Chapter 20 – Nutrition and Diabetes Mellitus

Chapter Outline Instructor Resources

I. Overview of Diabetes MellitusA. Introduction

1. Incidence of diabetes mellitus is steadily increasing2. Metabolic disorders characterized by:

a. Elevated blood glucoseb. Disordered insulin metabolism

3. May have:a. Impaired insulin secretionb. Cells that do not respond to insulin normally

4. Results in hyperglycemiaB. Symptoms of Diabetes Mellitus

1. Classic symptomsa. Glycosuriab. Polyuriac. Polydipsiad. Polyphagia

2. Other consequencesa. Blurred visionb. Increased infectionsc. Constant fatigue

C. Diagnosis of Diabetes Mellitus1. Oral glucose tolerance test2. HbA1c

3. Random plasma glucose 200 mg/dL or > & classic symptoms4. Fasting glucose level 126 mg/dL or > 5. Plasma glucose 2 hours after a 75-g glucose load = 200 mg/dL or >6. HbA1c ≥6.5%7. Prediabetes

a. Fasting glucose level 100-125 mg/dLb. Plasma glucose 2 hours after a 75-g glucose load = 140-199 mg/dLc. HbA1c = 5.7-6.4%

D. Types of Diabetes Mellitus1. Type 1 Diabetes

a. 5-10% of casesb. Autoimmune destruction of pancreatic beta cellsc. Insulin therapy neededd. May be genetically susceptible and at risk of developing other autoimmune

diseasese. Usually occurs in childhood or adolescencef. Ketoacidosis may be the first sign

2. Type 2 Diabetesa. 90-95% of casesb. Often asymptomaticc. Some insulin is producedd. Insulin resistance & relative insulin deficiencye. Beta cells get exhausted f. Risk increased with:

1. Obesity2. Age3. Physical inactivity4. Genetics (family history)

3. Type 2 Diabetes in Children and Adolescents - Prevalence is increasing in children and correlates with the rise in childhood obesity

E. Prevention of Type 2 Diabetes Mellitus1. Weight management2. Active lifestyle3. Dietary modifications4. Regular monitoring

F. Acute Complications of Diabetes Mellitus1. Overview of acute complications

a. Disturbances in energy metabolismb. Fluid & electrolyte imbalancesc. Hyper- & hypoglycemia

2. Diabetic Ketoacidosis in Type 1 Diabetesa. Fatty acids and amino acids fuel the liver to produce ketone bodies and

glucoseb. Ketonuriac. Ketosis d. Acidosis e. Hyperglycemia f. Acetone breathg. May see fatigue, lethargy, nausea or vomitingh. Diabetic comai. Treatment:

1. Insulin2. IV fluid and electrolyte replacement3. Bicarbonate to treat acidosis

j. Causes: Missed insulin, illness, infection, alcohol abuse, other physiological stressors

k. Higher mortality rate3. Hyperosmolar Hyperglycemic Syndrome in Type 2 Diabetes

a. Fluid & electrolyte lossesb. BG >600-2000 mg/dLc. Blood plasma becomes hyperosmolard. Associated neurological abnormalitiese. 10% lapse into comaf. Condition evolves slowlyg. Mortality rate as high as 20%

4. Hypoglycemia = low blood glucosea. Inappropriate managementb. Excessive insulin or antidiabetic drugsc. Prolonged exercised. Skipped/delayed or inadequate mealse. Alcohol without foodf. Most frequent cause of coma in insulin-treated patientsg. Symptoms

1. Sweating2. Heart palpitations3. Shakiness4. Hunger5. Weakness6. Dizziness7. Irritability

G. Chronic Complications of Diabetes Mellitus1. Overview

a. Formation of AGEs

b. AGEs cause damage to cells and blood vesselsc. Sorbitol production increases oxidative stress

2. Macrovascular Complicationsa. Accelerated atherosclerosisb. Peripheral vascular diseasec. Foot ulcers

3. Microvascular Complicationsa. Diabetic retinopathyb. Diabetic nephropathy

4. Diabetic Neuropathya. Pain & burningb. Numbness & tinglingc. Crampingd. Loss of sensatione. Sweating abnormalitiesf. Disturbances in bladder and bowel functiong. Sexual dysfunctionh. Constipationi. Delayed stomach emptying = gastroparesis

II. Treatment of Diabetes MellitusA. Overview

1. Diabetes mellitus is a chronic and progressive illness2. Balance:

a. Meal planningb. Medication timingc. Physical exercise

3. Type 1 - Requires insulin therapy4. Type 2

a. Diet therapyb. Exercise c. Oral medications or insulin

5. Requires education in self-management of diseaseB. Treatment Goals

1. Desirable blood glucose levels2. Prevent or reduce risk of complications3. Intensive diabetes therapy4. Healthy blood lipid concentrations5. Control blood pressure6. Manage weight7. CDE teaches methods of treatment

C. Evaluating Diabetes Treatment1. Daily monitoring

a. Self-monitoring of blood glucose testing - Type 1: 3 or more times/dayb. Continuous glucose monitoring

2. Long-Term Glycemic Controla. Glycated hemoglobin (HbA1c)

1. Measures glycemic control in past 2-3 months2. Goal = <7%

b. Fructosamine test1. Measures glycemic control in the preceding 2-week period2. Used to evaluate recent adjustments in diabetes treatment and glycemic

control in pregnancy3. Monitoring for Long-Term Complications

a. Routine blood pressure checks

b. Lipid screeningc. Urinary protein screening

4. Ketone TestingD. Nutrition Therapy: Dietary Recommendations

1. Macronutrient Intakesa. Macronutrient distribution depends on food preferences & metabolic factorsb. Day-to-day consistency in carbohydrate intake is associated with better

glycemic control 2. Total Carbohydrate Intake - Should not restrict carbohydrate intake to <130 g/d3. Carbohydrate Sources - Glycemic effects influenced by type of carbohydrate,

fiber content, preparation method, other foods included, & individual tolerance4. Sugars - Minimize foods & drink with added sugars

a. Moderate consumption not shown to adversely affect glycemic controlb. Sugar must be counted toward daily carbohydrate allowancec. Fructose may adversely affect blood lipid levelsd. Sugar alcohols and artificial sweeteners

5. Fiber - Same as general population6. Dietary Fat - Same as general population unless LDL increases7. Protein - 15-20% of kcalories8. Alcohol Use in Diabetes - Should be with food9. Micronutrients - Same as general population10. Body Weight in Type 2 Diabetes

a. Overweight or obese worsens insulin resistanceb. Weight loss is recommended for overweight or obese individualsc. Weight loss is most beneficial early in the course of diabetes

E. Nutrition Therapy: Meal-Planning Strategies1. Carbohydrate Counting

a. Simpler & more flexible than other methodsb. Person given a daily carbohydrate allowancec. Divided into pattern of meals & snacksd. How to Use Carbohydrate Counting in Clinical Practicee. Advanced level allows more flexibility & is best suited for patients using

intensive insulin therapy2. Exchange Lists for Meal Planning

a. More complex & difficult to learnb. Sorts foods according to their proportions of CHO, fat, & proteinc. Each food has similar macronutrient & energy content

F. Insulin Therapy1. Indications

a. For people that can’t produce enough insulinb. Type 1 diabetesc. Some persons with type 2

2. Insulin Preparations - differ by:a. Onset of activityb. Timing of peak activityc. Duration of effects

3. Insulin Deliverya. Subcutaneous injection with syringesb. Insulin pensc. Insulin pumpsd. At least 3 or more daily injections required for good glycemic control without

pumpe. Carbohydrate-to-insulin ratio

4. Insulin Regimen for Type 1 Diabetesa. Multiple daily injections

b. Several types of insulinc. Insulin pump

5. Insulin Regimen for Type 2 Diabetesa. 30% of persons need insulinb. Insulin alonec. Insulin with oral agents

6. Insulin Therapy and Hypoglycemiaa. Most common complicationb. Need immediate intake of glucose or CHO foodc. 15-20 gramsd. Resolves in about 15 minutes with CHO ingestione. 15 grams CHO =

1. 4 glucose tablets2. 4 tsp table sugar3. 4 tsp maple syrup4. ½ cup canned orange juice5. 15 small jelly beans

7. Insulin Therapy and Weight Gain - sometimes an unintentional side effecta. Associated especially with intensive insulin therapyb. Prevention: reduce ratio of basal insulin to mealtime insulin; improve CHO

counting skills to properly judge mealtime insulin requirements8. Fasting Hyperglycemia - 3 possible causes:

a. Waning insulin actionb. Dawn phenomenonc. Rebound hyperglycemia, a.k.a. Somogyi effect

G. Antidiabetic Drugs1. Stimulate insulin secretion2. Suppress glucagon secretion3. Increase insulin sensitivity4. Improve glucose use by tissues5. Reduce liver glucose production6. Delay stomach emptying7. Delay CHO digestion & absorption8. Treatment may be monotherapy or combination therapy

H. Physical Activity and Diabetes Management1. Medical Evaluation before Exercise2. Maintaining Glycemic Control - Don’t inject insulin right before exercise & check

BG before & after to avoid hypoglycemiaI. Sick-Day Management

1. Type 1 diabetes - Illness increases ketoacidosis risk2. Recommendations

a. Frequent blood glucose testingb. Continue use of medication(s)c. Select easy-to-manage foods and beveragesd. Consume adequate amounts of liquids throughout the day

III. Diabetes Management in PregnancyA. Introduction

1. Pregnancy increases insulin resistance & need for insulin2. Glycemic control more difficult3. Uncontrolled diabetes

a. Miscarriagesb. Birth defectsc. Fetal deaths

4. Increased risk for:

a. Delivery of large babies (macrosomia)b. May need C-section

B. Pregnancy in Type 1 or Type 2 Diabetes1. Need glycemic control2. At conception & during 1st trimester to reduce risks of birth defects3. 2nd & 3rd trimesters to minimize risks of large babies & infant mortality

C. Gestational Diabetes1. Risk factors:

a. Family history of diabetesb. Obesityc. Certain ethnic groupsd. Delivered babies weighing over 9 pounds

2. May need to restrict carbohydrates to 40-45% total kcalories3. Limit carbohydrates in the morning to 30 grams4. Space carbohydrates throughout the day5. Regular aerobic activity6. May need insulin

IV. Nutrition in Practice - The Metabolic SyndromeA. Introduction

1. Metabolic syndrome (MS) = cluster of metabolic abnormalities2. MS increases risk for CVD and type 2 diabetes

B. How is the metabolic syndrome diagnosed, and how common is it in the U.S.?1. MS is diagnosed when an individual has 3 of the following:

a. Hyperglycemiab. Abdominal obesityc. Hypertriglyceridemiad. Reduced HDLe. Hypertension

2. Risk varies among ethnic groupsC. What causes the metabolic syndrome?

1. Usually both genetic and environmental factors2. Obesity3. Abdominal obesity

D. How does obesity lead to insulin resistance?1. Exact mechanism is unclear2. High cellular fat content may alter cellular response to insulin

E. Can obesity cause other problems related to the metabolic syndrome?1. Blood lipid abnormalities2. Raise in blood pressure

F. How does the metabolic syndrome contribute to cardiovascular disease risk?1. Associated disorders are all independent risk factors for CVD2. Often associated with blood vessel dysfunction & the tendency to form blood

clotsG. What is the usual treatment for the metabolic syndrome? - Dietary & lifestyle

changes: primarily to promote weight lossH. What dietary strategies, other than weight loss, are suggested for people with the

metabolic syndrome? 1. Reduce added sugar & refined grains2. Increase servings of high-fiber foods3. Include fish in diet weekly4. Reduce sodium & increase fruits, vegetables, & low-fat milk products5. Choose a diet low in saturated and trans fats & cholesterol

I. Why is physical activity recommended for people with the metabolic syndrome?1. Weight management

2. May improve:a. Blood lipid concentrationsb. Blood pressurec. Insulin resistance

J. What types of medications are used to treat the metabolic syndrome? - If dietary and lifestyle changes are unsuccessful, may need medication to correct hypertriglyceridemia and hypertension