Nursing in Nutrition Chapter 19 diabetes mellitus

ACCEPTABLE MACRONUTRIENT DISTRIBUTION RANGE (AMDR) IS

45% TO 65% OF TOTAL CALORIES.

BEFORE RECOMMENDING DIETARY CHANGES, IT MAY BE USEFUL TO ASK THE CLIENT:

oWHAT ARE YOUR GOALS FOR NUTRITION COUNSELING? oWHAT BEHAVIORS DO YOU WANT TO CHANGE? oWHAT CHANGES CAN YOU MAKE IN YOUR PRESENT LIFESTYLE? oWHAT OBSTACLES MAY PREVENT YOU FROM MAKING CHANGES? oWHAT CHANGES ARE YOU WILLING TO MAKE RIGHT NOW? oWHAT CHANGES WOULD BE DIFFICULT FOR YOU TO MAKE?

FAT

oTHE ***TYPE*** OF FAT IS MORE IMPORTANT THAN THE AMOUNT OF FAT CONSUMED. oTHE AMOUNT OF SATURATED FAT, TRANS FAT, AND CHOLESTEROL RECOMMENDED FOR THE GENERAL PUBLIC IS ALSO APPROPRIATE FOR PEOPLE WITH DIABETES.

CONVERSELY, HYPOGLYCEMIA CAUSED BY OVERUSE OF MEDICATION, TOO LITTLE FOOD, OR TOO MUCH EXERCISE,

CAN ALSO BE LIFE-THREATENING.

MANY OF THE RISKS FOR TYPE 2 DIABETES ARE

CHARACTERISTICS OF METABOLIC SYNDROME (METS)

DIABETES IS ONE OF THE MOST

COSTLY AND BURDENSOME CHRONIC DISEASES OF OUR TIME.

CHANGING BEHAVIORS

DIAGNOSIS OF DIABETES OFTEN TRIGGERS ANXIETY AND UNCERTAINTY.

TYPE 2 DIABETES IS MANAGED BY

DIET AND EXERCISE

EVEN MODEST WEIGHT LOSS CAN

LESSEN THE RISKS ASSOCIATED WITH METABOLIC SYNDROME.

AN ESSENTIAL COMPONENT OF DIABETES MANAGEMENT

NUTRITION THERAPY

IDEALLY, POSITIVE CHANGES OCCUR

PROGRESSIVELY

SUGAR ALCOHOLS

PROVIDE FEWER CALORIES AND CAUSE A SMALLER INCREASE IN GLUCOSE

PROTEIN: FOR PEOPLE WITH DIABETIC KIDNEY DISEASE, THE RECOMMENDED DIETARY ALLOWANCE (RDA) FOR PROTEIN

(0.8G/KG) SHOULD BE MAINTAINED

TYPE 1 DIABETES IS MANAGED BY

A COORDINATED REGIMEN OF NUTRITION THERAPY AND INSULIN

A LOW GLYCEMIC INDEX DIET MAY PROVIDE

A MODEST BENEFIT IN CONTROLLING POSTPRANDIAL HYPERGLYCEMIA.

UNTREATED OR POORLY CONTROLLED DIABETES CAN LEAD TO

ACUTE LIFE-THREATENING COMPLICATIONS.

QUESTION TYPE 1 DIABETES, ONCE REFERRED TO AS INSULIN- DEPENDENT DIABETES, IS CAUSED BY WHAT? A. HYPERINSULINEMIA B. ABSENCE OF INSULIN C. SENSITIVITY TO INSULIN D. METABOLIC SYNDROME

B

PATIENT ACTIVELY INVOLVED IN

GOAL SETTING, SELF-MONITORING, AND RECORD KEEPING.

GESTATIONAL DIABETES

HYPERGLYCEMIA THAT DEVELOPS DURING PREGNANCY

PERIODIC AND ONGOING FOLLOW-UP

IMPROVES COMPLIANCE.

GLYCEMIC CONTROL DEPENDS ON

MATCHING CARBOHYDRATE INTAKE WITH THE ACTION OF INSULIN OR OTHER MEDICATION.

YPE 2 DIABETES DEMONSTRATE SIMILAR CHARACTERISTICS ASSOCIATED WITH

METS

MODIFIABLE RISK FACTORS FOR METABOLIC SYNDROME INCLUDE

EXCESS BODY FAT, A SEDENTARY LIFESTYLE, AND A HIGH-SATURATED FAT DIET.

PEOPLE WITH TYPE 1 DIABETES RELY ON

EXOGENOUS INSULIN FOR SURVIVAL.

DUE TO THE PROGRESSIVE NATURE OF THE DISEASE, MOST PEOPLE WITH TYPE 2 DIABETES EVENTUALLY REQUIRE

ORAL AGENTS, INSULIN, OR A COMBINATION OF BOTH TO MANAGE BLOOD GLUCOSE LEVELS.

TERTIARY PREVENTION: CONTROLLING DIABETES COMPLICATIONS

PROGRESSION OF MICROVASCULAR DIABETES COMPLICATIONS MAY BE MODIFIED BY IMPROVING GLYCEMIC CONTROL AND LOWERING BLOOD PRESSURE.

ATHEROSCLEROTIC CARDIOVASCULAR DISEASE (ASCVD)IS

THE LEADING CAUSE OF DEATH AMONG PEOPLE WITH DIABETES

PEOPLE WITH METS ARE

THREE TIMES AS LIKELY TO DEVELOP HEART DISEASE AND 5 TIMES AS LIKELY TO DEVELOP DIABETES COMPARED TO THOSE WITHOUT.

PRIMARY GOAL OF DIABETES MANAGEMENT IS

TO KEEP BLOOD GLUCOSE LEVELS AS NEAR NORMAL AS POSSIBLE.

QUESTION IS THE FOLLOWING STATEMENT TRUE OR FALSE? DIABETIC KETOACIDOSIS IS CHARACTERIZED BY GLUCOSE LEVELS GREATER THAN 250 MG/DL.

TRUE

QUESTION IS THE FOLLOWING STATEMENT TRUE OR FALSE? SUGAR ALCOHOLS PRODUCE A SMALLER RISE IN POSTPRANDIAL GLUCOSE LEVELS AND INSULIN SECRETION THAN SUCROSE

TRUE

GESTATIONAL DIABETES RISK FACTORS

oA HISTORY OF GESTATIONAL DIABETES oLIKE TYPE 2 DIABETES; OBESITY, BEING A MEMBER OF A CERTAIN ETHNIC POPULATION (AFRICAN AMERICAN, LATINO/HISPANIC, ASIAN AMERICAN, AND NATIVE AMERICAN) oA HISTORY OF GIVING BIRTH TO AN INFANT WEIGHING MORE THAN 9 POUNDS

RISK FACTORS FOR TYPE 2 DIABETES

oAGE 45 YEARS OR OLDER oOVERWEIGHT (BMI ≥25 KG/M2) oFIRST-DEGREE RELATIVE WITH DIABETES oPHYSICALLY INACTIVE OR EXERCISES FEWER THAN THREE TIMES PER WEEK oMEMBER OF HIGH-RISK ETHNIC GROUP: AFRICAN AMERICAN, LATINO, NATIVE AMERICAN, ASIAN AMERICAN, PACIFIC ISLANDER oPREVIOUSLY IDENTIFIED WITH FACTORS SUCH AS IMPAIRED FASTING GLUCOSE OR IMPAIRED GLUCOSE TOLERANCE oHISTORY OF GESTATIONAL DIABETES OR GIVING BIRTH TO A BABY WEIGHING MORE THAN 9 POUNDS oHYPERTENSIVE oPOLYCYSTIC OVARY SYNDROME oHDL <35 MG/DL AND/OR TRIGLYCERIDE LEVEL ≥250 MG/DL

SECONDARY GOALS OF MANAGING DIABETES

oATTAIN AND MAINTAIN CONTROL OF BLOOD LIPID LEVELS AND BLOOD PRESSURE. oPREVENT OR DELAY THE DEVELOPMENT OF COMPLICATIONS. oMEET THE INDIVIDUAL'S CULTURAL AND PERSONAL NEEDS. oMAINTAIN THE PLEASURE OF EATING BY NOT LIMITING ANY FOODS UNLESS INDICATED BY SCIENTIFIC EVIDENCE.

RISK FACTORS FOR TYPE 1 DIABETES MAY BE

oAUTOIMMUNE oGENETIC oENVIRONMENTAL

EXCHANGE LISTS FOR MEAL PLANNING

oCHOOSE YOUR FOODS: EXCHANGE LISTS FOR MEAL PLANNING (NOW REFERRED TO AS FOOD LISTS FOR DIABETICS) IS A FRAMEWORK FOR CHOOSING A HEALTHY5 DIET. oGROUP FOODS INTO LISTS THAT, PER SERVING SIZE GIVEN, ARE SIMILAR IN CARBOHYDRATE, PROTEIN, FAT, AND CALORIES, BASED ON ROUNDED AVERAGES oTHREE MAJOR CATEGORIES ARE CARBOHYDRATES, MEAT AND MEAT SUBSTITUTES, AND FATS. oSAMPLE MEAL PATTERN IS DESIGNED FOR CLIENTS BASED ON THEIR USUAL PATTERN OF EATING. oCLIENTS ARE ENCOURAGED TO EAT A VARIETY OF FOODS WITHIN EACH LIST AND TO MAKE HEALTHY CHOICES. oFOOD SHOULD BE WEIGHED OR MEASURED UNTIL PORTION SIZES CAN BE ACCURATELY ESTIMATED. oELIMINATES THE NEED FOR DAILY CALCULATIONS oSOME ITEMS ON SOME LISTS ARE COUNTED AS MORE THAN JUST ONE CHOICE OR ONE EXCHANGE. oSOME ITEMS APPEAR ON MORE THAN ONE LIST AND IN DIFFERENT AMOUNTS. oBEST SUITED TO PEOPLE WHO WANT OR NEED STRUCTURED MEAL-PLANNING GUIDANCE AND ARE ABLE TO UNDERSTAND COMPLEX DETAILS

ALCOHOL

oMODERATE USE OF ALCOHOL (1 DRINK/DAY OR LESS IN WOMEN AND 2 DRINKS/DAY OR LESS IN MEN) BY PEOPLE WHO HAVE WELL-CONTROLLED DIABETES MINIMALLY AFFECTS BLOOD GLUCOSE AND INSULIN LEVELS.

FIBER

oRECOMMENDATIONS FOR FIBER ARE THE SAME AS FOR THE GENERAL POPULATION. oFOODS RICH IN FIBER PROVIDE OTHER BENEFITS SUCH AS INCREASING SATIETY; PROVIDING VITAMINS, MINERALS, AND PHYTOCHEMICALS; AND LOWERING SERUM CHOLESTEROL LEVELS.

SWEETENERS

oSUCROSE AND SUCROSE-CONTAINING FOODS ARE NOT RESTRICTED. oFOODS HIGH IN SUGAR ARE USUALLY NUTRIENT POOR

DIABETIC DIETS IN THE HOSPITAL

•A CONSISTENT CARBOHYDRATE DIET •APPROPRIATE MODIFICATIONS IN FAT INTAKE ARE MADE. •CONSISTENT TIMING OF MEALS AND SNACKS IS STRESSED. •NO ONE WAY TO PROVIDE ADEQUATE NUTRITION FOR DIABETICS IN THE HOSPITAL

SICK-DAY MANAGEMENT

•ACUTE ILLNESSES CAN SIGNIFICANTLY RAISE BLOOD GLUCOSE LEVELS. •MAINTAIN NORMAL MEDICATION SCHEDULE, MONITOR BLOOD GLUCOSE LEVELS EVERY 2 TO 4 HOURS, AND MAINTAIN AN ADEQUATE FLUID INTAKE •A DAILY INTAKE OF 150 TO 200 G OF CARBOHYDRATES, APPROXIMATELY 50 G EVERY 3 TO 4 HOURS, IS RECOMMENDED.

EXERCISE

•AN IMPORTANT ASPECT OF TREATMENT FOR BOTH TYPES OF DIABETES •UNLESS IT IS CONTRAINDICATED FOR OTHER MEDICAL REASONS, THE CLIENT SHOULD EXERCISE EVERY DAY.

HYPOGLYCEMIA

•BLOOD GLUCOSE LEVEL LESS THAN 70 MG/DL •COMMONLY REFERRED TO AS "INSULIN REACTION" •OCCURS FROM TAKING TOO MUCH INSULIN, INADEQUATE FOOD INTAKE, DELAYED OR SKIPPED MEALS, EXTRA PHYSICAL ACTIVITY, OR CONSUMPTION OF ALCOHOL WITHOUT FOOD •SYMPTOMS...? •BLOOD GLUCOSE <70 MG IS TREATED WITH 15G OF INGESTED GLUCOSE. oSYMPTOMS NORMALLY IMPROVE IN 15 MINUTES. IF NOT REPEAT PROCESS •HYPOGLYCEMIC UNAWARENESS oCONSISTENT MONITORING OF BLOOD GLUCOSE IS ESPECIALLY IMPORTANT.

HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC SYNDROME (HHNS)

•CHARACTERIZED BY HYPERGLYCEMIA (>600 MG/DL) WITHOUT SIGNIFICANT KETONEMIA •OCCURS MOST COMMONLY IN PEOPLE WITH TYPE 2 DIABETES •DEHYDRATION AND HEAT EXPOSURE INCREASE THE RISK. •ILLNESS OR INFECTION IS USUALLY THE PRECIPITATING FACTOR IN THE ELDERLY •OLDER PEOPLE MAY BE PARTICULARLY VULNERABLE. •DEVELOPS SYMPTOMS RELATIVELY SLOWLY •BEST PROTECTION AGAINST HHNS IS REGULAR GLUCOSE MONITORING. •TREATMENT INCLUDES INSULIN AND FLUID AND ELECTROLYTE REPLACEMENT.

LIFE CYCLE CONSIDERATIONS FOR CHILDREN AND ADOLESCENTS

•CHILDREN WITH DIABETES APPEAR TO HAVE THE SAME NUTRIENT NEEDS AS THEIR AGE-MATCHED PEERS. •MANAGING DIABETES IN CHILDREN AND ADOLESCENTS IS COMPLICATED BY THE IMPACT OF GROWTH ON NUTRIENT NEEDS, IRREGULAR EATING PATTERNS, AND ERRATIC ACTIVITY LEVELS. •FAILURE TO PROVIDE ADEQUATE CALORIES AND NUTRIENTS RESULTS IN POOR GROWTH, AS DOES POOR GLYCEMIC CONTROL AND INADEQUATE INSULIN ADMINISTRATION. INDIVIDUALIZED MEAL PLANS AND INTENSIVE INSULIN REGIMENS CAN PROVIDE FLEXIBILITY FOR ERRATIC EATING, ACTIVITY, AND GROWTH. •INCREASINGLY LARGER NUMBERS OF AMERICAN YOUTHS ARE DIAGNOSED WITH TYPE 2 DIABETES. •WEIGHT CONTROL IS KEY TO PREVENTING TYPE 2 DIABETES IN CHILDREN.

CARBOHYDRATE COUNTING

•EASIER AND MORE FLEXIBLE ALTERNATIVE TO USING THE EXCHANGE SYSTEM •CLIENTS ARE GIVEN AN INDIVIDUALIZED MEAL PATTERN THAT SPECIFIES THE NUMBER OF CARBOHYDRATE "CHOICES" FOR EACH MEAL AND SNACK. •CARBOHYDRATE CHOICE LISTS •PROTEIN AND FAT CANNOT BE DISREGARDED. •APPROPRIATE FOR PEOPLE WHO UNDERSTAND THE IMPORTANCE OF CONSUMING A CONSISTENT CARBOHYDRATE INTAKE TO MATCH INSULIN OR MEDICATION PEAKS •FEEL MORE IN CONTROL AND BENEFIT FROM IMPROVED GLUCOSE CONTROL •KEEPING RECORDS OF BLOOD GLUCOSE TESTS AND FOOD INTAKE HELPS

TYPE 1 DIABETES

•FORMERLY KNOWN AS INSULIN-DEPENDENT DIABETES MELLITUS •CHARACTERIZED BY THE ABSENCE OF INSULIN •NO KNOWN WAY TO PREVENT TYPE 1 DIABETES •ALL PEOPLE WITH TYPE 1 DIABETES REQUIRE EXOGENOUS INSULIN TO CONTROL BLOOD GLUCOSE LEVELS. •MOST OFTEN DETECTED IN CHILDREN, ADOLESCENTS, AND YOUNG ADULTS •CLASSIC SYMPTOMS OF POLYURIA, POLYDIPSIA, AND POLYPHAGIA

NUTRITION FOR PATIENTS WITH DIABETES MELLITUS

•GLUCOSE CIRCULATING IN THE BLOOD IS A SOURCE OF READY FUEL FOR BODY CELLS. •THE AMOUNT OF CARBOHYDRATE CONSUMED AND, TO A LESSER EXTENT, THE TYPE OF CARBOHYDRATE EATEN ARE THE PRIMARY DETERMINANTS OF HOW QUICKLY AND HOW HIGH BLOOD GLUCOSE LEVELS RISE AFTER EATING. •A RISE IN POSTPRANDIAL BLOOD GLUCOSE LEVELS STIMULATES THE PANCREAS TO SECRETE INSULIN. •FASTING BLOOD GLUCOSE LEVELS OF 100 TO 126 MG/DL INDICATE PREDIABETES.

EXERCISE IN INSULIN USERS

•HAS BEEN SHOWN TO IMPROVE GLYCEMIC CONTROL •MAY WORSEN HYPERGLYCEMIA •IT IS NOT CLEAR WHETHER PHYSICAL ACTIVITY OFFERS THE SAME BENEFITS IN PEOPLE WITH TYPE 1 DIABETES •PHYSICAL ACTIVITY MAY CAUSE HYPOGLYCEMIA; SOURCE OF READILY ABSORBABLE CARBOHYDRATE SHOULD BE CARRIED AT ALL TIMES

DIABETES

•INCREASING IN EPIDEMIC PROPORTIONS •THE ESTIMATED DIRECT AND INDIRECT COST ASSOCIATED WITH DIABETES IN 2014 WAS $245 BILLION. •IN 2012, THE PREVALENCE OF PREDIABETES WAS 38% IN THE OVERALL POPULATION.

INSULIN THERAPY FOR PEOPLE WITH TYPE 1 DIABETES

•INSULIN PREPARATIONS VARY IN HOW QUICKLY THEY ACT, WHEN THEIR PEAK ACTION OCCURS, AND HOW LONG THEIR EFFECTS LAST. •INTERMEDIATE- OR LONG-ACTING INSULIN IS USED TO MEET BASAL NEEDS. •RAPID- OR SHORT-ACTING INSULIN IS USED BEFORE EACH MEAL. •CLOSELY RESEMBLES HOW INSULIN IS NORMALLY SECRETED •NIGHTTIME HYPOGLYCEMIA CAN BE A PROBLEM WITH NPH PEAKING DURING THE NIGHT.

MEAL PLANNING APPROACHES

•MONITORING CARBOHYDRATE INTAKE IS KEY TO CONTROLLING BLOOD GLUCOSE LEVELS. •MEAL PLAN SHOULD REFLECT THE INDIVIDUAL'S LIFESTYLE, PREFERENCES, AND WILLINGNESS/ABILITY TO MAKE DIETARY CHANGES.

TYPE 2 DIABETES

•OCCURS MOST OFTEN AFTER THE AGE OF 45 YEARS •ACCOUNTS FOR 90% TO 95% OF DIAGNOSED CASES OF DIABETES •A SLOWLY PROGRESSIVE DISEASE THAT USUALLY BEGINS AS A PROBLEM OF INSULIN RESISTANCE •TYPE 2 DIABETES IS OFTEN ASYMPTOMATIC •INSULIN RESISTANCE IS STRONGLY LINKED TO OBESITY.

EXERCISE IN TYPE 2 DIABETES

•OFFERS SUBSTANTIAL BENEFITS •HELPS TO MAINTAIN LONG-TERM WEIGHT REDUCTION •MONITOR BLOOD GLUCOSE LEVELS •INSULIN MAY NEED TO BE ADJUST THEIR PRE-EXERCISE CARBOHYDRATE INTAKE OR INSULIN DOSE TO VOID HYPOGLYCEMIA •STOP ACTIVITY IF SIGNS AND SYMPTOMS OF HYPOGLYCEMIA DEVELOP

GLUCOSE-LOWERING MEDICATIONS

•ORAL GLUCOSE-LOWERING MEDICATIONS VARY IN THEIR MECHANISM OF ACTION AND FOOD CONCERNS. •CONSIDERED ADJUNCT TO NUTRITION THERAPY AND EXERCISE, NOT A SOLE MODE OF THERAPY

DIABETIC KETOACIDOSIS (DKA)

•PEOPLE WITH TYPE 1 DIABETES ARE SUSCEPTIBLE TO DIABETIC KETOACIDOSIS (DKA). •CHARACTERIZED BY HYPERGLYCEMIA (GLUCOSE LEVELS >250 MG/DL) AND KETONEMIA •CAUSED BY A SEVERE DEFICIENCY OF INSULIN OR FROM PHYSIOLOGIC STRESS, SUCH AS ILLNESS OR INFECTION •POLYURIA MAY LEAD TO DEHYDRATION, ELECTROLYTE DEPLETION, AND HYPOTENSION. •HYPERVENTILATION OCCURS IN AN ATTEMPT TO CORRECT ACIDOSIS BY INCREASING EXPIRATION OF CARBON DIOXIDE. •FATIGUE, NAUSEA, VOMITING, AND CONFUSION DEVELOP. •DIABETIC COMA AND DEATH ARE POSSIBLE. •DKA IS SOMETIMES THE PRESENTING SYMPTOM WHEN TYPE 1 DIABETES IS DIAGNOSED. •DKA RARELY DEVELOPS IN PEOPLE WITH TYPE 2 DIABETES. •DKA IS TREATED WITH ELECTROLYTES, FLUID, AND INSULIN.

INTENSIVE INSULIN THERAPY FOR PEOPLE WITH TYPE 1 DIABETES

•POPULAR AND DYNAMIC INSULIN REGIMEN FOR TYPE 2 AND NEWLY DIAGNOSED TYPE 1 DIABETES •ALGORITHM GIVES FORMULAS FOR CLIENTS TO CALCULATE THE CARBOHYDRATE-TO-INSULIN RATIO FOR THE ANTICIPATED CARBOHYDRATE CONTENT OF A MEAL/SNACK. •REQUIRES MORE CALCULATIONS AT EACH MEAL BUT ALLOWS GREATER FLEXIBILITY IN WHEN MEALS ARE EATEN AND HOW MUCH CARBOHYDRATE IS CONSUMED

LONG-TERM COMPLICATIONS

•RETINOPATHY •NEPHROPATHY •NEUROPATHY •MYOCARDIAL INFARCTION •STROKE •PERIPHERAL VASCULAR DISEASE •MILD TO SEVERE FORMS OF NERVOUS SYSTEM DAMAGE •IMPAIRED WOUND HEALING •PERIODONTAL DISEASE •PREGNANCY COMPLICATIONS •INCREASED SUSCEPTIBILITY TO OTHER ILLNESSES

LIFE CYCLE CONSIDERATIONS FOR PEOPLE WITH DIABETES IN LATER LIFE

•UNIQUE CONSIDERATIONS RELATED TO AGING THAT AFFECT GLYCEMIC CONTROL •BLOOD GLUCOSE LEVELS RISE WITH AGE FOR REASONS THAT ARE UNCLEAR. •COGNITIVE IMPAIRMENTS MAY PRECLUDE SELF-MANAGEMENT. •OLDER ADULTS MAY BE AT GREATER NUTRITIONAL RISK FOR A VARIETY OF REASONS. •A FASTING TARGET LEVEL OF 90 TO 150 MG/DL MAY BE CONSIDERED APPROPRIATE.

CALORIES, OVERWEIGHT, AND OBESITY

•WEIGHT LOSS HAS TRADITIONALLY BEEN THE FOCUS OF NUTRITION INTERVENTION FOR OVERWEIGHT AND OBESE PEOPLE WITH PREDIABETES OR TYPE 2 DIABETES. oNO ONE PROVEN STRATEGY THAT CAN BE UNIFORMLY RECOMMENDED TO PROMOTE WEIGHT LOSS IN ALL CLIENTS oWEIGHT LOSS MEDICATIONS oBARIATRIC SURGERY

PREVENTING*** DIABETES

•WEIGHT LOSS THROUGH A COMBINATION OF HEALTHY EATING AND EXERCISE IS THE PRIMARY FOCUS OF DIABETES PREVENTION. •DIABETES PREVENTION PROGRAM (DPP) •A LOW SATURATED FAT INTAKE MAY REDUCE THE RISK FOR DIABETES BY IMPROVING INSULIN RESISTANCE AND PROMOTING WEIGHT LOSS. •SEVERAL STUDIES SHOW THAT AN INCREASED INTAKE OF WHOLE GRAINS AND FIBER LOWERS THE RISK OF DIABETES.

FOR SWEETENERS, THE USE OF FRUCTOSE AS AN ADDED SWEETENER IS NOT RECOMMENDED SINCE

●MAY ADVERSELY AFFECT SERUM LIPID LEVELS ●NO REASON FOR PEOPLE WITH DIABETES TO AVOID NATURALLY OCCURRING FRUCTOSE IN FRUIT AND VEGETABLES

SUGAR ALCOHOLS INCLUDE NONNUTRITIVE SWEETENERS LIKE

●SACCHARIN, ASPARTAME, ACESULFAME, AND SUCRALOSE ●MAY SAFELY BE USED BY PEOPLE WITH DIABETES