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NUTRICARE IN
DIABETES WITHSPECIAL CONDITIONS
PREGNANCY
ILLNESS
SURGERY
GERIATIC POPULATION
NUDRAT KHAN
Jr.M.Sc CND
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PREGNANCYAND DIABETES
GESTATIONAL DIABETES
Diabetes developed during pregnancy
PRE-GESTATIONAL DIABETESDiabetes predates pregnancy
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GESTATIONAL DIABETES (GDM)
Defined as glucose intolerance of
variable severity with onset or first
recognition during pregnancy.
It occurs in the latter stage of
pregnancy, usually developing
around the 24-28 weeks of pregnancy
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PATHOPHYSIOLOGY
Normal Pregnancy Maternal Metabolic
Adaptationy Diabetogenic state changes in carbohydrate
metabolism + physiological Insulin Resistance
y Hormones ofPregnancy Peripheral InsulinResistance
y Insulin needs doubled or tripled by the time of
delivery
y Pancreas respond by releasing more Insulin to Overcome Insulin Resistance
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PATHOPHYSIOLOGY (CONT.)
GDM reduced Insulin response to nutrients Glucose
Intolerance
y Chronic Insulin resistance Cell Dysfunction
y Diabetes + Obesity post-receptor defects are present
in the insulin signaling pathway in the placenta.
y Triggered by an Antigenic Load(Fetus)HLA-G is postulated to protect pancreatic islet cells.
Interaction between HLA-G and NF-B lead to GDM
development.
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PATHOPHYSIOLOGY (CONT.)
Rare cause ofGDMautoimmune destruction ofpancreatic -cells.
characterized by circulating anti-islet cell antibodies or
-cell antigens such as glutamic acid decarboxylase,
GAD, or insulin autoantibodies, IAA.
Seen in
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DIAGNOSTIC CRITERIA FOR GESTATIONAL
DIABETES:
100 gOGTT
is performed in the morning after an overnightfast of at least 8 hrs
Two of the above Values must be met or exceeded for a
diagnosis of gestational diabetes to be made.
TABLE 1: Diagnostic Criteria for
Gestational Diabetes
100 g OGTTFasting 95 mg/dl
1-hour 180 mg/dl
2-hour 155 mg/dl
3-hour 140 mg/dl
Source: ADA, 2008
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RISKOF GESTATIONAL DIABETES
MATERNAL RISKARE:-
HypertensionPolyhydramnios
Caesarian section
RISKTOBABYARE:-Macrosomia- >4kg or >90th percentile
y Common complication of vaginal birth like Shoulder dystocia.
Neonatal
Hypoglycemia
y Risks associated with this condition are seizures, cerebral
damage and rarely death.
Other Neonatal Metabolic Problems are Jaundice and
calcium or magnesium imbalance.
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RISKINTHE FUTURE
To the Mother are:-
T2Dy Risk Factor Obesity & Family History
y Screened at 6-12 weeks post-partum and every 3years.
y Maintain Normal BMI and Activity of 150mins/week to prevent development ofT2D.
GDM in subsequent pregnancies
To the Baby are :-Obesity & Glucose Intolerance in late adolescence and
early Adulthood
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MANAGEMENT STATEGIES
Regular monitoring ofBlood glucose at least 4 times a
day(fasting & 1 or 2 hour post prandial) & maintainingwithin target range.
MNT should be initiated immediately upon diagnosis.
SMBG should be initiated immediately after diagnosis is
made. All SMBG and urine ketone results should be
recorded. This helps in modifying the treatment plan.
The following Target Goals are suggested ADA Recommends
y 95 mg/dl, fasting
y 140 mg/dl, 1 hour postprandial
y 120 mg/dl, 2 hour postprandial
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MANAGEMENT STATEGIES (CONT.)
Ketones should be tested if the glucose levels is >200 mg/dl orit the women is sick.
One study found out the a positive correlation between thepresence of ketones and low intelligence score in children( Rizzoet al.,1991)
Measurement of fetal abdominal circumference early in the
third trimester may rule out excess macrosomia risk.
EXERCISE
y Advised to do regular low impact physical activity.
y Avoid high impact or strenuous exercise to induce premature labor.
y Exercise may induce hypoglycemia if the women is treated withinsulin. Check blood glucose before and after exercise tounderstand the impact of exercise and action needed to preventhypoglycemia.
y Exercise after meals may improve the postprandial blood glucose
levels.
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MANAGEMENT STATEGIES (CONT.)
INSULIN
If it is not possible to maintain blood glucose at target
levels for pregnancy within a short time after
diagnosis, the women should be started on Insulin.
ORALGLUCOSE MEDICATION
OHAare not routinely used in pregnancy. There are
some studies which show they may be safe to use but
because of concerns of teratogenicity and neonatalhypoglycemia it is not generally used.
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PRE GESTATIONAL DIABETES OR
PREGNANC Y IN PREEXISTING DIABETES.
Diabetic women planning pregnancy should ensure they haveHbA1c
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PRE-CONCEPTION CARE AND COUNSELLING
Its implementation has reduced the
perinatal mortality rate & survival rate
for both women n infant improved.
It should began atleast 3-4 months before
pregnancy is planned.
Helps to achieve better glycemic control
before becoming pregnant.
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RISK DURINGPREGNANCY
To the Mother:-y Progression of preexisting complication
y Hypoglycemia in 1st trimester.
y Preterm labour
y Polyhydramnios
y Pre-eclampsia
y Eclampsia
To the baby:-
Congenital Malformation(6-10% of the cases) A folic acid supplement of 1-4mg/day from preconception
till 13 weeks of
Macrosomia
Neonatal Hypoglycemia
Still Birth
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RISK AT DELIVERY
To the Mother
y Caesarian section
y Effects ofPre-eclampsia or eclampsia.
To the baby
y Same as for Gestational Diabetes
y Babies are not born with Diabetes.
RISKIN FUTURE:
To Mother-
y Potential Hypoglycemia if energy intake not inc. during Breast
feeding. To Baby
If mother is T1D-
y 25 yrs-1 in 100
If mother has T2D-1 in 7
If both parents have
T2D-1 in 2
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MONITORING
y SBGM and Ketone Testing should be doneregularly
y Recommended Glycemic Targets
Glycemic Target
Prepregnancy
HbA1c(%) 7.0(6.0, if possible)
Once Pregnant
FBG 60-90mg/dl
1-hour PPG
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SURGERY ANDDIABETES
PERIOPERATIVE DIABETES CAREHYPERGLYCEMIA has been identified as a risk
factor for perioperative morbidity and mortality
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Hemodynamic
Instability
Tachycardia
Electrolyte ImbalanceInc. levels of
inflammatory
mediators
Endothelial cell
dysfunctionDefects in immune
function
Increased oxidative
stressProthrombotic
changes
cardiovascular effects
Inc. susceptibility to
infection
Pathophysiology of hyperglycemia in Critically
Ill patients undergoing Surgery
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Surgical Risks and the Benefits of Improved Glucose Control
Source: Rizvi, A.A, Chillag, Chillag, K.J(2010) Perioperative Management of Diabetes and Hyperglycemia in
Patients Undergoing Orthopaedic Surgery. Surgery,J Am Acad Orthop Surg;18:426-435
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Undiagnosed diabetes and hospital-induced hyperglycemia
contribute to increased postoperative complications. They are
at even greater risk than those with preexisting diabetes. &
should be treated in a similar fashion
Because of associated musculoskeletal complications,
patients with diabetes undergo more surgical procedures
than do patients without diabetes.
(NICE-SUGAR) trial in which Intensive and conventional
glycemic control were compared in 6,104 patients in the
intensive care unit. Intravenous (IV) insulin was used to
achieve a blood glucose level of 81 to 108 mg/dL in the
intensive group and 144 to 180 mg/dL in the conventional
group.
Increased no. of death at 90 days, in intensive glucose
control as compared with conventional control
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Aconsensus statement of the
AmericanAssociation of Clinical Endocrinologists and
the American Diabetes Association has since
recommended (2009) revising glucose targets
as follows:
In critically ill patients, maintain the
glucose level between 140 and 180 mg/dL.
Greater benefit may be realized at thelower end of this range.
Targets
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PREOPERATIVE MANAGEMENT
Glycemic targets as close as possible to thoseadvocated by the American Diabetes Associationshould be achieved before a planned surgicalprocedure.
These targets include
HbA1C
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INPATIENT HYPOGLYCEMIA
Factors predisposingto hypoglycemia include
advanced age hypoglycemia unawareness or an altered ability to
report hypoglycemic symptoms,
renal insufficiency or dialysis,
liver disease,
malnutrition, sepsis, and CHF.
Use of oral sulfonylurea agents in elderly patients who
are prone to hepatorenal insufficiency,polypharmacy,
or drug interactions may be contributory factors.
Insulin errors and omissions are common. Insulin is
one of the major a high-risk medications in the
inpatient setting
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ILLNESS ANDDIABETES
SICK DAY MANAGEMENT
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SICK DAY MANAGEMENT
Diabetics should be aware that common illnessessuch as cold, flu-like symptoms like vomiting,diarrhoea, sore throat and infection may riseblood glucose levels.
Illnessstressrelease of counterregulatoryhormones to fight infection & liver glycogen isreleased.
Without extra insulin blood glucose willriseDKAor HHS will dev. If enough insulin isnot available.
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SICK DAY RULES
Following these rules may help people with
diabetes prevent the development of DKA orHHS.
1. Drink fluids
y To replace fluids lost through High Blood glucose,fever, vomiting and diarrhoea people should drink
250ml of sugar free, caffeine-free fluids evry hour. Every 3 hours soups that contains sodium.
2. Check Blood Glucose
y Every 2-4 hrs, report high levels to Dr. immediately.
3. Never skip an injection or medication
4. Check urine for ketones
y If bld Glu >240mg/dl
y Presence of ketones should be reported to Dr.immediately.
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GERIATRIC
POPULATIONAND
DIABETES
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EFFECT OF AGING ON GLYCEMIC CONTROL
Geriatric patients face various medical and environmental
problems which make it difficult for them to achieve goodglycemic control.
Reduced food Intake decreased appetite, lack of saliva,reduced taste buds, lack of teeth and gum diseases .Reducedphysical activity and basal metabolic rate.
Reduction in levels of gastric and intestinal enzymes poordigestion and absorption of food.
Malabsorption complicate the dietary and pharmalogicalmanagement of diabetes and predispose to malnutrition.
PHYSIOLOGICAL CHANGES
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Chronic drug administrationy Drug Interaction
y Nutritional deficiency
e.g., metformin causes folate and vitamin B12deficiency.
OrlistatG.I side effectMalabsorption.
Altered thirst perception and delayed fluid
supplementationDehydrationhyperosmolar coma
POLYPHARMACY
DEHYDRATION
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Cognitive dysfunction + loss of memory associated
decrease in compliance with drug therapy.
Ocular complications reduced Visualacuityreduces the effectiveness of visual cues
associated with appetite and hunger.
Co morbid conditions such as arthritis,osteoporosis, spinal disease and muscular disease
reduction in mobility, increase in fall and Injury.
FUNCTIONALIMPAIRMENT
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Loss of first-phase insulin release.
Obese elderly patients Insulin resistance.
Lean elderly patients Impaired glucose-induced insulin
release.
Islet cell antibodies and marked insulin deficiency areincreasingly seen in lean elderly diabetic patients.
Hypoglycemia is often a risk of diabetes treatment in the
elderly.
Glucose counter regulatory hormones responses tohypoglycemia are diminished reduction in autonomic
warning symptoms.
The renal threshold for glucose increases with advanced
age, and glucosuria is not seen at usual levels
ALTERATIONSIN CARBOHYDRATE
METABOLISM
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MANAGEMENT
Goals of therapy for elderly diabetic patients shouldinclude an evaluation of their functional status, lifeexpectancy, social and financial support, and their owndesires for treatment.
Therapy should be chosen based on the individual needsand issues of each patient.
In frail elderly patients, particular attention should begiven to functional goals and to avoiding therapies thatmay cause loss of independence or earlyinstitutionalization.
Restricting caloric intake in longterm care patients
should be done with much caution. Many already haveinsufficient caloric intake because of confusion,dysphagia, and diminished appetite.
When prescribing insulin or oral agent regimens for thispopulation, providers should pay special attention to
possible side effects and drug interactions
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Glucose monitoring equipment should be easy to handle.
Instruction should be given at slow pace along with hand
outs(memory aid).
Make sure that the patient understands how to identify
hypoglycemia. In the elderly, hypoglycemia may manifest
itself solely in terms of neuroglycopenic symptoms
(dizziness, weakness, confusion, delirium)
Taking into consideration personal preference, increasedadherence to plan & better outcome.
A daily multivitamin supplement may be appropriate,
especially for those older adults with reduced energy intake
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EXERCISE
Physical activity attenuate loss of lean body mass,
decrease central adiposity, and improve insulinsensitivity.
Exercise also poses potential risks such as cardiacischemia, musculoskeletal injuries, and
hypoglycemia in patients treated with insulin or
insulin secretagogues.
Elderly diabetic patient should undergo a thorough
medical evaluation before increasing physical
activity.
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FOOT CARE
Alterations in blood flow to the microvascular structures of
the feet, changes in autonomic nervous system function, arethe major causative factors in the pathogenesis of foot
ulcers infection and amputation
Elevated Glucose level
leaching of zinc in urinezincdeficiencyPoor wound healing.
Careful attention to the feet is of paramount importance in
older people with diabetes.
Appropriate foot wear, applications of lipid-based lotions to
dry feet and early intervention when feet lesions occur are
all key factors in the prevention of amputations.
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PHARMACOLOGICAL CONSIDERATION
For lean elderly patients with T2D, agents that promote insulinsecretion should be selected, while in obese elderly patients agents
that lower insulin resistance should be selected.
Alpha-glucosidase inhibitors are modestly effective for glycemiccontrol, but tolerance of these agents is a problem.
Thiazolinediones are effective but associated with an increasedincidence of edema and CHF in the elderly. Should be used withcaution in elderly patients with cardiovascular disease.
Sulfonylreas are effective agents in the elderly, but hypoglycemia
remains the main adverse effect of concern.
Insulin therapy poses special concerns. Dosage errors may resultwith loss of concentration and memory, failing eyesight andmanual dexterity. Use of premixed insulins or prefilled insulin
pens as an alternative to mixing insulins should be considered.
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BIBLIOGRAPHY
India Diabetes Educator Project(2008) DistanceLearning Manual.
Chau.D and Edelman S.V,(2001) ClinicalManagement of diabetes in Elderly, Clinical
Diabetes, Volume 19, Number 4Angela K. M. and Michael A. G.
(2009)Perioperative Glycemic Control,Anesthesiology 110:40821
Ali A.R., Shawn A.C.,KimJ.C,(2010)Perioperative Management of Diabetesand Hyperglycemia in Patients UndergoingOrthopaedic Surgery,J Am Acad OrthopSurg;18:426-435
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