Diabetes and
Micronutrients
TERESA MARTIN RD, CDE, LD
[email protected]
Disclosures
I HAVE WORKED AS A DIABETES EDUCATOR FOR
NOVO NORDISK FOR THE LAST 5 YEARS
TODAY’S PRESENTATION IS BASED ON MY
PROFESSIONAL EXPERIENCE OVER THE LAST 22 YEARS
AND MY RECENT LITERATURE REVIEW ON THIS TOPIC
THANK YOU NOVO NORDISK FOR ALLOWING ME TO
UTILIZE THEIR MASSIVE SCIENTIFIC LIBRARY FOR MY
LITERATURE REVIEW OF THIS TOPIC
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
VITAMIN D
Why Study Vitamin D and DM?
-Vit D receptors (VDRs) are found in all insulinresponsive 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
-Observational studies show a greater incidence of
both T1D and T2D with increased latitude
Early Vitamin 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
-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 Supplement Studies and T1D
— 1966 Finland study- gave 2000IU vit D during the first 5
years of life 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 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 2013:
— 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 (? >40 or even >60)
— Most pts will need at least 600-2000IU per day
Vit D- What to do? (cont)
ADA Position Statement Nov 2013 :
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 vitamin D
-1 TBSP Cod liver oil=1360 IU
-3 ½ oz fatty, wild-caught fish have 500-1000 IU
-3 ½ oz 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 vitamin 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
Why study vitamin 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 Show:
— 30% of people taking metformin malabsorb Vit B12
— People with diabetes need more than the RDA for vit B12
to prevent a deficiency--especially if they are taking
metformin
— No studies show taking B12 improves glucose control
— However, correcting a vit B12 deficiency corrects all the
negative side effects of the deficiency- dementia,
weakness, confusion, fatigue, numbness/tingling in
hands/feet
Vit B12- What to do?
AACE/ACE Clinical Practice Guidelines 2013:
— 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 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 Statement Nov 2013:
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 longterm metformin
-Give all pts on metformin an annual 1000 mcg injection (which is
sufficient to cover B12 needs for one year)
Vegan RD suggests: 10 mcg/day of liquid vit B12 for all vegans
RDA for adults=2.4 mcg/day
Upper Limit: none defined
Top 10 foods rich in B12:
3 oz Shellfish=84 mcg
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
VITAMIN C
Why Study Vitamin 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
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)
Vitamin C- What to do?
AACE/ACE Clinical Practice Guidelines 2013:
Meet the RDA, no evidence to support supplementation
Better to get vit C from diet
ADA Position Statement Nov 2013:
It is NOT advised to supplement with Vit C because of lack of evidence
of 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
VITAMIN E
Why Study Vitamin E
Vit E is a powerful antioxidant
Diabetes causes increased oxidative stress
In the past, increased vit E intake was
associated with decreased CV risk
Vitamin 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 2013:
Do not supplement with vit E due to possible increase risk of
prostate cancer and all-cause mortality
ADA Position Statement 2013:
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=22 IU/day
TUL: 1000 mg/day=1500 IU/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 broccoli=2.3 mg
1 c cubed cooked squash (pumpkin/butternut)=2.6 mg
1 TBSP wheat germ= 20mg
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
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
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)
Couple double-blind randomly controlled studies
showed improved DM control with zinc supps in T2D
(30-50mg/d)
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 2013:
Zn not mentioned-yet not enough evidence to support mineral supplements
ADA Position Statement Nov 2013:
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
occurs more frequently in pts w T2D, especially those
with poor glycemic control
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 2013:
-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 rhythmsSevere magnesium deficiency can result in hypocalcemia or
hypokalemia
ADA Position Statement Nov 2013:
-Insufficient evidence to support routine use of Mg supps
to improve glycemic control in people w DM.
-Supplement only if deficient
Magnesium
RDA:
Adult female= 310 mg (19-30 yo); 320 mg (>30 yo)
Adult male=400 mg (19-30 yo); 420mg (>30 yo)
TUL of supplemental magnesium = 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 micronutrients in the media
SeleniumMedia Claims: “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
Neither ADA or AACE rec selenium supplements
*1 brazil nut provides RDA of selenium (70mcg)
Other micronutrients in the media
Chromium-
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
Other micronutrients in the media
Beta-carotene:
Media- “may prevent T2DM”— “can fight dementia”—
“prevents cancer”
ADA – does not advise supplementing with carotene
because of lack of evidence and concern related to longterm safety
Warning- do not use beta-carotene supp in smokers
Food Sources: everything orange- sweet potato, carrots,
butternut squash, cantelope, peppers, apricots, brocolli
Cinnamon
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
Chocolate
The media says….
— “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
Evidence shows..
—
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
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 summarywhat 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- liquid
form is best
— Get your serum B12 and vit D levels checked at least once
a year- if either level is low consider the following:
¡
¡
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 summarywhat 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
Use your local RDs
Eat a variety of unprocessed foods including fruits,
vegetables, nuts, seeds, fish, and beans
If you do not eat a diet rich in vit D and live in NW
consider 500-1000IU vitD3 daily to prevent
deficiency
If you do not eat a diet rich in Mg consider taking 1-2
slowmg supps per day to prevent deficiency
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
Difference in vocabulary …..
What we say…
What the media says…
— “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 metabolismboosting 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
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
Example: “The Triple T Powerhouse Plan”
Teresa’s Top Ten Powerhouse Plan (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 simple 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 nut each day