Diabetes Management through Nutrition

 

Diabetes Management through Nutrition

•           Prevalence

•           Increases with age

•           Gender Difference

•           Racial, Ethnic – Disproportionate prevalence among African Americans, Hispanic Americans and American Indian

 

Increase in Overall Prevalence

•           Increasing Age of US population

•           Reduction in Mortality Rate

•           Increase in Risk Factors such as

–      Obesity

–      Physical Inactivity

 

Mortality Risk

•           Duration of Diabetes

•           Lack of Blood Glucose Control

•           Cardiovascular Risk Factors such as

–      Smoking

–      Hypertension

–      Abnormal Lipid Levels

–      Physical Inactivity

–      Central Obesity

 

Causes of Death Among People With Diabetes

Cause	% of Deaths
Ischemic heart disease	40
Other heart disease	15
Diabetes (acute complications)	13
Cancer	13
Cerebrovascular disease	10
Pneumonia/influenza	4
All other causes	5

Geiss LS et al. In: Diabetes in America. 2nd ed. 1995:233-257

 

 

Pathophysiology

•           Genes

•           Obesity

•           Sedentary Lifestyle

•           Aging

 

Classification

•           Diabetes Mellitus and Other Categories of Glucose Intolerance

–      DM (with four subclasses)

–      Impaired Glucose Tolerance

–      Gestational DM

 

Four Types of DM

•           Type I DM (Insulin Dependent)

•           Type II DM (Non-Insulin Dependent)

•           Secondary/other types of diabetes associated with certain conditions

•           Malnutrition related DM

 

Type I DM

•           Presence of ketosis

•           Almost complete lack of insulin or severe lack of

•           Autoimmune Cause

•           Patients commonly lean

 

 

 

 

 

Type II DM

•           Most Common

•           Strong Genetic Basis

•           Absence of Ketosis

•           Inadequate Insulin Secretion

•           Obesity a strong factor

 

Secondary/Other Type

•           Related to certain diseases, conditions or drugs

•           Known or probable cause

•           Treatment of underlying disorder may ameliorate the diabetes

•           Hyperglycemia present at level diagnostic of diabetes

 

Malnutrition Related Diabetes Mellitus

•           Mostly in developing countries

•           Among 10 to 40 year olds

•           Hyperglycemia present without ketoacidosis

•           Role of malnutrition as a causal factor is unknown.

 

 

 

 

Impaired Glucose Tolerance

•           Higher than normal plasma glucose but lower than the diagnostic values for DM

•           Precursor for Type II

•           Only about 25% develop into type II and rest go back to normal

•           Patients are more susceptible to macrovascular diseases. 

 

Gestational DM

•           2-4% during second or third trimester

•           Onset of DM with pregnancy

•           More common in older women with family history of dm

•           Higher chance of developing NIDDM

 

Types of DM

characteristic	Type 1 DM	Type 2 DM
Age of onset	Childhood or adolescence	Age 40 or older
Rapid of onset	Usually abrupt	Usually gradual
Family history	Usually no	Common
Etiology	Unknown-heredity-autoimmune/viral infections	Unknown-heredity
Body weight	Usually thin	Obesity Common
Endogenous Insulin	Very little to none	Normal /high or low
Ketosis	Common	Un Common
Symptoms	Polyuria/dipsia/phagia and body loss	Polyuria/dipsia or none

 

 

Diagnosis of Diabetes

•            Polydipsia – Increased thirst

•            Polyuria – Increased frequency of urination

•            Fatigue

•            Polyphagia – Increased Fatigue

•            Weight Loss

•            Abnormal Healing

•            Blurred Vision

•            Increased occurrence of infections

 

 

 

Diagnostic Criteria

 

Result	Fasting Plasma Glucose (FPG)
Normal	less than 100 mg/dl
Prediabetes	100 mg/dl to 125 mg/dl
Diabetes	126 mg/dl or higher
Result	Oral Glucose Tolerance Test (OGTT)
Normal	less than 140 mg/dl
Prediabetes	140 to 199 mg/dl
Diabetes	200 mg/dl or higher

 

 

 

 

Random (also called Casual) Plasma Glucose Test

This test is a blood check at any time of the day when you have severe diabetes symptoms.

• Diabetes is diagnosed at blood glucose of greater than or equal to 200 mg/dl

 

Risk Factors for Asymptomatic Patients

•           Strong Family History

•           Obesity

•           Certain Races

•           Women with previous GDM

•           Previous IGT

•           Hypertension or hypertriglyceridemia

•           40 years old with any of the above

 

Goals of Treatment

•           Alleviate symptoms

•           Prevent complications

•           Prevent progression of current complications

•           Improve quality of life

 

 

 

Blood Glucose Target

 

Test	Normal	Goal
Before Meals	< 110	90 - 130
Peak Post Prandial	< 140	< 180
Bedtime	< 120	110 -150

 

 

 

Insulins

•           Rapid acting: Lispro (Humalog)  

•           Short acting: Regular

•           Intermediate: NPH or Lente

•           Long-acting: human Ultralente

•           Basal insulin: Glargine

 

Insulin action

Type	Onset	Peak	Duration
Rapid	5-15 min	1-2 h	3-4 h
Short	30-60 min	2-4 h	6-8 h
Intermed	1-2 h	4-10 h	10-20 h
Long	2-4 h	???	16-20 h
Basal	4-6 h	none	>24 h

 

Nutrition

•           Nutrition Therapy – The Most Fundamental Component of the Diabetes Treatment Plan

•           Goals:

–      Near Normal Glucose Levels

–      Normal Blood Pressure

–      Normal Serum Lipid Levels

–      Reasonable Body Weight

–      Promotion of Overall Health

 

Nutrition Therapy Diet Teaching

•           Goal - independence; effective self-management.

•           Include Family.

•           Follow prescribed plan; accurate portions

•           Never skip meals

•           Concern - Alcohol

•           Concern - Dietetic Foods

 

Nutrition Consult

•            Conduct Initial Assessment of Nutritional Status

•            Diet History, Lifestyle, Eating Habit

•            Provide Patient Education Regarding

–       Basic principles of diet therapy

–       Meal planning

–       Problem solving

–       Developing individualized meal plan

–       Emphasize one or two priorities

–       Minimize changes from the patient’s usual diet

 

Nutrition Therapy

•           Provide Follow-up assessment of the meal plan to

–      Determine effectiveness in terms of glucose and lipid control and weight loss

–      Make necessary changes based on weight loss, activity level, or changes in medication

–      Provide ongoing patient education and support

 

Nutrition Goals forType 1 DM          

•           Increase in energy intake possible

•           Diet and Insulin nec. to control BS

•           Equal distribution of CHO through meals for insulin activity 

•           Consistency in daily intake - control BS

•           Timing of meals - crucial

•           Snacks - frequently necessary

•           Additional food for exercise - CHO 20 g/h for moderate physical activity

 

Nutrition Goals forType 2 DM

•           Reduction of energy intake for obese

•           Diet alone may control blood glucose

•           Equal distribution of CHO desirable, not essential;low fat desirable

•           Consistency in daily intake - control wt.

•           Timing of meals not essential

•           Snacks - not recommended

•           Additional food for exercise if on sulfonylurea or insulin

 

Dietary Management of Diabetes

•           Maintain as near-normal blood glucose levels as possible by balancing food, insulin and exercise

•           Achieve recommended serum blood lipid levels

•           Provide energy intake to maintain or attain healthy weight

•           Prevent and treat acute and long-term diabetes-related complications

•           Enhance over all health

 

 

Weight Loss

•           Improves Glucose Control

•           Increases Sensitivity to insulin

•           Lower lipid levels and blood pressure

•           Corresponding lowering of the dosage of pharmacologic agents

 

 

For a Successful Outcome

•           Modest Caloric Restrictions

•           Spreading caloric intake throughout the day

•           Increased Physical Activity

•           Behavior Modification

•           Psychosocial Support

 

Nutrient Components

•           Protein*

•           Fat*

•           CHO*

•           Sucrose and Fructose

•           Nutritive Sweeteners

•           Fat Replacements*

•           Vitamins and Minerals

 

Protein Intake

•            Small to medium portion of protein once daily

•            12-20% of daily calories

•            From both animal and vegetable sources

•            Vegetable source less nephrotoxic than animal protein

•            3-5oz of meat, fish or poultry daily

•            Patient with nephropathy should limit to less than 12% daily

 

Fat Intake

•           <35% of total calories

•           Saturated fat <10% of total calories

•           Polyunsaturated fats 10% of total calories

•           Cholesterol consumption < 300 mg

•           Moderate increase in monounsaturated fats such as canola oil and olive oil (up to 20% of total calories)

 

CHO Intake

•           CHO intake determined after protein and fat intake have been calculated.

•           Emphasize on whole grains, starches, fruits, and vegetables

•           Fiber same as for nondiabetics (20g to 35g)

•           Rate of digestion related to the presence of fat, degree of ripeness, cooking method, and preparation

 

Nutritive Sweeteners and Fat Replacements

•           Nutritive Sweeteners: corn syrup, fruit juice concentrate, honey, molasses, dextrose, and maltose have same impact on calorie and glycemic response

•           Fat substitutes are derived from CHO or protein sources.  So, CHO and Protein content should be reviewed before using

 

Nutrition

•           Individualized Diet Treatment Plan

•           Diet changes do not have to be dramatic

•           Regular monitoring of blood glucose, glycated hemoglobin, lipid levels, blood pressure, and body weight

 

Exercise

•           Potential Benefits

–      Improved Glucose tolerance

–      Weight loss or maintenance or desirable weight

–      Improved cardiovascular risk factors

–      Improved response to pharmacologic therapy

–      Improved energy level, muscular strength, flexibility, quality of life, and sense of well being

 

Precautions and Considerations

•            Consult a physician

•            Rule out significant cardiovascular diseases or silent ischemia

•            Prevent hypoglycemia with self-monitoring of capillary blood

glucose (SMCBG) both before and after exercising

•            Strenuous exercise not recommended for people with poor metabolic control and significant complications

 

Exercise Prescription

•           Interest

•           Capacity

•           Motivation

•           Physical status

•           Individualized approach

 

Types of exercise

•           Walking

•           Biking and stationary cycling

•           Lap swimming and water aerobics

•           Weight lifting

•           At least 3-4 times a week, 30-40 minutes per session, 50 to 70% of maximum oxygen uptake

 

Acute Complications

•           Metabolic

–      Diabetic Ketoacidosis (DKA)

–      Hyperosmolar Hyperglycemis Nonketotic Syndrome (HHNS)

–      Hypoglycemia

•           Infection

•           Quality of Life

 

Complications of Diabetes

•           Macrovascular

–      coronary artery disease (MI)

–      cerebrovascular disease (Stroke)

–      peripheral vascular disease

•           Microvascular

–      retinopathy

–      nephropathy

–      neuropathy

 

Diabetes complications

•           Retinopathy (blindness?)

•           Nephropathy (kidney problems)

•           Feet ulceration and/or amputations

•           Hypertension

•           Hyperlipidemia (cholesterol?)

•           Gestational diabetes (during pregnancy)

•           Diabetes and HIV

•           Erectile Dysfunction

 

Long-term Complications of DM

•            Macrovascular Diseases

–       Hypertension

–       Dyslipidemia

–       Myocardial Infarction

–       Stroke

•            Microvascular Complications

–       Diabetic Retinopathy, Diabetic Nephropathy, Diabetic Neuropathy, Diabetic Diarrhea, Neurogenic Bladder, Impaired Cardiovascular Reflexes, Sexual Dysfunction

•            Diabetic Foot Disorders

 

Hypoglycemia

•           Factors Attributing to Hypoglycemia:

–      Exercise

–      Alcohol Intake

–      Other Drugs

–      Decreased Liver or Kidney Function

 

Signs of Hypoglycemia

•           Glucose level < 60 mg/dL

•           Mild Hypoglycemia:

–      Pallor, Diaphoresis, Tachycardia, Palpitations, Hunger, Paresthesias, Shakiness

•           Moderate Hypoglycemia

–      Inability to Concentrate, Confusion, Slurred Speech, Irrational or uncontrolled behavior, slowed reaction time, blurred vision, somnolence, extreme fatigue

•           Severe Hypoglycemia

–      Completely automated/disoriented behavior

–      Loss of Consciousness

–      Inability to arouse from sleep

–      seizures

 

Treatment

•            Goal is to normalize the plasma glucose level as quickly as possible

•            Mild Hypoglycemia: 3 glucose tablets, ½ cup fruit juice, 2 tablespoon rains, 5 lifesavers candy, ½ to ¾ cup regular soda, 1 cup milk

•            Moderate Hypoglycemia: Larger amount of CHO that are rapidly absorbed

•            Severe Hypoglycemia: IV glucose or Glucagon (1mg), Glucose gel, Honey, syrup, jelly

 

Prevention

•            Know the signs and symptoms of hypoglycemia

•            Try to eat regular meals

•            Carry a source of CHO

•            Perform SMCBG regularly

•            Use regular insulin 30 minutes before eating

•            Schedule exercise appropriately, adjust meal times, calorie intake, insulin dosing

•            Check blood glucose before sleeping

 

Gestational Diabetes

•             GDM develops in 1-3% of all pregnancies.

•             Women with GDM are characterized by a relatively diminished insulin secretion coupled with a pregnancy-induced insulin resistance primary located in skeletal muscle tissue.

•             Glucose tolerance returns to normal postpartum in the majority of women with GDM.

•             Women with previous GDM have a high risk of developing overt diabetes mellitus later in life.

 

 

 

DM Management in Pregnancy

•            Hormonal changes increase insulin resistance and the need for insulin for women with DM

•            Women with DM 1 and DM 2 may have difficulty maintaining glycemic control during pregnancy

•            Up to 7% of women with gestational diabetes are at higher risk of developing type 2 later in life

 

 

Effect of DM on pregnancy:Uncontrolled DM -

–    Linked with increased rate of spontaneous abortion

–    Higher incidences of birth defects and fetal deaths – than women without DM

 

 

–    Newborns more likely to have respiratory distress syndrome, hypoglycemia, jaundice, hypocalcemia

 

–    More likely to have babies with macrosomia – difficult delivery, birth trauma or cesarean section

 

Pregnancy in DM 1 or DM 2 Management

–      Glycemic control at conception and during the first trimester substantially reduces the risks of birth defects and spontaneous abortion during pregnancy

 

–      Maintenance of glycemic control during 2nd and 3rd trimester minimizes risks of macrosomia and morbidity of newborns

 

–      Nutrient requirements similar to that for women without DM

–      Dietary adjustments – individualized

 

–      Regular meals and snacks help avoid hypoglycemia

 

–      Evening snack usually necessary to prevent overnight hypoglycemia and ketosis

 

–      Insulin and medication changes often needed

 

Gestational Diabetes Management

–      Women who develop gestational DM – usually overweight or obese

 

–      Modest kcaloric reduction (about 30% less than total energy needs) may improve glycemic control without increasing the risk of ketosis

 

–      Restricting carbohydrate to 40 – 50 % of total diet – improve blood glucose levels after meals

 

–      Reducing carbohydrate at breakfast – poorly tolerated in morning – divided between remaining meals and snacks

–      Regular aerobic exercise

 

–      If women fail to achieve glycemic goals by diet and exercise – may need insulin therapy

–      Oral anti-diabetic drugs not generally prescribed during pregnancy, pending further research

 

 

Quality of life

•           Patients with blood glucose values consistently greater than 200 mg/dL will have a reduced quality of life. 

•           Poor work performance, infections, periodontal diseases, blurred vision, and among elderly, higher incidence of falls