chapter 20 nutrition and diabetes mellitus

Nutrition and Diabetes Mellitus

2020

Copyright © 2017 Cengage Learning. All Rights Reserved.

© Cengage Learning 2017

Introduction

• In the United States:– 12.3% of adults aged 20 and older have

diabetes (about 29 million people)– Seventh leading cause of death– Contributes to development of other

life-threatening diseases• Heart disease and kidney failure



Overview of Diabetes Mellitus

• Elevated blood glucose concentrations and disordered insulin metabolism– Inability to produce sufficient insulin and/or

inability to use insulin effectively• Effects

– Defective glucose uptake and utilization in muscle and adipose cells

– Unrestrained glucose production in the liver



Overview of Diabetes Mellitus (cont’d.)

• Hyperglycemia– Marked elevation in blood glucose levels– Can ultimately cause damage to blood

vessels, nerves, and tissues• Symptoms of diabetes mellitus

– Related to the degree of hyperglycemia present

• Above 200 mg/dL: exceeds renal threshold




• Diagnosis of diabetes mellitus– Based primarily on plasma glucose levels

• Measured under fasting conditions or at random times during the day

– Oral glucose tolerance test– Indirect measure: glycated hemoglobin

(HbA1c)



Overview of Diabetes Mellitus: Diagnosis of Diabetes Mellitus (cont’d.)

• Current diagnosis criteria– After a fast of at least eight hours

• Plasma glucose concentration: 126 mg/dL or higher

– Random sample during the day• Plasma glucose concentration: 200 mg/dL or

higher• Classic symptoms of hyperglycemia present



Overview of Diabetes Mellitus: Diagnosis of Diabetes Mellitus (cont’d.)

• Current diagnosis criteria– Two hours after a 75-gram glucose load

• Plasma glucose concentration: 200 mg/dL or higher

– HbA1c level: 6.5% or higher• If people with prediabetes are usually

asymptomatic, why is this condition a concern?




• Types of diabetes mellitus– Main types

• Type 1 diabetes• Type 2 diabetes

– Gestational diabetes: during pregnancy– Can also result from medical conditions that

damage the pancreas or interfere with insulin function



Overview of Diabetes Mellitus:Types of Diabetes Mellitus (cont’d.)

• Type 1 diabetes– Caused by autoimmune destruction of the

pancreatic beta cells– Insulin must be supplied exogenously– Usually develops in children or teens– Classic symptoms: polyuria, polydipsia,

weight loss, and weakness or fatigue




• Type 2 diabetes– Most prevalent form of diabetes (90-95%)– Insulin resistance coupled with relative insulin

deficiency– Hyperinsulinemia: abnormally high blood

insulin– Obesity substantially increases type 2

diabetes risk (80% of cases obese)




• Type 2 diabetes in children and adolescents– Risk factors

• Overweight/obesity • Family history of diabetes

– Types 1 and 2 may be difficult to distinguish in children




• Prevention of type 2 diabetes mellitus– Weight management

• Sustained weight loss of ~7% of body weight recommended for overweight and obese individuals

– Dietary modifications• Increase intake of whole grains and dietary fiber• Limit intake of sugar-sweetened beverages• Decrease dietary fat if overweight/obese




• Prevention of type 2 diabetes mellitus– Active lifestyle

• At least 150 minutes of moderate physical activity weekly

– Regular monitoring• Annual monitoring for individuals at risk



Effects of Insulin Insufficiency




• Acute complications of diabetes mellitus– Diabetic ketoacidosis in type 1 diabetes

• Caused by severe lack of insulin• Severe ketosis (abnormally high levels of ketone

bodies)• Acidosis (pH <7.30)• Hyperglycemia (usually >250 mg/dL)• Symptoms: acetone breath, marked fatigue,

lethargy, nausea, and vomiting



Overview of Diabetes Mellitus:Acute Complications (cont’d.)

• Diabetic ketoacidosis in type 1 diabetes– Mental state: alert to diabetic coma– Treatment:

• Insulin therapy• Intravenous fluid and electrolyte replacement• In some cases, bicarbonate therapy




• Hyperosmolar hyperglycemic syndrome in type 2 diabetes– Severe hyperglycemia and dehydration that

develop in the absence of significant ketosis– Symptoms: neurological abnormalities, e.g.,

confusion, speech impairment, seizures, etc.– Treatment: intravenous fluid and electrolyte

replacement and insulin therapy




• Hypoglycemia: low blood glucose– Due to inappropriate management of diabetes– Caused by excessive dosages of insulin or

antidiabetic drugs, prolonged exercise, skipped or delayed meals, etc.

– Symptoms: sweating, heart palpitations, shakiness, hunger, weakness, etc.

– Treatment: glucose tablets, juice, or candy




• Chronic complications of diabetes mellitus– High levels of advanced glycation end

products (AGEs)• Alter protein structures• Stimulate metabolic pathways that damage tissues

– Sorbitol• Increases oxidative stress • Causes cellular injury



Overview of Diabetes Mellitus:Chronic Complications (cont’d.)

• Macrovascular complications: damage to large blood vessels– Accelerates the development of

atherosclerosis in the arteries of the heart, brain, and limbs

– Peripheral vascular disease: claudication, foot ulcers, gangrene




• Microvascular complications: damage to small blood vessels (capillaries)– Diabetic retinopathy: weakened retinal

capillaries leak fluid, lipids, or blood, causing local edema or hemorrhaging

– Diabetic nephropathy• Causes microalbuminuria• Decreased urine production with accumulation of

nitrogenous wastes




• Diabetic neuropathy: nerve damage– Extent determined by severity and duration of

hyperglycemia– Symptoms: deep pain or burning in the legs

and feet, weakness of the arms and legs, numbness and tingling in hands and feet

– Occurs in about 50% of diabetes cases



Treatment of Diabetes Mellitus

• Requires lifelong treatment– Balancing meals, medications, exercise– Frequent adjustments necessary to establish

good glycemic control• Treatment goals

– Maintain blood glucose levels within a desirable range

• Prevent or reduce the risk of complications



Treatment of Diabetes Mellitus (cont’d.)

• Treatment goals– Maintain healthy blood lipid concentrations,

control blood pressure, and manage weight– Diabetes education

• Certified Diabetes Educator (CDE)• Patients learn: meal planning, medication

administration, blood glucose monitoring, weight management, appropriate physical activity, prevention and treatment of complications




• Evaluating diabetes treatment– Monitor glycemic status

• Self-monitoring of blood glucose• Continuous glucose monitoring

– Long-term glycemic control• Why does the percentage of HbA1c reflect

glycemic control over the preceding two to three months?

• Fructosamine test: measures nonenzymatic glycation of serum proteins to determine glycemic control over the preceding 2-3 weeks




• Evaluating diabetes treatment– Monitoring for long-term complications

• Blood pressure at each checkup; annual lipid screening; routine checks for urinary protein, etc.

– Ketone testing• Checks for ketoacidosis• Most useful for type 1 diabetes or gestational

diabetes patients




• Nutrition therapy: dietary recommendations– Improves glycemic control– Slows the progression of diabetic

complications– Macronutrient intakes

• % of kcal distribution depends on food preferences and metabolic factors

• Maintain consistent day-to-day carbohydrate intake (unless using intensive insulin therapy)



Treatment of Diabetes Mellitus:Dietary Recommendations (cont’d.)

• Total carbohydrate intake– Based on metabolic needs, type of insulin or

other medications, and individual preferences– Recommended sources: vegetables, fruits,

whole grains, legumes, milk products• Glycemic index (GI)

– Choosing low- over high-GI foods may modestly improve glycemic control




• Sugars– Minimize added sugars– Sugary foods counted in the daily

carbohydrate allowance– Fructose as an added sweetener not advised– Artificial sweeteners can be used safely

• Whole grains and fiber– Recommendations similar to those for general

public: include fiber-rich foods




• Dietary fat– Increase omega-3s from fatty fish or plants– Saturated fat: <10% of total kcalories– Trans fat: minimized– Cholesterol: <300 milligrams daily

• Protein: similar to general population– High intakes may harm kidney function in

patients with nephropathy




• Alcohol use in diabetes– 1 drink/day for women; 2 drinks/day for men– Which groups should avoid alcohol?

• Micronutrients– Same recommendations as general

population– Supplements not currently recommended for

managing diabetes




• Body weight in type 2 diabetes– What are the benefits of moderate weight loss

(5% to 10% of body weight) for overweight or obese patients?




• Nutrition therapy: meal-planning strategies– Carbohydrate counting

• Widely used for planning diabetes diets• Dietician:

– Learns about patient’s usual food intake– Calculates nutrient and energy needs– Provides patient with daily carbohydrate allowance

divided into a pattern of meals and snacks

• Box 20-8 describes this process for basic carbohydrate counting



Treatment of Diabetes Mellitus:Meal-Planning Strategies (cont’d.)

• Carbohydrate counting– What is the advantage of advanced

carbohydrate counting?• Food lists for diabetes (Appendix C)

– Meal plan created by choosing foods with specified portions from the lists

– Less flexible than carbohydrate counting– Lists are useful resources for CHO counting




• Insulin therapy– Required by people with:

• Type 1 diabetes• Type 2 diabetes who are unable to maintain

glycemic control with medications, diet, and exercise

– Ideally, insulin treatment should reproduce the natural pattern of insulin secretion as closely as possible



Treatment of Diabetes Mellitus:Insulin Therapy (cont’d.)

• Insulin preparations (Table 20-6)– Forms: rapid acting, short acting, intermediate

acting, long acting, and insulin mixtures• Insulin delivery

– Administered by subcutaneous injection• Using syringes, insulin pens, or insulin pump

– What prohibits the use of oral delivery?



Effects of Insulin Preparations




• Insulin regimen for type 1 diabetes– Best managed with intensive insulin therapy

• Multiple daily injections of several types of insulin or use of an insulin pump

– To learn amounts required for meals:• Patient keeps records of food intake, insulin doses,

and blood glucose levels• Carbohydrate-to-insulin ratio calculated

– What is the honeymoon period?




• Insulin regimen for type 2 diabetes– ~30% of patients can benefit from insulin

therapy– Different regimens

• Insulin alone or combined with antidiabetic drugs• One or two daily injections

– Single injection of long-acting insulin at bedtime– Two or more injections of mixed insulin




• Insulin therapy and hypoglycemia– Hypoglycemia is the most common

complication of insulin treatment– Corrected by immediate intake of glucose or

glucose-containing food (15-20 g CHO)• Insulin therapy and weight gain

– Unintentional side effect• Particularly with intensive insulin treatment




• Fasting hyperglycemia– Typically develops in the early morning after

an overnight fast of at least 8 hours• Insufficient insulin during the night• Dawn phenomenon• Rebound hyperglycemia (Somogyi effect)

– Treatment: adjust the dosage or formulation of insulin administered in the evening




• Antidiabetic drugs (Table 20-7)– For type 2 treatment– Oral medications and injectable drugs other

than insulin– Box 20-10 lists nutrition-related effects of

these drugs




• Physical activity and diabetes management– Improves glycemic control considerably– At least 150 minutes of moderate-intensity

aerobic activity per week over at least 3 days– Both aerobic and resistance exercise can

improve insulin sensitivity



Treatment of Diabetes Mellitus: Physical Activity & Diabetes Management (cont’d.)

• Medical evaluation before exercise– Screen for potential problems

• Aggravated by certain activities– Exercise safety considerations

• Maintaining glycemic control– Adjust insulin and/or medication doses– Check glucose before and after exercise– Avoid vigorous activity during ketosis




• Sick day management– During illness: measure blood glucose and

ketone levels several times daily– Continue drugs or insulin as prescribed

• Adjust doses if diet is altered or persistent hyperglycemia develops

– Maintain prescribed CHO intakes– Consume liquids to prevent dehydration



Diabetes Management in Pregnancy

• More difficult to maintain glycemic control– Due to hormonal changes

• Women with gestational diabetes have a greater risk of developing type 2 diabetes later in life

• What are the health risks of uncontrolled diabetes for mother and fetus?



Diabetes Management in Pregnancy (cont’d.)

• Pregnancy in type 1 or type 2 diabetes– Glycemic control at conception and during the

first trimester of pregnancy • Substantially reduces the risks of birth defects and

spontaneous abortion– Women with type 1 require intensive insulin

therapy during pregnancy– Women with type 2 are usually switched to

insulin therapy



Diabetes Management in Pregnancy (cont’d.)

• Pregnancy in type 1 or type 2 diabetes– To avoid hypoglycemia and hyperglycemia:

• Carbohydrate intakes must be balanced with insulin treatment and physical activity

• Gestational diabetes– What factors increase the risk of gestational

diabetes?



Diabetes Management in Pregnancy: Gestational Diabetes (cont’d.)

• Overweight women– Modest kcal reduction (~30% less than

needs) may improve glycemic control• Limiting CHO intake to 40% to 45% of kcal

may improve blood glucose after meals• Restricting CHO to ~30 g at breakfast may

help



Diabetes Management in Pregnancy: Gestational Diabetes (cont’d.)

• Space carbohydrate intake throughout the day

• Regular aerobic activity can improve glycemic control

• If glycemic control not achieved by diet and exercise, insulin or an antidiabetic drug may be necessary



Nutrition in Practice: Metabolic Syndrome

• Diagnostic criteria (Table NP20-1)• Theories regarding obesity and metabolic

abnormalities• Relationship with cardiovascular disease• Treatment

– Weight loss– Dietary modifications– Physical activity– Medications


chapter 20 nutrition and diabetes mellitus

Education