1. Diabetes Mellitus Chapter 20 1

2. Objectives: Identify the nature of diabetes Identify metabolic patterns of diabetes Describe general management of diabetes Define diet therapy based on the balance concept Define diet therapy based on exchange system Describe a diabetes education program 2

3. Key Concepts DM is a metabolic disorder of glucose metabolism with many causes and forms A consistent, sound diet is the keystone of diabetes care and control Good self-care skill practiced daily enable a person with diabetes to remain healthy and reduce risks for complications 3

4. Key Concepts Blood glucose monitoring is a critical practice for blood glucose control A personalized care plan, balancing food intake, exercise, and insulin regulation, is essential to successful diabetes management 4

5. Definition “A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.” 5

6. Nature of Diabetes For glucose to be used by the cells in the body, it first has to be taken out of the blood and transported to the cells. For this to happen, the hormone – insulin- has to be present Without insulin, glucose accumulates in the blood stream 6

7. Classification of Diabetes Mellitus And Glucose Intolerance TYPE 1 DM ◦ Previously called insulin-dependent or juvenile diabetes Severe, unstable form Caused by autoimmune destruction of the beta cells in the pancreatic cells Can occur at any age – usually before 30 Requires exogenous insulin 7

8. Classification of Diabetes Mellitus And Glucose Intolerance TYPE 2 DM ◦ Previously called adult- onset or non-insulin-dependent diabetes Initial onset usually after age 40 Now being diagnosed in children Strong genetic link 8

9. Classification of Diabetes Mellitus And Glucose Intolerance Type II: Prevalent in older, obese people Usually treated with diet, exercise, sometimes oral hypoglycemic medication

10. Classification of Diabetes Mellitus And Glucose Intolerance TYPE 2 DM cont. ◦ Caused by insulin resistance or defect ◦ The body is either not producing enough insulin or the insulin it is producing cannot be used. 10

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16. Risk Factors for Type 2 DM Family history of diabetes Age 45 years or older Overweight Not physically active Race/ethnicity (African American, Hispanic American, Native American, Asian American, Pacific Islander) 16

17. Risk Factors for Type 2 DM History of gestational diabetes Woman who has delivered infant weighing more than 9 pounds Identified impaired glucose tolerance

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19. Gestational Diabetes Temporary form of disease occurring in pregnancy Presents complications for mother and fetus/infant including “macrosomia” – i.e. abnormally large infant Screening for GDM at 24- 28 wks. Gestation ◦ Oral glucose tolerance test (OGTT) Must be carefully monitored and controlled 19

20. Other Types of Diabetes (Secondary) Causes ◦ Genetic defect – in the beta-cells of the pancreas or insulin action ◦ Pancreatic conditions or disease ◦ Endocrinopathies—imbalance with other hormones in the body – Eg. Cushings Syndrome ◦ Drug/toxin- or chemical-induced DM  impair insulin secretion or action 20

21. Impaired Glucose Tolerance (IGT) Above normal fasting blood glucose but not high enough to be diabetes (= or >110mg/dl and <126 mg/dl) IGT is a risk factor for developing type 2 diabetes Underlying conditions (hypercholesterolemia, HTN, obesity) often present “Pre-diabetes” 21

22. Symptoms of Diabetes Initial signs ◦ Increased thirst ◦ Increased urination ◦ Increased hunger ◦ Unintentional weight loss (Type 1) ◦ Unusual weight loss (Type 2) 22

23. Symptoms of Hyperglycemia Dry skin Blurred vision Drowsiness Nausea Laboratory Test Results ◦ Glycosuria (sugar in urine) ◦ Hyperglycemia (elevated blood sugar) ◦ Abnormal glucose tolerance tests ◦ HgbA1C 23

24. Symptoms of Diabetes Clinical s/sx: blurred vision, skin irritation/infection(esp.recurrent yeast), general weakness, loss of strength Progressive Results ◦ Water, electrolyte imbalance ◦ Ketoacidosis (excess production of ketones; a form of metabolic acidosis which occurs from burning body fat for energy  coma and death) 24

25. Metabolic Patterns Diabetes is especially related to metabolism of carbohydrate and fat – our body’s 2 main fuels. It is important to control blood glucose within normal levels of 70 to 110 mg/dl. Sources of blood glucose: diet, glycogen (back up source from stores in liver, muscles Use of Blood Glucose: ◦ Burned during cell oxidation ◦ Changed to glycogen for storage ◦ Changed to fat for longer periods of storage 25

26. Metabolic Patterns Pancreatic Hormone Control ◦ Specialized cells in the Islets of Langerhans in the pancreas provide 3 hormones that work together:  Insulin  Glucagon  Somatostatin 26

27. Metabolic Patterns Pancreatic Hormone Control cont. ◦ Insulin – helps transport circulating glucose into cells by activating insulin receptors ◦ Glucagon – acts in the opposite manner of insulin: can rapidly breakdown stored glycogen for circulation  raising the blood sugar (protects brain, etc. while we sleep) ◦ Somatostatin – acts as a referee for several other hormones affecting blood glucose levels 27

28. Three Key Hormones Islets of Langerhans produce: ◦ Insulin ◦ Glucagon ◦ Somatostatin 28

29. Abnormal Metabolism in Uncontrolled Diabetes If diabetes is uncontrolled and insulin is lacking: ◦ Glucose cannot enter the cells and builds up in the blood  hyperglycemia. ◦ Fat tissue breaks down  ketones. ◦ Protein breaks down, causing weight loss and nitrogen loss. 29

30. Long-Term Complications of Diabetes Retinopathy – small hemorrhages from broken arteries in the retina, with yellow, waxy discharge or retinal detachment ◦ Diabetic retinopathy is the leading cause of new cases of blindness in adults 20- 74 yrs old ◦ Has few warning signs – ongoing eye evals are important ◦ Treatment: laser photocoagulation therapy 30

31. Long-Term Complications of Diabetes Nephropathy – end-stage renal disease; diabetes is the #1 cause- Primary Symptom: microalbuminuria Disease can be slowed with better blood glucose control and antihypertensive therapy 31

32. Long-Term Complications of Diabetes Neuropathy – mild to severe forms of nervous system damage; esp. in legs and feet  prickly sensation, pain, numbness Loss of nerve reaction  tissue damage and infection including cellulitis, amputation, and ulcerations

33. Long-Term Complications of Diabetes Heart disease – the major cause of death for people with diabetes Medical care is aimed at: blood lipid levels, blood pressure, aspirin use, and smoking cessation ◦ Dyslipidemia—elevated triglyceride, decreased HDL cholesterol  Medical Management: lower the LDL, raise the HDL, lower triglycerides ◦ Hypertension—a major comorbid condition; recommendation for adults with DM = 130/80 33

34. General Management of Diabetes Early detection and monitoring ◦ Community screening programs ◦ Physical examination ◦ OGTT (oral glucose tolerance test) ◦ FBS (fasting blood glucose) ◦ HgA1C (reflects blood glucose for previous 3 months; normal range = 4- 6%) 34

35. Management of Diabetes 3 Basic Goals of Care ◦ Maintaining optimal nutrition ◦ Avoiding symptoms of hyperglycemia, hypoglycemia or glycosuria ◦ Preventing complications Good Self-care skills Basic Elements of DM management: ◦ Healthy diet ◦ Physical exercise ◦ Blood glucose control 35

36. Management of Diabetes: Nikki Wallis

37. Management of Diabetes Special considerations in pregnancy for the diabetic mother ◦ Body metabolism changes to meet the increased physiologic needs of the pregnancy while battling the manifestations of diabetes 37

38. Medical Nutrition Therapy Core Problem: Glycemic control ◦ 3 main principles of nutrition therapy:  Total kcals necessary for energy balance  Ratio of these kcals in relative amounts of the 3 energy nutrients: CHO, fat, protein  A food distribution pattern for the day 38

39. Medical Nutrition Therapy Practically this means: Total Energy Balance: ◦ Weight control/reduction (type 2) – starts in childhood ◦ Sufficient energy intake ◦ Balance of energy intake and output – physical exercise increases the body’s ability to use glucose by increasing the insulin-receptor sites Nutrient Balance ◦ Balance of carbohydrate, fat, protein 39

40. Medical Nutrition Therapy Starch and Sugar: ◦ A food’s Glycemic Index is determined by measuring the increase in blood glucose after ingestion of 50g CHO sample ◦ The rate of digestion and absorption of a CHO determines its Glycemic Index ◦ The Glycemic Index indicates that starch foods greatly differ from one another in their ability to raise plasma glucose levels 40

41. Medical Nutrition Therapy Fiber: consume what is recommended for the general public Sugar Substitute Sweeteners ◦ Nutritive and nonnutritive ◦ Consume only in moderation Protein –high protein intake is generally not recommended due to the saturated fat content and stress on kidneys from the excretion of excess nitrogen Fat – usual recommendations; control fat-related foods to reduce development of atherosclerosis 41

42. Food Distribution Balance Basic pattern: Eat even amounts of food at regular intervals. Plan ahead! Maintain even blood glucose supply. Snacks may be needed. 42

43. Food Distribution Balance Adjust eating according to activity level and stress. Regulate glycemic response according to physical activity/exercise Medication influence on glucose throughout day

44. Diet Management Individual Needs  appropriate and realistic care Clinical/Nutritional Dietician services  variety of methods Food Exchange System: This was a plan that allowed people to swap foods of similar nutritional value A tool to calculate the patient’s energy and nutrient needs Commonly used foods are grouped into 3 basic exchange lists according to roughly equal food value 44

45. Diet Management CHO counting: ◦ A way to balance CHO intake with insulin injections Special Concerns ◦ “diabetic” special foods not needed if using a regular, well-balanced diet  Use fresh foods as much as possible 45

46. Diet Management/Special Concerns Limit alcohol; plan carefully. Take with food which will slow its absorption; do not increase insulin dose because the overall effect of alcohol is to lower blood sugar Avoid hypoglycemia. ◦ Hypoglycemia can occur from too high a dose of insulin or oral hypoglycemic medications; if a snack is delayed, or increased exercise without increased kcals 46

47. Diet Management/Special Concerns Illness: adjust food and insulin ◦ Maintain food intake if possible ◦ Avoid skipping meals; adjust texture to liquid nourishment if needed ◦ Do not omit insulin; follow an adjusted dosage ◦ Monitor blood glucose level frequently ◦ Contact health care provider prn 47

48. Diet Management/Special Concerns Travel: consider food choices of where you will be going ◦ Review meal planning skills, exchange options ◦ Plan for time-zone changes ◦ Carry quick-acting CHO ◦ Inform companions about s/sx hypoglycemia ◦ Wear ID bracelet ◦ Obtain cover letter from health care provider re: Insulin prescription, needles and syringes 48

49. Diabetes: medic alert tags

50. Diet Management/Special Concerns Eating Out: Plan ahead! ◦ Adjust food eaten before or after eating out in order to maintain the continuing day’s balance Stress – affects diabetes because of the hormonal responses that are antagonistic to insulin action. ◦ Learn useful stress-reduction exercises and activities as a part of self-care skills 50

51. Diabetes Education Program Person-Centered Care: Any effective and successful diabetes education program must focus on personal needs and informed self-care skills. 51

52. Diabetes Education Program Tools for Self-care: ◦ Understand nature of diabetes ◦ Nutrition—develop sound food plan ◦ Insulin—know type, duration of action, combinations ◦ Monitor glucose levels ◦ Control emergencies, illness ◦ Identification bracelet

53. Diabetic Educators Health professionals such as doctors, nurses, dietitians, pharmacists, exercise specialists, and social workers who specialize in the treatment of people with diabetes. 53