lec 3 nutrition therapy that apply to specific situations

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Postgraduate Diploma in Diabetes Education (PDDE(

Nutrition therapy: Dietary advice in case of complications

lec. 3 nutrition therapy that apply to specific situations

Prepared by; Dr. Siham M.O. Gritly

Dr. Siham M.O. Gritly 2

Complications of Diabetes


Complications of Diabetes

• Complications of Diabetes In both types of diabetes;

• glucose fails to gain entry into the cells

• and consequently accumulates in the blood.

• These two problems lead to both acute and chronic complications.


Metabolic Patterns in Diabetes

• Diabetic subjects are constantly relying on protein and fat for fuel.

• Proteins are degraded for gluconeogenesis.

• Glycolysis is inhibited and gluconeogenesis is stimulated.

• glucose (and water) are removed in urine. The diabetic subject suffer from acute hunger and thirst


• A lack of insulin action leads to mobilization of fat from adipose tissue, β-oxidation and formation of ketone bodies.

• In general metabolism shift from carbohydrate usage to fat usage.

• Excessive buildup of ketone bodies leads to lowering of the pH.

• When the kidneys can’t keep up with acid-base homeostasis, ketoacidosis can be fatal


the metabolic changes and acute complications that can arise in Uncontrolled diabetes . Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning

• The metabolic consequences of type 1 diabetes differ from those of type 2.

• Chronically elevated blood glucose alters glucose metabolism in every cell of the body.

• Some cells begin to convert excess glucose to sugar alcohols, for example, causing toxicity and cell distention;

• distended cells in the lenses of the eyes, for example, cause dim vision.

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• Some cells produce glycoproteins by attaching excess glucose to an amino acid in a protein; the altered proteins cannot function normally,

• The structures of the blood vessels and nerves become damaged, leading to loss of circulation and nerve function.

Dr. Siham M.O. Gritly


• Infections occur due to poor circulation coupled with glucose-rich blood and urine.

• People with diabetes must pay special attention to hygiene and keep alert for early signs of infection.


Metabolic Consequences of Untreated Diabetes Type 1 diabetes

• In type 1, no insulin is available to allow any glucose to enter the cells.

• When glucose cannot enter the cells, a metabolic changes quickly follows.


Metabolic Consequences of Untreated DiabetesType 1 diabetes

• No glucose enters the cells → • Cells break down protein and fat which

lead to → • Ketones produced for energy (ketosis) or

→• Weight loss that lead to → • Excessive eating (polyphagia)


• Diabetic ketoacidosis manifested by:• Ketones in the breath (acetone breath)• Ketones in the blood (ketonemia)• Ketones in the urine (ketonuria)• This result in Diabetic coma


Ketone Body Metabolism

• Adipose TG’s provide the major storage form of readily-available energy

• adipose triglycerids provides FFA’s to liver which makes ketones that are necessary for prolonged starvation


• acetoacetate, β-hydroxybutyrate, and acetone (minor) released into blood since liver cannot utilize them

• Ketones are used by skeletal, brain and cardiac muscle, the renal cortex, and other tissues


• When the rate of synthesis of ketone bodies exceeds the rate of utilization, their concentration in blood increases;

• acetoacetic acid and beta-hydroxybutyric acid

are acidic, and, if levels of these ketone bodies are too high, the pH of the blood drops, resulting in ketoacidosis


• ketonemia. This is followed by ketonuria – excretion of ketone bodies in urine.

• The ketonemia and ketonuria is commonly referred as ketosis.

• Smell of acetone in breath is a common feature in ketosis



• In type 2 diabetes, some glucose enters the cells.

• In this case the body does not shift into the metabolism of fasting (losing weight and producing ketones).



• Some glucose enters the cells, but slowly → • Hunger →

• Excessive eating (polyphagia) →

• Weight gain


What is Diabetic nephropathy

• Diabetic nephropathy is the impact of diabetes on the kidneys tissues, lead to loss of protein in the urine, and eventually chronic kidney disease requiring dialysis .

• Diabetic nephropathy is a clinical syndrome characterized by the following: Persistent albuminuria (>300 mg/d or >200 μg/min) that is confirmed on at least 2 occasions 3-6 months apartProgressive decline in the glomerular filtration rate (GFR)Elevated arterial blood pressure


• Symptoms• edema: swelling, usually around the eyes in the

mornings; • later, general body swelling may result, such as

swelling of the legs• foamy appearance of the urine (caused by the

proteinuria)• unintentional weight gain (from fluid accumulation)• anorexia (poor appetite)


Diabetic nephropathy Kidney failure aggravated by glomerulosclerosis leads to fluid filtration deficits and other disorders of kidney function

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The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. At this stage, the kidney may leak more serum albumin (plasma protein) than normal in the urine ( albuminuria),This stage is called microalbuminuria.

Dr. Siham M.O. Gritly


During diabetic nephropathy the kidney becomes damaged and more protein than normal collects in the urine. As the disease progresses, more of the kidney is destroyed. Over time, the kidney's ability to function starts to decline, which may eventually lead to chronic kidney failure.


Dietary Management of Diabetic Nephropathy

• Reduce protein to 0.8-1 g/kg/day in individuals with microalbunimuria.

• Some researchers suggested that In diabetic nephropathy, protein restriction may vary between 0.4 – 0.6 g per kilogram


What is diabetic neuropathy?Diseases of the Nerves

• Neuropathy is damage to nerves, and diabetic neuropathy is damage to nerves that occurs as a result of diabetes.

• Diabetic neuropathy is the most common complication of diabetes.

• Diabetic neuropathy can affect different parts of the body, and symptoms can range from mild to severe.


• Different types of diabetic neuropathy include • Peripheral neuropathy, • focal neuropathy, • Autonomic neuropathy causes symptoms related

to dysfunction of an organ system, such as urinary incontinence diarrhea, constipation

• and proximal neuropathy. proximal neuropathy characterized by painful muscle wasting and weakness.


Peripheral neuropathy most commonly causes pain, burning, tingling, and numbness of the feet and lower legs.

diabetic neuropathy together with vascular disease in the legs, contributes to the risk of diabetic-related foot problems (such as diabetic-food ulcers) that can be difficult to treat and occasionally require amputation


Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning

Nerve tissues may also deteriorate with diabetes, expressed at first as a painful prickling sensation, often in the arms and legs. Later, the person loses sensation in the hands and feet. Injuries to these areas may go unnoticed, and infections can progress rapidly. With loss of both circulation and nerve function, undetected injury and infection may lead to death of tissue (gangrene). gangrene is the death of tissue, usually due to deficient blood supply,


dietary management of diabetic neuropathy

• control of blood sugar levels is the best way to prevent diabetic neuropathy and other complications of diabetes


Diabetes and Celiac Disease

• Coeliac Disease is a condition where the lining of the small intestine is damaged due to sensitivity to a protein in food called gluten.

• Gluten is a protein found in grains such as wheat, rye, oats, barley. also be found in processed foods with ingredients such as wheaten corn flour, wheat starch, malt, malt extract, malt dextrin and the thickeners


Coeliac Disease and diabetes may occur together and is more common in people with type 1 than type 2 diabetes.

• Celiac disease

• villous atrophy • malnutrition


the lining of the small intestine is damaged due to

sensitivity to a protein in food gluten.

A healthy mucosa with villi The purpose of the villi is to increase the absorption area of the intestinal mucosa

When the villi are destroyed by celiac antibodies the absorption area decrease

Adapted from; Ragnar Hanas, MD, PhD Dept. of Pediatrics, Uddevalla, Sweden


The mucosa seen through a microscopeRef. Ragnar Hanas, MD, PhD

Dept. of Pediatrics, Uddevalla, Sweden

Celiac diseaseNormal villi


Onset of celiac disease in first year of life

Symptoms associated

with Celiac Disease

Chronic diarrhoea

Failure to thrive

Abdominal distension

growth failure in children with diabetes may indicate the presence of coeliac disease


Symptoms associated with Celiac Disease

• Symptoms vary from person to person and range from mild to severe

• Malabsorption commonly occurs in people with undiagnosed coeliac disease and Type 1 DM.

• hypoglycaemia• Diarrhoea• Streatorrhoea (floating, fatty stools)• Loss of weight • Abdominal bloating or distension • Flatulence


dietary management of diabetic Celiac Disease

• A gluten-free diet is currently the only known treatment for Coeliac Disease.

• Gluten-free foods include corn, rice, sago نشوي الحنطة tapioca, buckwheat ,دقيق

,potato, soy, arrowroot, fresh fruit , السوداءvegetables, meat (except most processed meats), poultry, fish and most dairy foods


• Beans and legumes can be used to increase fiber content of the diet

• Foods that are low in saturated fat

• Plenty of fruit and vegetables.

• Calcium supplements to be given to reduce risk of osteoporosis if dietary intake is < 1500 mg/day.


• avoid grains such as • wheat,• rye, • oats, الشوفان • barley. الشعير • processed foods with ingredients such as wheaten corn flour,• wheat starch, • malt, • malt extract, الشعير malt dextrin and the مستخلص

thickeners


Diabetes and Cystic fibrosis

• Cystic fibrosis a disease that cause damage to the pancreas (pancreatic insufficiency)

• If enough beta cells are damaged, the body can’t make enough insulin to metabolize food

• Decreased amounts of insulin lead to raise the blood glucose levels


• Common symptoms, • increased thirst • increased urination, are caused by high blood

sugar levels (hyperglycemia).• fatigue, • weight loss• and unexplained decline in lung function


• Weight loss can occur rapidly because of low insulin levels and high glucose levels

• high-energy diet with extra calories from fat and no restriction on carbohydrate is required.

• Keeping blood glucose levels at a normal or near-normal level

Insulin is primary treatment


Special situations Inter-current illness

• During acute intercurrent illness, advise on;• adequate hydration/nutrition especially easily

digested foods/drinks, e.g. soup, yoghurt, jelly, fruit juice.

• Increase fluids especially if there is fever, vomiting, or diarrhoea.

• Commercial oral rehydration salts can be used or even tomato juice or broth.

• Continue medication when ill


• Hospital care

• allow persons with diabetes to make their own food

choices.

• Hospital dieticians should ensure menus have appropriate or healthy food choices.

• All wards should have food and drink for oral treatment of hypoglycaemia.


Catabolic illness

• The energy needs of most hospitalised persons can be met by providing 25-35 kcal/kg body weight.

• • In catabolic illness, at least 1.0 g/kg body weight up to 1.5

g/kg body weight in more stressed persons. • • Avoid overfeeding to prevent hyperglycaemia,

hypertriglyceridaemia and hypertonic dehydration.

• Correct mineral/vitamin deficiencies before enteral or parenteral feeding is begun when indicated


Palliative care

• A WHO statement explained palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable (perfect) assessment and treatment of pain and other problems, physical, psychosocial and spiritual."


• the term "palliative care" may refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means; thus, palliative treatments may be used to alleviate the side effects of curative treatments, such as;

• relieving the nausea associated with chemotherapy

• affirms life and regards dying as a normal process;• intends neither to hasten nor to postpone death


• integrates the psychological and spiritual aspects of patient care;

• offers a support system to help patients live as actively as possible;

• offers a support system to help the family cope;• uses a team approach to address the needs of

patients and their families;• will enhance quality of life;


• Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.


References

• American Diabetes Association (2002). Clinical Practice Recommendations:2002. Diabetes Care 25 (suppl. 1):S64-S68.

• Sareen Gropper, Jack Smith and James Groff, Advanced Nutrition and Human Metabolism, fifth ed. WADSWORTH

• Melvin H Williams 2010; Nutrition for Health, Fitness and Sport. 9th ed, McGraw Hill

• Heymsfield, SB.; Baumgartner N.; Richard and Sheau-Fang P. 1999.

Modern Nutrition in Health and Disease; Shils E Maurice, Olson A. James, Shike Moshe and Ross A. Catharine eds. 9th edition

• Guyton, C. Arthur. 1985. Textbook of Medical Physiology. 6th edition, W.B. Company


• American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34 Suppl 1:S11-61

• American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31:S61-S78.

• American Diabetes Association. Carbohydrate counting. Available at http://www.diabetes.org/food-and-fitness/food/planning-meals/carb-counting. Accessed December 8, 2012.

lec 3 nutrition therapy that apply to specific situations

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