side effects of teplizumab?

skin rash, leukopenia, lymphocytopenia, headache, nausea, vomiting, neutropenia

What are the warnings and precautions of teplizumab?

cytokine release syndrome, serious infections, lymphopenia, HS reactions, vaccinations (live)

When should we screen pediatric patients for T2DM?

at least 10 years old and BMI is in at least the 85th percentile

What lifestyle changes should be made for pediatric T2DM patients?

comprehensive diabetes and lifestyle education for patient and family; aim for a 7-10% weight loss

What exercise recommendation should be made for pediatric T2DM patients?

30-60 min of moderate to vigorous physical activity at least 5 days per week

What A1C goal do pediatric patients with T2DM have?

< 6.5% if hypoglycemia can be avoided

What special criteria exist for geriatric patents who are not functional or cognitively intact?

relaxed goals & deintensification of regimens

A1C <7.5%

avoid hypoglycemia

limit hyperglycemia and avoid complications

What are the 4Ms of age friendly person-specific issues that can affect DM?

mentation, medications, mobility, and what matters most

How often should adults over 65 years be screened for neurocognitive function?

initial visit, annually, and as appropriate

What is the recommendation for CGMS for older adults with T1DM?

recommended use of CGMs to improve glycemic outcomes

What is the recommendations for CGMs for older adults with T2DM?

offer to adults on insulin therapy to improve glycemic outcomes and reduce hypoglycemia

What is the goals for time in ranges for older adults with intermediate or complex health on CGMs?

time in range is 50%

time below range <1%

What medications should be avoided in older adults with T2DM?

medications with risk of hypoglycemia

What changes should be made to T2DM older adults pharmacologic therapy?

deintensify!!

What medications should be held during a sick day?

metformin, SGLT-2i, and GLP-1s

What are the general management points for sick days?

test blood glucose every 2 hours

T1DM should test ketones every 4 hours

monitor temps

keep hydrated

track symptoms

What would be considered a sick day?

infection, injury, surgery, trauma, invasive procedures, or major life stress

What screening should be done for cystic fibrosis related diabetes?

OGTT should begin by age 10 (A1C is not recommneded)

How do you treat cystic fibrosis related diabetes?

insulin

When should individuals with risk factors test for gestational diabetes?

before 15 weeks

When should individuals with no diabetes be screened for gestational diabetes?

at 24-28 weeks

How should individuals be screened for gestation diabetes postpartum?

the “one step” 75g OGTT or the older two step option

What is the preferred agent for diabetes in pregnancy?

insulin

What is the preferred agent for gestational diabetes?

insulin; after delivery consider starting metformin

What are the targets for treatment of diabetes in pregnancy?

A1C < 6%

FBG < 95

one hour postprandial < 140

two hours postprandial < 120