Diabetes Management through Nutrition

 Diabetes Management through Nutrition

Prevalence

•         Increases with age

•         Gender Difference

•         Racial, Ethnic – Disproportionate prevalence among African Americans, Hispanic Americans and American Indian

Increase in Overall Prevalence

•         Increasing Age of US population

•         Reduction in Mortality Rate

•         Increase in Risk Factors such as

–       Obesity

–       Physical Inactivity

Mortality Risk

•         Duration of Diabetes

•         Lack of Blood Glucose Control

•         Cardiovascular Risk Factors such as

–       Smoking

–       Hypertension

–       Abnormal Lipid Levels

–       Physical Inactivity

–       Central Obesity

Causes of Death Among People With Diabetes

Geiss LS et al. In: Diabetes in America. 2nd ed. 1995:233-257.

Pathophysiology

•         Genes

•         Obesity

•         Sedentary Lifestyle

•         Aging

Classification

•         Diabetes Mellitus and Other Categories of Glucose Intolerance

–       DM (with four subclasses)

–       Impaired Glucose Tolerance

–       Gestational DM

Four Types of DM

•         Type I DM (Insulin Dependent)

•         Type II DM (Non-Insulin Dependent)

•         Secondary/other types of diabetes associated with certain conditions

•         Malnutrition related DM

Type I DM

•         Presence of ketosis

•         Almost complete lack of insulin or severe lack of

•         Autoimmune Cause

•         Patients commonly lean

Type II DM

•         Most Common

•         Strong Genetic Basis

•         Absence of Ketosis

•         Inadequate Insulin Secretion

•         Obesity a strong factor

Secondary/Other Type

•         Related to certain diseases, conditions or drugs

•         Known or probable cause

•         Treatment of underlying disorder may ameliorate the diabetes

•         Hyperglycemia present at level diagnostic of diabetes

Malnutrition Related Diabetes Mellitus

•         Mostly in developing countries

•         Among 10 to 40 year olds

•         Hyperglycemia present without ketoacidosis

•         Role of malnutrition as a causal factor is unknown.

Impaired Glucose Tolerance

•         Higher than normal plasma glucose but lower than the diagnostic values for DM

•         Precursor for Type II

•         Only about 25% develop into type II and rest go back to normal

•         Patients are more susceptible to macrovascular diseases. 

Gestational DM

•         2-4% during second or third trimester

•         Onset of DM with pregnancy

•         More common in older women with family history of dm

•         Higher chance of developing NIDDM

  

Types of DM

* growing incidence in adolescents

 Diagnosis of Diabetes

•         Polydipsia – Increased thirst

•         Polyuria – Increased frequency of urination

•         Fatigue

•         Polyphagia – Increased Fatigue

•         Weight Loss

•         Abnormal Healing

•         Blurred Vision

•         Increased occurrence of infections

Diagnostic Criteria

FPG = Fasting Plasma Glucose                                                                 RPG = Random Plasma Glucose                                                              OGTT = Oral Glucose Tolerance Test

FPG = Fasting Plasma Glucose                                                                 RPG = Random Plasma Glucose                                                              OGTT = Oral Glucose Tolerance Test

Risk Factors for Asymptomatic Patients

•         Strong Family History

•         Obesity

•         Certain Races

•         Women with previous GDM

•         Previous IGT

•         Hypertension or hypertriglyceridemia

•         40 years old with any of the above

Goals of Treatment

•         Alleviate symptoms

•         Prevent complications

•         Prevent progression of current complications

•         Improve quality of life

ADA Goals of Treatment _(cont.)

ADA Goals of Treatment _(cont.)

•         Before Meals

–       normal                                  < 110

–       goal                            90 - 130

•         Peak Post Prandial

–       normal                                  < 140

–       goal                            < 180

•         Bedtime

–       normal                                  < 120

–       goal                            110 -150

Insulins

•         Rapid acting: Lispro (Humalog) 

•         Short acting: Regular

•         Intermediate: NPH or Lente

•         Long-acting: human Ultralente

•         Basal insulin: Glargine

 Insulin action

Nutrition

•         Nutrition Therapy – The Most Fundamental Component of the Diabetes Treatment Plan

•         Goals:

–       Near Normal Glucose Levels

–       Normal Blood Pressure

–       Normal Serum Lipid Levels

–       Reasonable Body Weight

–       Promotion of Overall Health

Nutrition Therapy Diet Teaching

•         Goal - independence; effective self-management.

•         Include Family.

•         Follow prescribed plan; accurate portions

•         Never skip meals

•         Concern - Alcohol

•         Concern - Dietetic Foods

Nutrition Consult

•         Conduct Initial Assessment of Nutritional Status

•         Diet History, Lifestyle, Eating Habit

•         Provide Patient Education Regarding

–       Basic principles of diet therapy

–       Meal planning

–       Problem solving

–       Developing individualized meal plan

–       Emphasize one or two priorities

–       Minimize changes from the patient’s usual diet

Nutrition Therapy

•         Provide Follow-up assessment of the meal plan to

–       Determine effectiveness in terms of glucose and lipid control and weight loss

–       Make necessary changes based on weight loss, activity level, or changes in medication

–       Provide ongoing patient education and support

Nutrition Goals for
    Type 1 ***                                                                                     *** Type 2

Nutritional Goals (con’t)

      Type I **                                                                                               **Type 2

Dietary Management of Diabetes

•         Maintain as near-normal blood glucose levels as possible by balancing food, insulin and exercise

•         Achieve recommended serum blood lipid levels

•         Provide energy intake to maintain or attain healthy weight

•         Prevent and treat acute and long-term diabetes-related complications

•         Enhance over all health

Weight Loss

•         Improves Glucose Control

•         Increases Sensitivity to insulin

•         Lower lipid levels and blood pressure

•         Corresponding lowering of the dosage of pharmacologic agents

For a Successful Outcome

•         Modest Caloric Restrictions

•         Spreading caloric intake throughout the day

•         Increased Physical Activity

•         Behavior Modification

•         Psychosocial Support

Nutrient Components

•         Protein*

•         Fat*

•         CHO*

•         Sucrose and Fructose

•         Nutritive Sweeteners

•         Fat Replacements*

•         Vitamins and Minerals

Protein Intake

•         Small to medium portion of protein once daily

•         12-20% of daily calories

•         From both animal and vegetable sources

•         Vegetable source less nephrotoxic than animal protein

•         3-5oz of meat, fish or poultry daily

•         Patient with nephropathy should limit to less than 12% daily

Fat Intake

•         <35% of total calories

•         Saturated fat <10% of total calories

•         Polyunsaturated fats 10% of total calories

•         Cholesterol consumption < 300 mg

•         Moderate increase in monounsaturated fats such as canola oil and olive oil (up to 20% of total calories)

CHO Intake

•         CHO intake determined after protein and fat intake have been calculated.

•         Emphasize on whole grains, starches, fruits, and vegetables

•         Fiber same as for nondiabetics (20g to 35g)

•         Rate of digestion related to the presence of fat, degree of ripeness, cooking method, and preparation

Nutritive Sweeteners and Fat Replacements

•         Nutritive Sweeteners: corn syrup, fruit juice concentrate, honey, molasses, dextrose, and maltose have same impact on calorie and glycemic response

•         Fat substitutes are derived from CHO or protein sources.  So, CHO and Protein content should be reviewed before using

Nutrition

•         Individualized Diet Treatment Plan

•         Diet changes do not have to be dramatic

•         Regular monitoring of blood glucose, glycated hemoglobin, lipid levels, blood pressure, and body weight

Exercise

•         Potential Benefits

–       Improved Glucose tolerance

–       Weight loss or maintenance or desirable weight

–       Improved cardiovascular risk factors

–       Improved response to pharmacologic therapy

–       Improved energy level, muscular strength, flexibility, quality of life, and sense of well being

Precautions and Considerations

•         Consult a physician

•         Rule out significant cardiovascular diseases or silent ischemia

•         Prevent hypoglycemia with self-monitoring of capillary blood glucose (SMCBG) both before and after exercising

•         Strenuous exercise not recommended for people with poor metabolic control and significant complications

Exercise Prescription

•         Interest

•         Capacity

•         Motivation

•         Physical status

•         Individualized approach