3/14/2021
                                                                                                                                                                                                                                                                                                                                                                    Objectives
                                                                      Updated Diabetes Guidelines on                                                                                                                                                                                            • Describe key concepts and latest evidence from the 
                                                                                           Meals, Meds, and More                                                                                                                                                                                      American Diabetes Association’s Nutrition        
                                                                                                                                                                                                                                                                                                      Consensus Report
                                                                                                                                                    th
                                                                                                                    March 26 , 2021                                                                                                                                                             • Review oral agents, non-insulin injectables and insulin 
                                                                                                                MAND ANCE 2021                                                                                                                                                                        for patients with diabetes
                                                                                                                                                                                                                                                                                                • Discuss how diabetes technology (tech) can minimize 
                                                                                             Rachel Stahl, MS, RD, CDN, CDCES                                                                                                                                                                         challenges of diabetes self-care management and 
                                                              Registered Dietitian/Certified Diabetes Care and Education Specialist                                                                                                                                                                   improve clinical outcomes
                                                                                      Division of Endocrinology, Diabetes & Metabolism
                                                                                NewYork-Presbyterian Hospital/Weill Cornell Medicine
                                                                                                                                New York City
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                                                Prediabetes and diabetes in United States                                                                                                                                                                                                  Diagnosing prediabetes & diabetes
                                                                                                                                                            https://www.cdc.gov/diabetes/pdfs/library/socialmedia/diabetes-infographic.pdf
                                                                                                                                                                                    http://www.cdc.gov/diabetes/basics/index.html
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                                             Treatment goals: ADA vs AACE/ACE for                                                                                                                                                                                                        Limitations of A1C: It’s just an average!
                                             non-pregnant adults with diabetes                                                                                                                                                                                                           But now we have CGM Targets & Metrics like Time in Range 
                                                                                                                                           AACE1                                             ADA2
                                                                      Pre-prandial                                                  <110 mg/dL                                   80-130 mg/dL
                                                                      Blood Glucose(BG)
                                                                      Post-prandial (pp)                                         <140 mg/dLat                                       <180 mg/dL
                                                                      BG                                                                  2 hrs pp                                     1-2 hrs pp
                                                                      A1C (%)                                                               ≤6.5%                                              ≤7%
                                                                                                                  **Individualization is key**                                                                                                                                           TIR is the percentage of time that a person 
                                                                                         Tighter targets (6.0 – 6.5%) – younger, healthier                                                                                                                                               spends with their blood glucose levels in a 
                                                Looser targets (7.5 – 8.0%) – older, co-morbidities, hypoglycemia prone, end of life                                                                                                                                                     target range
                                       ADA: American Diabetes Association; AACE=American                     1. Garber AJ, Abrahamson MJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and AmericanCollege of                                                                                                                                                                                             CGM = continuous glucose monitoring
                                       Association of Clinical Endocrinologists ; ACE= American College      Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm –2019 Executive Summary. EndocrPract. 2019;25(No.1):69-100.                                                                                                                                                                                                 TIR = time in range 
                                       of Endocrinology; A1C = Hemoglobin A1c                                2. American Diabetes Association (ADA). Standard of Medical Care in Diabetes –2021.
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                    CGM-Based Targets for Different Populations                                                                   Meeting these goals can be challenging!
                                                                                                                                        There are at least 42 
                                                                                                                                      factors that affect blood 
                                                                                                                                        glucose levels – what 
                                                                                                                                     factors can you think of?
                                         More time in range means less severe highs and lows –
                                         and is correlated with better quality of life
                                                         Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations 
                                                         from the international consensus on time in range. Diabetes Care 2019;42:1593–1603
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                      There are at least                                                                                            On the Menu
                           42 factors that                                                                                                    Nutrition
                              affect blood 
                           glucose levels                                                                                                     Medications
                                                                                                                                              Diabetes Technology
                                                                    42 Factors That Affect Blood Glucose?!
                                                                    A Surprising Update. (2019, October 30). Retrieved from https://diatribe.org/42factors
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                       On the Menu                                                                                                Patients have many concerns about 
                                                                                                                                  nutrition that should be addressed…
                                Nutrition                                                                                            • How many carbohydrates can I eat each day?
                                                                                                                                     • How should I adjust my insulin dosage based                   
                                Medications                                                                                             on what I eat?
                                                                                                                                     • I started taking elderberry, gingko, Fenugreek, bitter 
                                                                                                                                        melon, cinnamon supplements…will these help lower my 
                                Diabetes Technology                                                                                     blood sugar?
                                                                                                                                     • Should I go keto? What about intermittent fasting?
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                                                                                                                                                                                                              3/14/2021
                   Patients have many concerns about                                                                        The ADA Nutrition Consensus Report 
                   nutrition that should be addressed…and                                                                   has guidance
                   don’t know where to go for reputable 
                   information
                                                                                                                         ADA = American Diabetes Association        EvertABet al.Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care2019;42:731–754
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                    Key Nutrition Consensus Messages                                                                        Key Nutrition Consensus Messages
                     • No one-size-fits-all                                                                                  • No one-size-fits-all
                     • Variety of eating patterns are acceptable for the                                                     • Variety of eating patterns are acceptable for the 
                        management of prediabetes and diabetes                                                                 management of prediabetes and diabetes
                     • Increase fiber intake                                                                                 • Increase fiber intake
                     • Mealtime insulin dosing guidelines are individualized                                                 • Mealtime insulin dosing guidelines are individualized
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                     Nutrition care plan needs to be individualized:                                                         Nutrition care plan needs to be individualized:
                                           “No One-Size-Fits-All”                                                                                  “No One-Size-Fits-All”
                  •Type of diabetes                           •Patient’s preferences/health goals                         •Type of diabetes                           •Patient’s preferences/health goals
                  •Comorbidities                              •Exercise                                                   •Comorbidities                              •Exercise
                  •Labs                                       •Health literacy                                            •Labs                                       •Health literacy 
                  •Medications                                •Health numeracy                                            •Medications                                •Health numeracy
                  •Cultural factors                           •Potential limitations–physical,                            •Cultural factors                           •Potential limitations–physical, 
                  •Appetite                                    psychological, technological                               •Appetite                                    psychological, technological
                  •Weight                                     •Food access especially during                              •Weight                                     •Food access especially during         
                                                               COVID-19                                                                                                COVID-19
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                        Nutrition care plan needs to be individualized:                                                                    Nutrition care plan needs to be individualized:
                                                “No One-Size-Fits-All”                                                                                             “No One-Size-Fits-All”
                    •Type of diabetes                                •Patient’s preferences/health goals                                •Type of diabetes                                •Patient’s preferences/health goals
                    •Comorbidities                                   •Exercise                                                          •Comorbidities                                   •Exercise
                    •Labs                                            •Health literacy                                                   •Labs                                            •Health literacy 
                    •Medications                                     •Health numeracy                                                   •Medications                                     •Health numeracy
                    •Cultural factors                                •Potential limitations–physical,                                   •Cultural factors                                •Potential limitations–physical, 
                    •Appetite                                         psychological, technological                                      •Appetite                                         psychological, technological
                    •Weight                                          •Food access especially during                                     •Weight                                          •Food access especially during         
                                                                      COVID-19                                                                                                            COVID-19
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                        Nutrition care plan needs to be individualized:                                                                   Key Nutrition Consensus Messages
                                                “No One-Size-Fits-All”                                                                     • No one-size-fits-all
                                                                                                                                           • Variety of eating patterns are acceptable for the 
                    •Type of diabetes                                •Patient’s preferences/health goals                                     management of prediabetes and diabetes
                    •Comorbidities                                   •Exercise                                                             • Increase fiber intake
                    •Labs                                            •Health literacy 
                    •Medications                                     •Health numeracy                                                      • Mealtime insulin dosing guidelines are individualized
                    •Cultural factors                                •Potential limitations–physical,
                    •Appetite                                         psychological, technological
                    •Weight                                          •Food access especially
                                                                       during COVID-19
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                                                                                     https://diatribe.org/what-eat-diabetes-or-prediabetes-adas-new-nutrition-guidelines                                https://diatribe.org/what-eat-diabetes-or-prediabetes-adas-new-nutrition-guidelines
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