2/14/2014 Objectives Dia betes a nd Micronutrients Review most popular micronutrients being studied in adults living with diabetes Examine whether we have enough evidence to warrant supplementation TE R E S A M A R TI N R D , CD E , LD Review current nutritional recommendations related to micronutrients in the 2013 AACE/ ACE Clinical Practice 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 Guidelines and most current ADA position statement Discuss current media claims related to Diabetes and Micronutrients that your patients may have read/ heard Why talk about micronutrients and diabetes? Disclosures 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 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 Serum or tissue content of copper, manganese, iron and 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 selenium can be higher in people with DM than people w/ o DM 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 Serum vit C, B vits, and vit D are often lower in individuals with 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 DM where levels of vit A and E have been reported to be normal 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 or higher 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 In the field of diabetes, the m ost popular m icronutrients being studies today include: VITAMIN D Vitamin D Vitamin B12 Vitamin C Vitamin E Zinc Magnesium 1
2/14/2014 Why Study Vitam in D and DM? Early Vitam in D Studies -Rodents with DM that were given vit D had improved glucose levels -Vit D receptors (VDRs) are found in all insulin-responsive tissues as well as in pancreatic beta-cells -Many observational studies have linked vit D deficiency to an increased risk of T2DM -VDRs are found on many immune cells (? Link w/ T1D) -Epidemiological studies show correlations between low serum vit D -25(OH)D - concentrations and increased insulin resistance and impaired beta cell function –vit D plays a role in decreasing the inflammatory response- inflammatory pathways interferes with normal metabolism and -NHANES study showed an inverse correlation between serum 25(OH)D disrupts proper insulin signaling concentrations and the incidence of T2DM -Clear correlations have been observed between vit D deficiency and GDM and a -Vt D suppresses macrophage migration and appears to play a precursor to the development of T2DM role in atherogenic cholesterol metabolism -Vit D supplementation given early in early childhood has been found to decrease the incidence of T1D -Observational studies show a greater incidence of both T1D and T2D with increased latitude Vitam in D-Points to Ponder Vit D Supplem ent Studies and T1D - Serum vit D concentration is inversely correlated with body fat 1966 Finland study- gave 2000IU vit D during the first 5 content and BMI so… .is it the low vit D or the obesity increasing the years of live and had an 80% reduction in the risk of developing T2DM? development of T1D - Vit D deficiency and high serum levels of vit D also affects serum 1999 study (EURODIAB) repeated study and found 33% calcium levels and calcium is a critical ion in insulin secretion and action reduction in T1D Many current studies have found no correlation between - VDR knockout mice have completely normal glucose tolerance and early vit D supp and T1D- yet many studies may have beta cell function when calcium levels are kept normal used insufficient doses or too short of exposure - Will supplementing with Vit D lower the risk of developing DM? Most researcher today believe there is not enough evidence to rec’d mega doses of vit D in children or - Will Vit D supplements improve glucose homeostasis in people that have diabetes? adults Vit D Supplem ent Studies in T2D Vit D Supp Studies in T2D 499 pts with T2D being treated with diet, oral agents, insulin, or a In Korea, 158 people with T2D with A1c<8.5% and insulin+orals were given either 2000IU vit D3 per day or took a serum vit D level <20ng/ mL studied for 24 weeks placebo and were told to get more sun exposure (Alkharfy et al 2013) -Placebo= 100mg calcium bid -Treatment=1000IU vit D+ 100 mg calcium bid 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 Results levels than placebo - Significantly higher serum vid D levels in supp group -metformin group showed the highest increase in circulating vit D (15 vs 30) yet no difference in A1c levels (7.2 vs 7.4) -the insulin+oral group on Vit D benefited the most in improving cardiovascular risk (improved TG, BP, TC, HDL) 2
2/14/2014 Vit D Supp Studies in T2D Vit D- What to do? 100 pts with T2D were given 50,000 units of vit D3 for 8 weeks AACE/ ACE Clinical Practice Guidelines 20 13: (24% were vit D def at start of study) Check serum 25(OH)D in individuals at risk for vit D deficiency (elderly, malnourished, institutionalized, Significant Results those with osteopenia or osteoporosis) Mean serum 25(OH)D concentration increased to 43ng/ mL FPG dropped sig from 138 to 131 mg/ dl Supplement with Vit D3 to keep serum levels>30ng/ mL Insulin dropped 10.76 down to 8.6 uIu/ ml HOMA-IR levels dropped 3.57 to 2.89 Most pts will need at least 600-2000IU per day CONCLUSION: mega doses of vit D supplementation caused sig For pts with advanced renal failure- calcitriol should be reduction in insulin resistance in T2D within 8 weeks given to allow adequate intestinal absorption of calcium Vit D- What to do? (cont) Top 10 foods highest in vitam in D -1 TBSP Cod liver oil=1360 IU ADA Position Statem ent Nov 20 13 : -100 gms fatty, wild-caught fish have 500-1000 IU Do not take vit D supplement unless deficient; not enough evidence that vit D supp improve glycemic -100 gms fatty, farm raised= 100-250IU control; meet RDA -1 cup fortified milk/ soy milk=120IU -1 cup fortified cereals=170 IU Institute of Medicine (www.iom.edu ): -6 medium oysters= 320 IU RDA: -1 tsp caviar=37 IU 600IU from 1-70 yrs -1 oz salami/ ham=16 IU 800 IU >70 yrs -1 egg=17 IU -1 oz mushrooms=8 IU Tolerable Upper Limit (TUL): 2000 IU * 10 min direct, midday sunlight on legs/ arms of fair skinned, young individuals= ~10,000IU Why study vitam in B12 and DM? VITAMIN B12 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 3
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