Karen Chapman-Novakofski, RD, LDN, PhD
© 2006 Wolf Rinke Associates, Inc. All rights reserved for this self-directed
learning program. Reproduction in whole or part without written permission from
the publisher is prohibited.
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CUSTOMER COMMENTS
Karen Coles: "The case studies were helpful, kept my interest and applied knowledge."
Amelia Murphy Bell: "Course was practically oriented. Course was peer
reviewed."
OVERVIEW AND INSTRUCTIONS
Obesity and diabetes are both increasing in the U.S. population. Obesity is
a strong predictor of type 2 diabetes, although everyone who is obese does not
have diabetes. Genetics, environment and adipose tissue distribution also are
determinants of diabetes development (Dagogo-Jack, 2003).
Nutrition therapy has been shown to have a statistically significant impact
on weight loss and metabolic control in persons with diabetes (Brown et al.,
1996). Effective nutrition therapy requires careful meal planning and food selection
(American Diabetes Association, 2002). However, research has shown that people
with diabetes have limited knowledge of how to apply nutrition information to
their individualized meal plans (Miller et al., 1997). Many patients have reported
that completing self-management tasks is even more stressful than the diagnosis
alone (Anderson et al., 1995). Patients with diabetes have also indicated that
adherence to diet is the largest problem in self-care (Peterson and Lowry, 1992).
The goal of this educational program is to provide the nutrition professional
with an understanding of the pathology of these conditions, and develop competency
in designing strategies to prevent or treat obesity and type 2 diabetes.
Chapter 1 describes the normal physiology of tissues and systems involved in
the non-obese, non-diabetic person as well as how these tissues and secretions
change with developing obesity and insulin resistance. In Chapter 2, the theories
of how obesity is involved in the development of type 2 diabetes are explained.
The pathophysiology and diagnosis of pre-diabetes, type 2 diabetes, and obesity
are included in Chapter 3.
Medical Nutrition Therapy for type 2 diabetes and its application to obesity
are the focus of Chapter 4. Modifications of fat, protein, and carbohydrate
are described as well as the recommended distribution of the macronutrients.
Information about sugar substitutes, fiber, and the glycemic index are also
included.
Exercise and physical activity are important considerations in both type 2 diabetes
and obesity. The role of aerobic and strength training in these conditions is
explored in Chapter 5. Equally important is knowledge of medications used to
treat diabetes and obesity, which are included in Chapter 6. Clinical implications
are highlighted in each chapter. A case study integrates the information from
these six chapters and provides examples of diagnosis and treatment. Also included
is a listing of additional sources for your continued learning as well as organizations
that are resources for additional information or updates.
This self-directed learning program is a Category II Continuing Professional
Education (CPE) program approved for 10 Continuing Professional Education Units
(CPEUs), meaning that the reader has general knowledge of the literature and
professional practice within the area covered. The focus of the program is to
enhance knowledge and application.
To get the most benefit from this program, I suggest that you follow these four
steps:
Step 1: Review the objectives for the program.
Step 2: Study each chapter. As you read, think of patients or clients from your
own practice who fit the situation described.
Step 3: Assess what you have learned by completing the self-assessment instrument
at the end of this program.
Step 4: Compare your answers to the answer key that has been provided. If you
score at least 80 percent correct, you are ready to transfer your answers to
the CONTINUING PROFESSIONAL EDUCATION (CPE) REPORTING FORM. If you scored less
than 80 percent correct, re-read this learning program until you score at least
80 percent correct.
After you have successfully completed this program, mail or fax the completed
CPE REPORTING FORM to:
Wolf Rinke Associates, Inc. P.O. Box 350 Clarksville, MD 21029 Fax: (410) 531-9282
Happy Learning!
Karen Chapman-Novakofski, RD, LDN, PhD
OBJECTIVES
Upon completion of this accredited, self-directed learning program, the nutrition
professional should be able to:
CHAPTER 1. NORMAL PHYSIOLOGY 1
Adipocytes 1
Adipose Tissue 1
Adipose Tissue Distribution 2
Endocrine Function 3
Pancreas 4
Insulin 4
Glucagon 7
Somatostatin 7
Pituitary gland 7
Growth hormone 8
Adrenal glands 8
Cortisol 8
Epinephrine and norepinephrine 9
Stomach and gastrointestinal tract 9
Ghrelin 9
Peptide YY3-36 10
Adipose tissue 10
Leptin 10
Adiponectin 12
Resistin 12
Cytokines 12
Protease inhibitors 13
Clinical Implications 13
CHAPTER 2. OBESITY'S ROLE IN TYPE 2 DIABETES 15
Genetic Studies 15
Portal/Visceral Fat Hypothesis 17
Ectopic Fat Storage Hypothesis 17
Adipose Tissue As Endocrine Organ Hypothesis 18
Clinical Implications 18
CHAPTER 3. PATHOPHYSIOLOGY, CLASSIFICATIONS, DIAGNOSIS
AND SYMPTOMS 21
Pre-Diabetes 21
Type 2 Diabetes 22
Obesity 23
Body mass index 23
Waist circumference 23
Skinfold thicknesses 25
Measurements of body fat for research rather
than clinical applications 25
Bioelectrical impedance analysis 25
Dual energy x-ray absorptiometry 26
Computed tomography 26
Magnetic resonance imaging 26
Clinical implications 27
CHAPTER 4. DIET AND THE TREATMENT OF TYPE 2 DIABETES AND OBESITY 29
Modification of Fat 29
Total fat 29
Saturated fat 30
Unsaturated fat 30
Omega-three fatty acids 31
Trans fatty acids 33
Modification of Protein 33
Modification of Carbohydrate 34
Total carbohydrates 34
Fructose 34
Whole grains and fiber 35
Glycemic response 36
Low calorie nutritive and nonnutritive sweeteners 37
Modification of Calories 40
Distribution of Macronutrients 41
Meal Planning Tools 42
The plate method 43
Food Guide Pyramid (MyPyramid) 43
Pre-planned menus 44
The exchange system 45
Carbohydrate counting 46
Clinical Implications 49
CHAPTER 5. PHYSICAL ACTIVITY AND THE TREATMENT OF TYPE 2 DIABETES AND OBESITY
51
Aerobic Activity 52
Resistance Training or Strength Training 53
Recommendations 54
Clinical Implications 56
CHAPTER 6. MEDICATIONS AND THE TREATMENT OF TYPE 2
DIABETES AND OBESITY 57
Oral Medications for Treatment of Diabetes 57
Sulfonylureas 57
Meglitinides 58
Biguanides 59
Thiazolidinediones 60
Alpha-glucosidase inhibitors 61
Oral Medications for Treatment of Obesity 61
Insulin 63
Clinical Implications 64
CASE STUDY 1 65
CASE STUDY 2 71
CASE STUDY 3 77
REFERENCES 81
FOR YOUR CONTINUING LEARNING 89
LIST OF ABBREVIATIONS 91
GLOSSARY 93
RESOURCES 97
SELF-ASSESSMENT QUESTIONS 101
ANSWER KEY 111
EXPLANATION OF ANSWERS TO SELF-ASSESSMENT QUESTIONS 113
ABOUT THE AUTHOR 119
ABOUT WOLF RINKE ASSOCIATES, INC. 120
ABOUT THE AUTHOR
Dr. Chapman-Novakofski earned her bachelor's degree from the University of
Illinois at Urbana-Champaign (UIUC), her Master's degree from Eastern Illinois
University, and her doctorate from UIUC. She completed her dietetic internship
at the University of Alabama in Birmingham, was a dietitian at the VA Medical
Center in Danville, Illinois for 11 years, has been at UIUC in the College of
Medicine since 1983 and in the Department of Food Science and Human Nutrition
and Division of Nutritional Sciences since 1991.
As an Associate Professor, Dr. Chapman-Novakofski has over 100 abstracts, proceedings,
and journal publications, most addressing some aspect of geriatric nutrition.
In addition to healthy aging, her research and publications address diabetes
and nutrition education strategies for this age group. She has written the newsletter
Diabetes Lifelines since 2000, which is posted and archived on the website http://www.urbanext.uiuc.edu/diabetes/index.html
in English and Spanish. In 2004, Dr. Chapman-Novakofski was honored with two
awards: the Mid-Career Award in Nutrition Education from the Society for Nutrition
Education and the Innovative or Outstanding Team Program from Illinois Extension
for their community-based diabetes education program.