Diabetes Mellitus

Williams’ Basic Nutrition and Diet Therapy Chapter 20

Diabetes Mellitus• Definition:

– Diabetes mellitus refers to a group of metabolic diseases that are characterized by an excessively high (hyperglycemia) blood glucose level

• Disruption of metabolism of carbohydrates, proteins, and fats

Diabetes Mellitus Incidence

• 246 million people worldwide have diabetes

• 20.8 million Americans have diabetes (7% of population)

• Estimated total cost of diabetes in US was $174 billion in 2007 (32% increase since 2002)

• Seventh most common cause of death in US (mainly due to CV disease)

Diabetes Mellitus Incidence

• African American, Native American, Latin American, and Asian Americans have a 3 times higher incidence than Northern European Americans

• Increased incidence with aging:

> 33% over age of 60

• Males/females equally affected

History of Diabetes

• Symptoms date back to about 1500 BC

• Diabetes is Greek meaning siphon

• Mellitus is Latin for honey

• Insulin comes from the Latin word insula meaning island

• Paul Langerhans found special clusters of cells called islets of Langerhans in the pancreas

Islets of Langerhans Cells• Special groups of cells

in the pancreas called alpha, beta, and delta cells

• Make and secrete the following hormones that work together to regulate blood glucose levels:– Insulin, Glucagon,

and Somatostatin

Insulin • A peptide (chain of amino acids) hormone

produced in the beta cells of the islets of Langerhans in the pancreas

• Transports glucose into cells for energy and storage as glycogen in liver and muscles

• Stimulates free fatty acid storage in fat deposits

• Stimulates protein synthesis (anabolic hormone)

Glucagon• A peptide hormone produced in the alpha

cells of the islets of Langerhans in the pancreas

• The effect of glucagon is reciprocal to that of insulin - it raises blood glucose levels by causing the breakdown of glycogen in the liver.

• It protects the brain and other tissues during sleep and fasting.

Somatostatin• A peptide hormone produced in the

delta cells of the islets of Langerhans in the pancreas

• It tells the body when to make insulin and glucagon

Types of Diabetes Mellitus

• Prediabetes

• Type 1 Diabetes

• Type 2 Diabetes

• Gestational Diabetes

• Diabetes due to other causes

Prediabetes

• Characterized by blood glucose levels higher than normal yet not high enough to be diagnosed

• Before contracting diabetes mellitus people usually have prediabetes:– Family history of diabetes mellitus– Hypertension– History of gestational diabetes– Low HDL and high LDL levels– Overweight/obesity

Types of Diabetes Mellitus

• Type 1 Diabetes Mellitus

- Formerly known as juvenile onset diabetes or insulin-dependent diabetes mellitus

• Type 2 Diabetes Mellitus

- Formerly known as adult onset or non insulin-dependent diabetes mellitus

Type 1 Diabetes Mellitus• Autoimmune disease (an attack initiated

by the body's immune system against its own tissues) that effects the beta cells of the pancreas

• Beta cells do not produce insulin or they produce it in small amounts that the body cannot use glucose (blood sugar) for energy

Type 1 Diabetes Mellitus• Genetic predisposition to this disease

or a virus may have affected the pancreas

• Typically occurs in people age 30 years of age and younger

• In most cases, 10-12 in girls and 12-14 in boys

Type 1 Diabetes Mellitus• Insulin injections required• Different forms of insulin:

– Short, medium, and long acting• Insulin pumps worn on hip like a

beeper and attach to a long catheter that can release insulin directly into the body through a small needle that is left in the skin

• Insulin pump is more convenient than injections

• Some success has occurred with stem cell transplants

Type 1 Diabetes Dietary Strategy• Individuals need to consume meals and snacks at

regular intervals each day

• A person should consume a simple carbohydrate if blood glucose level is less than 100 mg per dl

• The simple sugar will be quickly absorbed into the bloodstream

• People with diabetes should carry high-carb foods with them all of the time-while exercising, in the car, at work…

Type 1 Diabetes Overview

Type:

Age of Onset:

Body Weight:

Treatment:

Dietary Strategy:

Insulin Dependent

Usually <30 Years old

Usually Low

Insulin Injections

Increase Calories, Meal Frequency with Proper Nutritional Balance

Type 2 Diabetes Mellitus• The pancreas does produce insulin, but the

number of insulin receptors may be down regulated (a decrease in the number of receptors on the surface of target cells, making the cells less sensitive to a hormone) , resulting in decreased tissue sensitivity to insulin

• Typically a comorbidity (concurrent health conditions) of overweight and obesity

Type 2 Diabetes Mellitus• Usually occurs after the age of 40, but

increased rate of obesity in all ages• People can usually manage the disease

by losing weight• Many people take oral hypoglycemic

agents:– For example: Metformin or glucophage

• Some may require insulin

Type 2 Diabetes Dietary Strategy

• If weight loss recommended, decrease total daily caloric intake

• Decrease portion size• Increase meal frequency• Minimize high starchy foods• Increase fiber intake • Limit sweets, sugars and sugar substitutes• Limit or eliminate alcohol consumption

Type 2 Diabetes Challenge

Try this next time you dine out!• Ask the waitperson the carbohydrate content of each

item you order• Try to avoid starchy foods like bread, potatoes & rice• Be cautious with or avoid any rich sauces or gravies• Choose fiber- rich vegetables (watch the butter!)• Eat half your portion (box the rest!)• Limit yourself to one alcoholic beverage• No dessert!!!

Type 2 Diabetes Overview

Type:

Age of Onset:

Body Weight:

Treatment:

Dietary Strategy:

Insulin ResistantUsually >40 Years oldUsually OverweightWeight Loss, Exercise,

Oral Hypoglycemic agents

Decrease Calories with Proper Nutritional Balance

Gestational Diabetes

• Characterized by high blood glucose levels during pregnancy

• All diabetic symptoms usually disappear following delivery

• Treatment for gestational diabetes includes special diet, exercise, and insulin injections

Diabetes Due to Other Causes

• Metabolic Syndrome- Following conditions must be present:– Obesity: abdominal obesity greater than 40

inches in males and 35 inches in females– Blood Pressure greater than 130/85mmHg– Fasting blood glucose levels >110 mg per dl– HDL cholesterol levels: <40 mg per dl in

men and <50 mg per dl in females– Triglyceride levels: >150 mg per dl

Diabetes Due to Other Causes• Genetic defects

• Pancreatic Conditions or Disease

• Endocrinopathies (Hormone Dysfunction)

-Cushing’s Syndrome

-Pheochromocytoma

-Aldosteronoma

• Drug or Chemical Induced Diabetes

Medical Diagnosis of Diabetes Mellitus

• Primary tests used:– Fasting plasma (blood) glucose test (FPG)– Oral glucose tolerance test (OGTT)

• FPG is assessment of blood glucose levels when a person has fasted

• The OGTT is measured both at fasting and then 1 and 2 hours after consumption of a glucose beverage (50 g)

Medical Diagnosis of Diabetes Mellitus

• Fasting plasma glucose > 126 mg/dl after no caloric input for at least 8 hr.

or

• Classic symptoms of diabetes + glucose level > 200 mg/dl

or

• 2-hour postload glucose > 200 mg/dl during an oral glucose tolerance test

Medical Diagnosis of Diabetes Mellitus

FPG OGTT

Signs and Symptoms of Diabetes Mellitus

• Polyuria:

– increased frequency of urination

• Polydipsia:

– increased thirst

• Polyphagia:

– increased appetite

• Lethargy:

– general weakness

Signs and Symptoms of Diabetes Mellitus

• Repeated infections or sores that heal slowly or not at all

• Blurred vision

• Tingling or numbness in hands or feet

• Ketoacidosis

Ketoacidosis

• The body cannot use glucose for energy because little or no insulin is present to deposit glucose into cells

• Body starts to break down its fat stores for energy

• Although fat has more energy than carbohydrates excessive breakdown of fat leads to a buildup of ketone bodies

Ketoacidosis• The CNS can use ketone bodies for a short time

(prefer glucose) but the build up of ketone bodies makes the blood more acidic and results in ketoacidosis:– A life-threatening condition in which ketones (result

from the breakdown of fat for energy) accumulate in the bloodstream and the pH of the blood decreases

– May lead to a coma and possibly death

• Moderate or large ketones are present in the urine as well as in the body

Measuring for Ketones• A blood test is the most accurate method of

measuring ketones

• A urine test is the most commonly used method of measuring ketones

•

Low Carbohydrate Diets

• The goal of high protein low carbohydrate diets is to increase ketone production in the body

• The negative effect of high ketone bodies is that they will not sustain the energy needed for the brain and spinal cord which prefers glucose

• Ketoacidosis may occur, which may lead to a coma

Low Carbohydrate Diets

• Q: Does ketosis help lose weight?

• A: Yes.

• Q: Is it safe?

• A: I wouldn't recommend it. I think it is a dangerous way to lose weight.

Long Term Complications of Uncontrolled Diabetes Mellitus

• Retinopathy:– Disease of the eyes that can lead to blindness

– Diabetes mellitus is the leading cause of blindness in people 20 to 74 years of age

• Nephropathy:– Disease of the kidneys that can lead to kidney

failure

• Heart Disease (HTN/Dyslipidemia/CAD)

Long Term Complications of Uncontrolled Diabetes Mellitus

•Neuropathy: •Disease of the peripheral nervous system that can cause loss of sense of feeling, which often leads to wounds that never heal because the person does not feel them.•Amputations may result if these infections result in gangrene

Exercise Clearance• Before beginning an exercise program, clients with

diabetes mellitus should have medical clearance from their physician

• Exercise enhances the absorption of insulin, increases the muscle uptake of glucose, and impairs the mobilization of glucose in blood

Glycemic Control and Exercise

• Moderate to intense activity may cause blood glucose levels to decrease after 24 hours

• If blood glucose levels are less than 100 mg per dl immediately after exercise the individual should do the following:– Increase carbohydrate intake before exercise– Decrease insulin dosage following exercise – Consume a carbohydrate and protein snack

Hypoglycemia• The major goal is to prevent hypoglycemia (blood glucose

level of 65 mg per dl or lower) as a result of exercise• Recommendations:

– Measure blood glucose before, during, and after exercise

– During exercise, easily absorbable carbohydrate may have to be consumed

– After exercise, an extra carbohydrate-rich snack may be necessary

– Consume 15g of carbohydrate if not planning to eat 30-60 minutes before exercise

– Take in 15 grams of carbohydrate and 7 grams of protein if not planning to eat for more than 60 minutes before exercise

Hypoglycemia During Exercise• May be caused by:

– Increased exercise intensity– Longer exercise duration– Inadequate caloric intake prior to exercise– Not eating on time– Missing meals– Taking too much insulin– Insulin injection into exercising muscle– Colder environmental temperatures

Hypoglycemia

• Emergency situation (consider calling 911)

• If blood glucose levels drop the individual may become confused, disoriented, or lose consciousness

• Greater concern for clients with type 1 diabetes mellitus

Signs and Symptoms of Hypoglycemia

• Cold clammy or sweaty skin

• A staggering gait

• Abdominal pain or nausea

• Excessive hunger

• Headache

• Shaking or shivering

• Irritability, hostility

• Blurry vision

• Tachycardia

• Dizziness

• Confusion

• Convulsion

• Syncope (fainting)

• Unconsciousness

• Coma

• Sweating

Responding to a Client Who Has Hypoglycemia

• Clients with diabetes should always wear a medical alert bracelet in case of a hypoglycemic reaction

• Do not leave client alone• Measure blood glucose level with a glucose

monitor device if available• Give sugar immediately!

Responding to a Client Who Has Hypoglycemia• If blood glucose level is below 70 mg per dl, provide 15 g

of carbohydrate, which is equivalent to:

– About 3-4 glucose tablets

– 3 packets of table sugar dissolved in water

– ½ cup of fruit juice or soft drink

– 6 life savers

– 1 tablespoon of honey

– 6 saltine crackers

• Wait 10-15 minutes, treat again and remeasure glucose level until blood glucose level rises above 70 mg per dl.

Hyperglycemia• High blood glucose levels due to too

much food, not enough insulin, illness, or stress

• Do not give sugar if individual is unconscious, having a seizure, or unable to swallow

• Call 911!

Signs and Symptoms of Hyperglycemia

• Nausea

• Drowsiness

• Blurry vision

• Vomiting

• Extreme thirst

• Frequent urination

Contraindications to Exercise• Blood glucose levels greater than 240 mg per dl and ketones

in urine for type 1 diabetes• Blood glucose greater than 300 mg per dl without ketones• Clients with retinopathy should avoid strenuous high

intensity activity• Severe kidney disease• Clients with a loss of protective sensation in the feet should

avoid outdoor walking and jogging. Swimming and biking is recommended.

• Acute illness, infection, or fever• Evidence of underlying cardiovascular disease that has not

been medically evaluated

Guidelines For Safe Exercise• Do not exercise when insulin is working at peak

action

• Don’t inject insulin into a part of the body you will be exercising. It will be absorbed faster there.

• Eat a small snack or drink fruit juice 15-20 minutes before exercising if blood sugar levels are below 100mg/dL

• The personal trainer should not give advice to the client about the use of insulin or timing of meals

Benefits of Exercise• Improved insulin sensitivity• Improved blood lipids and lipoproteins• Increased caloric expenditure resulting in reduction or

maintenance of body weight, reduction in body fat, and preservation of lean body mass

• Improved physical fitness• Improved flexibility and strength• Decreased BP in those with hypertension• Decreased risk of cardiovascular disease• Improved psychological well-being, including enhanced

quality of life, improved self esteem

Aerobic Conditioning Guidelines for People with Diabetes Mellitus

• Frequency: 4-6 days or daily• Duration: 20-60 minutes• 40-70% VO2 • Monitor exercise intensity via RPE• A snack may be needed before exercise• Monitor blood glucose before and after exercise• Include a 5-10 minute warm-up and cool-down

period• Large muscle activities

Resistance Training for People with Diabetes Mellitus

• Frequency: 2-3 nonconsecutive days/week

• Muscular Endurance: 1-3 sets/10-15 reps

• Up to 8-10 exercises

• Can begin with body weight exercises and progress to free weights and machines

• Clients with well controlled diabetes can progress to strength training

Flexibility Training for People with Diabetes Mellitus

• Minimum of 2-3 sessions per week

• Hold static stretches for 10-30 seconds

• Yoga is a good example for flexibility training

Basic Elements of Diabetes Management

1. Healthy diet for good glucose management

2. Physical exercise provides an important balance to maintain good glucose control

3. Medications ensure adequate insulin activity

4. Introduce stress coping skills to reduce hormonal imbalance (yoga, meditation)