VITAMIN D Vitamin D Vitamin B12 Vitamin C Vitamin E Zinc - - PDF document

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TE R E S A M A R TI N R D , CD E , LD

T E R E S A N U T R I T I O N @ B E N D B R O A D B A N D . CO M

Dia betes a nd Micronutrients

Objectives

 Review most popular micronutrients being studied in

adults living with diabetes

 Examine whether we have enough evidence to warrant

supplementation

 Review current nutritional recommendations related to

micronutrients in the 2013 AACE/ ACE Clinical Practice Guidelines and most current ADA position statement

 Discuss current media claims related to Diabetes and

Micronutrients that your patients may have read/ heard

I H A V E W O R K E D A S A D I A B E T E S E D U C AT O R F O R N O V O N O R D I S K F O R T H E L A S T 5 Y E A R S T O D AY ’ S P R E S E N TAT I O N I S B A S E D O N M Y P R O F E S S I O N A L E X P E R I E N C E O V E R T H E L A S T 2 2 Y E A R S A N D M Y R E C E N T L I T E R AT U R E R E V I E W O N T H I S T O P I C T H A N K Y O U N O V O N O R D I S K F O R A L L O W I N G M E T O U T I L I Z E T H E I R M A S S I V E S C I E N T I F I C L I B R A R Y F O R M Y L I T E R AT U R E R E V I E W O F T H I S T O P I C

Disclosures

Why talk about micronutrients and diabetes?

Micronutrients are involved in carb metabolism, glucose metabolism, insulin release and insulin sensitivity Trace-elements and water-soluble vitamin losses are increased during uncontrolled hyperglycemia and glycosuria Serum or tissue content of copper, manganese, iron and selenium can be higher in people with DM than people w/ o DM Serum vit C, B vits, and vit D are often lower in individuals with DM where levels of vit A and E have been reported to be normal

• r higher

In the field of diabetes, the m ost popular m icronutrients being studies today include: Vitamin D Vitamin B12 Vitamin C Vitamin E Zinc Magnesium

VITAMIN D

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Why Study Vitam in D and DM?

• Vit D receptors (VDRs) are found in all insulin-responsive

tissues as well as in pancreatic beta-cells

• VDRs are found on many immune cells (? Link w/ T1D)

–vit D plays a role in decreasing the inflammatory response- inflammatory pathways interferes with normal metabolism and disrupts proper insulin signaling

• Vt D suppresses macrophage migration and appears to play a

role in atherogenic cholesterol metabolism

• Observational studies show a greater incidence of both T1D and

T2D with increased latitude

Early Vitam in D Studies

• Rodents with DM that were given vit D had improved glucose levels
• Many observational studies have linked vit D deficiency to an increased risk of

T2DM

• Epidemiological studies show correlations between low serum vit D -25(OH)D -

concentrations and increased insulin resistance and impaired beta cell function

• NHANES study showed an inverse correlation between serum 25(OH)D

concentrations and the incidence of T2DM

• Clear correlations have been observed between vit D deficiency and GDM and a

precursor to the development of T2DM

• Vit D supplementation given early in early childhood has been found to decrease

the incidence of T1D

Vitam in D-Points to Ponder

• Serum vit D concentration is inversely correlated with body fat

content and BMI so… .is it the low vit D or the obesity increasing the risk of developing T2DM?

• Vit D deficiency and high serum levels of vit D also affects serum

calcium levels and calcium is a critical ion in insulin secretion and action

• VDR knockout mice have completely normal glucose tolerance and

beta cell function when calcium levels are kept normal

• Will supplementing with Vit D lower the risk of developing DM?
• Will Vit D supplements improve glucose homeostasis in people that

have diabetes?

Vit D Supplem ent Studies and T1D

 1966 Finland study- gave 2000IU vit D during the first 5

years of live and had an 80% reduction in the development of T1D

 1999 study (EURODIAB) repeated study and found 33%

reduction in T1D

 Many current studies have found no correlation between

early vit D supp and T1D- yet many studies may have used insufficient doses or too short of exposure

 Most researcher today believe there is not enough

evidence to rec’d mega doses of vit D in children or adults

Vit D Supplem ent Studies in T2D

499 pts with T2D being treated with diet, oral agents, insulin, or a insulin+orals were given either 2000IU vit D3 per day or took a placebo and were told to get more sun exposure (Alkharfy et al

2013)

RESULTS:

• no change in weight or glucose levels was observed in any group
• all groups taking vit D supps had higher circulating serum vit D

levels than placebo

• metformin group showed the highest increase in circulating vit D
• the insulin+oral group on Vit D benefited the most in improving

cardiovascular risk (improved TG, BP, TC, HDL)

Vit D Supp Studies in T2D

In Korea, 158 people with T2D with A1c<8.5% and serum vit D level <20ng/ mL studied for 24 weeks

• Placebo= 100mg calcium bid
• Treatment=1000IU vit D+ 100 mg calcium bid

Results

• Significantly higher serum vid D levels in supp group

(15 vs 30) yet no difference in A1c levels (7.2 vs 7.4)

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Vit D Supp Studies in T2D

100 pts with T2D were given 50,000 units of vit D3 for 8 weeks (24% were vit D def at start of study) Significant Results

 Mean serum 25(OH)D concentration increased to 43ng/ mL  FPG dropped sig from 138 to 131 mg/ dl  Insulin dropped 10.76 down to 8.6 uIu/ ml  HOMA-IR levels dropped 3.57 to 2.89

CONCLUSION: mega doses of vit D supplementation caused sig reduction in insulin resistance in T2D within 8 weeks

Vit D- What to do?

AACE/ ACE Clinical Practice Guidelines 20 13:

 Check serum 25(OH)D in individuals at risk for vit D

deficiency (elderly, malnourished, institutionalized, those with osteopenia or osteoporosis)

 Supplement with Vit D3 to keep serum levels>30ng/ mL  Most pts will need at least 600-2000IU per day  For pts with advanced renal failure- calcitriol should be

given to allow adequate intestinal absorption of calcium

Vit D- What to do? (cont)

ADA Position Statem ent Nov 20 13 : Do not take vit D supplement unless deficient; not enough evidence that vit D supp improve glycemic control; meet RDA Institute of Medicine (www.iom.edu ): RDA:

 600IU from 1-70 yrs  800 IU >70 yrs

Tolerable Upper Limit (TUL): 2000 IU

Top 10 foods highest in vitam in D

• 1 TBSP Cod liver oil=1360 IU
• 100 gms fatty, wild-caught fish have 500-1000 IU
• 100 gms fatty, farm raised= 100-250IU
• 1 cup fortified milk/ soy milk=120IU
• 1 cup fortified cereals=170 IU
• 6 medium oysters= 320 IU
• 1 tsp caviar=37 IU
• 1 oz salami/ ham=16 IU
• 1 egg=17 IU
• 1 oz mushrooms=8 IU

*10 min direct, midday sunlight on legs/ arms of fair skinned, young

individuals= ~10,000IU

VITAMIN B12

Why study vitam in B12 and DM?

 Low serum B12 and Folate levels have been linked to

increased oxidative stress markers in people living with DM

 People living with diabetes that have low levels of

B12 are more likely to have peripheral neuropathy compared to people with DM that do not have low levels of B12

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Why study vitam in B12 and DM? (cont)

 It’s been reported that ~20 % of adults >60 yrs

malabsorb vitamin B12 (34 million Americans >65 yrs have pre-diabetes)

 Vit B12 deficiency is high prevalent among patients with

T1 and T2D

 Vit B12 deficiency causes megaloblastic anemia, fatigue,

weakness, constipation, confusion, depression, poor balance, dementia, poor memory, numbness and tingling in hands/ feet- if not treated, it can cause permanent nerve damage

Vit B12 Studies

6867 people >50 yo living with or without T2D either on metformin or not, either taking supplements or not Results:

 B12 deficiency was observed in 5.8% of people w/ T2D on

metformin vs 2.4% not on metformin vs 3.3% without DM

 Consumption of a supplement containing B12 was not

associated with a reduction in vit B12 def in people with DM yet was associated with a reduction in people without DM Conclusion: Might need more than IOM RDA of 2.4ug/ day for people living with DM and even more for those taking metformin

Vit B12 Studies

Bell, D et al studied Metformin and B12 deficiency and reported (2010)

 30% of patients on metformin malabsorb vit B12  Vit B12 deficiency can present as reversible megaloblastic anemia or

non-reversible central and/ or peripheral neuronal lesions

 With an absolute vitamin B12 deficiency, it takes twelve to fifteen

years to totally deplete pre-existing vitamin B12 stores

 Since metformin has been available for fifteen years in the United

States, we may be approaching an epidemic of metformin-induced vitamin B12 deficiency

 Suggest the cause of B12 malabsorption is caused by the effect

metformin has on calcium-dependent membrane action in the terminal ileum

Vit B12- What to do?

AACE/ ACE Clinical Practice Guidelines 20 13:

 Rec at least 10-15 mcg per day for individuals >50 yrs old  Check B12 levels annually for anyone that is >60 yo, anyone

taking metformin, or has any s/ s of deficiency

 If pt has s/ s of deficiency yet B12 is within range (yet at low

end), measure methyl malonic acid (can confirm B12 deficiency if mma is high)

 If B12 deficient- treat pts with 1000 mcg/ d oral vit B12

(crystal cobalamin) and encourage pts to each a diet rich in vit B12 (turkey, eggs, liver, corned beef)

Vit B12- What to do? (cont)

ADA Position Statem ent Nov 20 13: Does not mention B12 yet states there is no clear evidence of any benefit from vit/ min supplementation in people living with DM who do not have an underlying deficiency Bell, D et al suggest-

• Check annual serum B12 levels in all pts who have been on long-term

metformin

• Give all pts on metformin an annual 1000 mcg injection (which is

sufficient to cover B12 needs for one year)

• Consider giving 1.2 grams of calcium carbonate daily which may correct

the loose stools associate with metformin and improve B12 absorption

RDA for adults=2.4 mcg/ day Upper Lim it: none defined

Top 10 foods rich in B12:

3 oz Shellfish=84 umg 3 oz Liver= 70.7 mcg 3 oz Mackerel= 16.2 mcg 3 oz fortified tofu= 2 mcg 1 cup fortified cereal=18 mcg 3 oz beef= 5.1 mcg 1 cup low fat milk= 1.2 mcg 1 oz cheese (swiss)= 1 mcg 1 egg yolk= 0.3 mcg

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VITAMIN C

Why Study Vitam in C and DM?

Vit C has the same transport mechanism as that of glucose in the body People with DM tend to have lower blood levels of vit C than those w/ o DM Some believe low serum vit C levels contribute to the depressed immune function, compromised wound healing ability and reduced blood vessel integrity seen in DM Chronic low-grade inflammation resulting from oxidative stress has been associated with insulin resistance Antioxidants may reduce the level of protein glycation and DNA damage caused by hyperglycemia Vit C is an antioxidant and has been found to play a role in both iron absorption wound healing

Vit C and DM studies

2,000 postmenopausal women w DM studied for 15 yrs and found those that took more than 300mg vit C/ d were twice as likely to die of heart disease or stroke compared to those that took no vit C supp Physicians’ Health Study II- (>50 yo men) randomized study, given 500mg vit C and 400IU Vit E for 8 yrs; found no effect on the prevention of major CV events and vit E was associated with increased risk of hemorrhagic stroke 2010 meta-analysis found no association between Vit C supps or plasma levels of vit C and diabetic retinopathy (Lee 2010)

Vit C and DM studies (cont)

Franke, S et al (2013) found that low dose vit C supp (250 mg/ d) improved cell survival by reducing cytotoxicity yet did not change A1c, FBG, DNA damage in adults w/ T2D Gutierrez et al (2013) found that vit C supplements lead to increased serum vit C levels yet serum vit C levels did not change glucose, insulin, TG or have any impact on lipid parameters,

• xidative stress, inflammation or hypercoagulability following a

large meal in adults w/ T2D Mazloom et al A(2013) evaluated the effect of 1000 mg vit C/ day x 6 wks on fasting, postprandial oxidative stress and lipid profile in T2D living in Iran and found a sig decrease in fasting and pp

• xidative stress yet no change on lipid profile

Vitam in C- What to do?

AACE/ ACE Clinical Practice Guidelines 20 13: Meet the RDA, no evidence to support supplementation Better to get vit C from diet ADA Position Statem ent Nov 20 13: It is NOT advised to supplement with Vit C because of lack of evidence

• f efficacy and concern related to long-term safety

Caution: high doses can cause renal stones, GI upset RDA: 75 mg/ day for women 90 mg/ day for men TUL=2000 mg/ day

Top 10 foods highest in vit C

1 c guava= 377 mg 1 whole pepper= 132 mg (green)- 340 mg (yellow) ½ c chopped chili peppers= 108mg (red)- 181 mg (green) 1 c raw kale= 80 mg 1 c raw broccoli=81 mg (1 c raw cauliflower= 46 mg) 1 Kiwi =85 mg 1 c cubed Papayas= 87 mg 1 orange= 85 mg 1 c sliced strawberries=98mg 1 tbsp fresh chopped parsley= 78 mg

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VITAMIN E

Vitam in E Studies

39,876 women >44 yrs old participated in a randomized trial for 10 yrs; given 600IU vit E or placebo; found no overall benefit major CV events

(Lee 2005)

SELECT- trial studied vit E and selenium was stopped early because they found an increase risk in prostate cancer and diabetes in the supplemented group (Lippman

2005)

Meta-analysis of vit E trials reported mild increase in all-cause mortality with vit E use (Miller 2005)

Vit E- What to do?

AACE/ ACE Clinical Practice Guidelines 20 13: Do not supplement with vit E due to possible increase risk of prostate cancer and all-cause mortality ADA Position Statem ent 20 13: It is NOT advised to supp with Vit E Caution- may increase risk for cancer and possible bleed RDA: Adult men and women=15 mg/ day TUL: 1000 mg/ day

Top 10 foods highest in vit E

3 oz firm tofu=4.4 mg 1 cup cooked spinach=3.7 mg 1 oz almonds= 7.3 mg 1 oz sunflower seeds= 10.2 mg ½ c cubed avocado=1.5 mg 3 oz shrimp= 1.9 mg 3 oz fish (trout/ swordfish)=2.4 mg 1 tbsp olive oil= 2 mg 1 c chopped cooked brocolli=2.3 mg 1 c cubed cooked squash (pumpkin/ butternut)=2.6 mg

ZINC

Why Study Zinc and DM?

Zinc plays a role in the regulation of amylin; in zinc starved cells, amylin is unregulated and can clump together and shut down beta cells function Zinc has been found to possibly reduce the risk of getting the common cold and severity of the cold sx Evidence from animal studies suggest that zinc deficiency may lead to glucose intolerance There is increasing evidence that the metabolism of zinc is altered in T1D A few studies have found increase prevalence of CAD, DM and glucose intolerance with lower zinc intake or low serum zinc levels

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Studies on Zinc and DM

Nurses’ Health Study (2009): Higher zinc intake may be associated with a slightly lower risk of Type 2 diabetes in women (correlational) Double-blind, randomized study- 56 obese women, no DM, given 30 mg zinc for 4 weeks found sig decrease in insulin resistance (Marreiro 2002) Two, double-blind randomly controlled studies showed improved DM control with zinc supps in T2D:

 30 mg zinc supplements x 3 months sig decreased A1c

(Hussain 2006)

 50 mg zinc x 3 months sig improved the impaired FG (Al-

Maroof 2006)

Studies on Zinc and DM (cont)

Other studies show conflicting results:

 50 mg zinc x 4 weeks only improved glucose control

in T2D w A1c>7.4 (Oh 2008)

 No sig change on glucose levels or A1c:

 20 mg zinc x 7.5 yrs (Czernichow 2006)  30 mg zinc x 6 mos (Roussel 2003)  30 mg zinc x 6 mos (Anderson 2001)

One study showed increased A1c for those people taking 50 mg Zn x 28 days (Cunningham 1994)

Zinc- what to do?

AACE/ ACE Clinical Practice Guidelines 20 13: Zn not mentioned-yet not enough evidence to support mineral supplements ADA Position Statem ent Nov 20 13: Does not mention Zn yet states there is insufficient evidence to support the routine use of micronutrients to improve glycemic control in people living with DM JDRF- not enough human studies to rec zinc supplementation RDA: Adult women=8 mg/ day Adult men=11 mg/ day TUL: 40 mg/ d

Top 10 foods highest in Zinc

Seafood-3 oz cooked oysters=67 mg Beef & Lamb-3 oz cooked= 11 mg ¼ c toasted wheat germ= 4.7 mg 3 oz pork/ chicken= 4.3 mg ½ c cashews= 3.9 mg ½ c pumpkin seeds=3.3 mg 1 c cooked spinach= 1.4 mg 1 c raw mushrooms= 1.4 mg ½ c beans= 0.9 mg 2 tbsp cocoa powder=0.6 mg

MAGNESIUM

Why Study Magnesium & DM?

 Magnesium is a cofactor of various enzymes in

carbohydrate oxidation

 Mg plays an important role in glucose transporting

mechanism of the cell membrane

 Mg is involved in insulin secretion, binding and

activity

 Nurses Health Study showed an association between

greater Mg intake and lower incidence of T2D

 Observational studies have shown hypomagnesemia

• ccurs more frequently in pts w T2D, especially those

with poor glycemic control

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Studies with Mg and DM

4 clinic trials suggest that oral Mg supps may improve insulin sensitivity and glucose control in people with DM that have a Mg deficiency

 15 mmol Mg aspartate hydrochloride x 6mos  20.7 mmol MgO or 41.4 mmol MgO x 30 days  15 mmol Mg x 4-16 weeks  50 ml MgCl2 x 16 weeks

2 clinic trials showed no effect on glycemic control

 15 mmols Mg x 3 months  360 mg x 8 weeks (11 subjects)

Mg- What to do?

Studies are promising but… AACE/ ACE Clinical Practice Guidelines 20 13:

• no specific recs for Mg
• meet needs though food; supp prn if deficient
• s/ s of deficiency: loss of appetite, nausea, vomiting, fatigue, weakness, numbness, tingling, muscle

cramps, seizures, personality changes, abnormal heart rhythms-Severe magnesium deficiency can result in hypocalcemia or hypokalemia ADA Position Statem ent Nov 20 13:

• Insufficient evidence to support routine use of Mg supps to improve glycemic control in people w

DM.

• Supplement only if deficient

RDA: Adult female= 310 mg (19-30 yo); 320 mg (>30 yo) Adult male=400 mg (19-30 yo); 420mg (>30 yo) TUL of supplem ental m agnesium = 350 mg/ day *high doses of magnesium supplements/ medications often result in diarrhea that can be accompanied by nausea and abdominal cramping

Top 10 foods highest in Mg

 1 c cooked spinach=156 mg  Nuts and Seeds:

 1 oz almonds= 80 mg  1 oz cashews= 74 mg  2 tbsp peanut butter=49 mg

 1 c soy milk=61 mg  1 c beans and lentils (soy beans)= 148 mg  3 oz fish (Mackerel)= 82 mg  1 baked potato w skin (3.5 oz)=43 mg  1 c brown rice=86 mg  1 c plain, low fat yogurt=47 mg  1 med banana= 32 mg  ½ avocado= 29 mg

WHAT ELSE?

Other m icronutrients in the m edia

Selenium-

 Media Claim s: “improves immune system” -- “protects

against bacteria/ viral infections” -- “can treat prostate cancer”-- “heals burns”-- “alleviates dandruff” -- “increases HDL” –”prevents cognitive decline” (Newsmax) Not enough evidence to support these claims

• ? high doses may increase risk of prostate cancer
• Some evidence that selenium may decrease risk of GI cancer

and skin cancer

• Neither ADA or AACE rec selenium supplements
• 1 brazil nut provides RDA of selenium

Other m icronutrients in the m edia

Chrom ium -

Media Claims- “promotes muscle growth and fat loss” --“prevents diabetes” -- “decreases insulin resistance”--Reader’s Digest says “take 200 mcg/ day to help normalize your blood sugar and enhance the action of insulin” No evidence to support these claims

• Meta-analysis showed chromium supp had no effect on glucose or insulin

concentrations in subjects without diabetes nor did it reduce these levels in subjects with diabetes

• one study showed improved glucose tolerance if chromium def pts with DM

took 200-1000 mcg/ day

• ADA says there is insufficient evidence to support the use of chromium

supplement

• Chromium is found in whole grains, broccoli, garlic, beef, turkey, red wine
• can meet RDA (25-35 mcg/ d) with 1.5 c broccoli or 10 oz red wine

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Other m icronutrients in the m edia

Beta-carotene: Media- “may prevent T2DM”—“can fight dementia”— “prevents cancer” ADA – does not advise supplementing with caotene because of lack of evidence and concern related to long-term safety Warning- do not use beta-carotene supp in smokers

Cinnam on

Media Claims in 2013- “boosts female fertility”; “reduces diabetics’ sugar levels”; “reduces inflammation” “averts Alzheimer's Disease” ADA- after reviewing the literature concluded there is insufficient evidence to support the use of cinnamon for the treatment of diabetes Warning:

• cinn oil contains coumarin- blood thinner
• Can worsen heartburn
• May cause increase LFTs
• cinn challenge- has been linked to collapsed lung, scared lungs

The m edia says…. The m edia says…. Evidence shows.. Evidence shows..

 “Drinking Choc Tea can curb

sugar cravings and help with wt loss”~ Dr Oz

 “Chocolate may help keep

brain healthy” ~Press release from AAN

 “Eat chocolate, lose weight”

~Fox News Magazine in 2012

 Dark Choc is good for your

heart~ Dr Oz, Dr Weiles



Consuming 200 mg of flavanols from chocolate has been shown to improve blood flow



Several studies show that the more chocolate people eat, the more weight they gain



There is promising, yet not conclusive, evidence that flavanols can lower blood pressure and improve brain function

Chocolate 200 mg of flavanols from Chocolate=

 1 ¾ TBSP Cocoa Powder=20 kcals  ½ oz Baking Chocolate= 70 kcals  1 ½ oz semi-sweet chips= 200 kcals  2 oz dark chocolate bar= 320 kcals  1 cup of chocolate syrup= 840 kcals  10 ½ oz of milk chocolate=1,580 kcals  FYI- cocoa that is processed with alkali or “Dutch-

processed” contains almost no flavanols

In summary- what can you tell your patients with diabetes?

 If you are taking metformin, over 60 yo, or a vegan

consider taking daily vit B12 supp: 10-15mcg/ day

 Get your serum B12 and vit D levels checked at least once

a year- if either level is low talk to your doctor about taking a supplement

 1000 mcg/ d vit B12 orally or via annual injection  600-2000 IU/ d vit D  Dose depends on severity of deficiency

 Avoid mega doses of all supplements (except vit D, B12

as prescribed to correct deficiency)

In summary- what can you tell your patients with diabetes? (cont)

 Stop taking daily supplementation of vit C, vit E, beta

carotene to avoid possible risky side effects

 Save your money and skip the cinnamon, chromium,

and selenium supplements

 ADA and AACE/ ACE recommends that individuals

• ptimize food choices in meal plans to meet RDA

and DRI intakes for all micronutrients

 Use your local RDs  Eat a variety of unprocessed foods including fruits,

vegetables, nuts, seeds, and beans

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Why do our patients believe the unbelievable yet not believe the believable?

The brain reacts to novelty by releasing dopamine which makes us want to go exploring in search of a reward “Eat your fruits and veg and move more” is not novel therefore, it is not worth much attention- no dopamine AADE/ ADA Accredited Programs say…

 Our experienced team of certified diabetes educators will provide you

with all the information you need to take control of this serious disease.

 Learn about carbohydrate counting to help with your diabetes

management

 Most insurance providers, cover the cost of diabetes education yet a

referral from your physician may be necessary. Our core classes will cover :

 Diabetes Overview  Nutrition Basics  Meal Planning  Preventing Complications  Follow-up

What the m edia says… What the m edia says… What we say… What we say…



“its never been easier”--‘its quick”  “Remove fat promoting toxins”  “DETOX your system”  “Recharges your metabolism”  “Powerful Antioxidants”  “Safe Blood Sugar Support”  ‘All-In-One” supplement  “Supernutrients”  “Chocolate tea has metabolism- boosting properties “  “curb your sweet tooth”(Dr Oz)  Better Health, Made Simple (supplement ad)  we will show you how to “Outsmart Diabetes”



It wont be simple, but it will be worth it



It will be a slow process- nothing happens overnight



It is not easy, but it is possible



You will be the one making the choices everyday… we are here to help you learn more about your choices so you can have more control over this disease



White foods and sugar can fit in to a healthy diet



Limit processed foods and liquid kcals



Move every day



Move more

Difference in vocabulary ….. I challenge each of you….

• 1. Pick the top 5 things that you learned at this conference

that you are most excited to share with your pts

• 2. Then, transform this information into dopamine

releasing recommendations

• 3. Use your MI skills to share this dopamine-releasing

suggestion at the most appropriate time

• 4. Share your success with other CDE’s

Example: “The Triple T Powerhouse Plan”

Teresa ’s Top Ten Pow erhouse Pla n (TTT-PP) Try this powerhouse meal plan to help maximize your body’s energy potential – give your body what it needs and you will be amazed with the results!!!! Follow these sim ple energizing steps: Sleep at least 6 hrs/ night Drink at least 4-6 cups of water per day Pick 1-2 foods from the top ten food lists every day (that’s 6-12 amazingly healthy food choices/ day!!) For every 30 min of sitting, move for 2 min And for an added bonus… . Eat 1 dark chocolate covered brazil nuts each day