ESPEN LLL Course
Topic 21 – Consequences of Diabetes Mellitus on the Nutritional
Status
Diabetes and Nutritional
Status
Module 21.1.
Dr. Irit Chermesh
Medical Director of Clinical
Nutrition
Gastroenterology Dept
Rambam Healthcare Campus
Israel
21.03.2016
When was this written?
“There are entirely too many diabetic patients in the
1.1920
country. Statistics for the last thirty years show
so great 2.1950
an increase in the number that, unless
this were3.1980
in part explained by a better
recognition of the disease, the outlook for the
4.2010
future would be startling.”
Joslin EP. The Prevention of Diabetes Mellitus JAMA 1921;76:79-84.
Diabetes Physical inactivity Obesity
2004
2010
Metabolism and
Nutrition in DM
–High BMR
–Relative low LBM and high fat mass
–Low muscle strength
Diabetes Mellitus Type 1
(DMT1)
Inability to metabolise glucose due to insulin
deficiency
1.Physiological starvation
2.Undernutrition
3.Stress metabolism and nutrient ‘spillage’ through
glycosuria
4.Weight loss (LBM)
5.Overt protein energy malnutrition
High BMR
–Elevated inflammatory cytokines
– IL-6
– TNF-alpha
– IL-1 beta
– CRP
–Found pre-diagnosis of DM
DMT2A day
a whole
in the life ofdifferent story
public health…
Specific deficiencies
–Vitamin (25) D
–Vitamin B12
–Magnesium
–Vitamin E
–Vitamin B1 (thiamine)
–Chromium
Vitamin (25) D
Role in D.M?
• Improvement insulin secretion and/or
action?
– Improvement in systemic inflammation
– Effects of vitamin D and/or Ca. on cytokines
Al-Shoumer KA World J Diabetes 2015
Pittas J Clin Endocrinol Metab. 2007
Vitamin D and DMT2 risk
Highest to the lowest category of 25(OH)D levels
RR for DMT2 - 0.62 (95% CI 0.54–0.70)
YIQING SONG DIABETES CARE 2013
Prospective Placebo
Controlled Trial
Ca plus vitamin D vs. placebo
• 314 Caucasian adults
• 500 mg calcium citrate and 700 IU vitamin D or
placebo
• Participants with impaired fasting glucose at
baseline
• Lower rise of fasting plasma glucose
• Lower increase in insulin resistance
2007 Diabetes Care. Pittas AG
Recommended intake
• Vitamin D
• Aim at concentrations of 25-OHD>50 nmol/l
• >65 years 800 IU/d
• >65 years ~400 IU/d (lack of information)
Balvers MG J Nutr Sci. 2015
B12 and DM
• Up to 40% patients may have low levels
• Levels of B12 may be normal whereas
levels of the metabolite MMA are elevated
• It is presumed that B12 resistance is
present.
Solomon Blood Rev. 2007
Vischer DIABETIC Medicine 2010
Methylmalonyl-CoA Mutase
Pathway
~50% patients with
borderline B12 levels
have elevated MMA
J Am Board Fam Med. 2009
Vitamin B12 and Metformin
Recent meta-analysis
OR for B12 deficiency with Metformin 2.45
Niafar M Intern Emerg Med. 2015
Liu Q PLoS One. 2014
Metformin and B12
Intervention Study
patients 390
De Jager BMJ 2010
B12 recommendations
• B12 levels should be checked in every DM patient
when normal, - MMA levels
• When low B12 and high MMA levels -treatment
• Clinical and laboratory follow-up needed
Magnesium
• It is a co factor of > 300 cellular processes
• Related to:
– Activity of tyrosine kinase
– Metabolism of glucose
– Synthesis of tissue constituents
– Growth and thermogenesis
Tosiello Arch Intern Med 1996 Mooren Diabetes, Obesity and Metabolism 2015
Håglin Acta Diabetol. 2007 Nasri J Renal Inj Prev. 2014
Barragan-Rodríguez Arch Med Res. 2007 Rodríguez-Hernández Arch Med Res. 2005
Pham Clin Nephrol. 2005 Atabek Diabetes Res Clin Pract. 2006
Sales Clin. Nutr 2006
Hypomagnesemia
• Early atherosclerosis
~>20% diabetics low Mg- serum and/or intracellular
• DM retinopathy
Correlates with
A definitive cause-and-effect relationship between
• Renal dysfunction
magnesium
•Impairedstatus
fastingand glucose
glucose homeostasis
(IFG), remains
impaired glucose
5to be demonstrated
• Early neuropathy
tolerance (IGT) and metabolic syndrome
••Incidence ofsymptoms
Depressive type DMT2
• hyperlipidemia
•Complications of DMT2
• All cause mortality
Mooren Diabetes, Obesity and Metabolism 2015
Mg recommendations
• 25-40% of diabetics are Mg deficient
• Trial of Mg supplementation is
reasonable with laboratory and clinical
follow-up
Chaudhary et al Biol Trace Elem Res. 2010
Vitamin E
• Vitamin E treatment lowered HbA1C in
– Patients with HbA1C>8%
– Patients with vitamin E deff.
No routine treatment recommended
Consider treatment in patients belonging to categories above
Suksomboon Journal of Clinical Pharmacy and Therapeutics 2011
Thiamin and Chromium
• Involved with carbohydrate metabolism
• Deficiencies have been documented
• Supplement- clinical and laboratory follow-up
Thiamine
Thornalley Diabetologia 2007
Al-Attas OS J Endocrinol Invest. 2011
Altogether….
• The most frequent origin of micronutrient
deficiencies is an inadequate diet and
persons with diabetes should receive
appropriate nutritional counseling..”
Guerrero-Romero Arch Med Res. 2005
Take home messages
Micronutrient deficiencies are common in diabetic
patients specifically-
• Vitamin (25) D, Vitamin B12, Vitamin B1
(thiamine), Magnesium, Chromium, Vitamin E
• Deficiencies should be thought and treated-
sometimes a trial is recommended
