Diabetes mellitus and Carbohydrate disorder

Diabetes mellitus and Carbohydrate disorder

DIABETES MELLITUS DM 

– complex chronic metabolic disorder leading to multiorgan complications Main pathophysiological questions related to DM

Why and how the DM develops?

Why and how develop the complications of DM?

What are the mechanisms involved in manifestation of diabetic symptoms and signs  ?

Regulation of the blood glucose level depends on liver:

                1. extracting glucose from blood

                2. synthesizing glycogen

3. performing glycogenolysis

4.performing gluconeogenesis

•       Plasma glucose is tightly regulated by hormones:

 ↓Plasma glucose

  Insulin

 ↑Plasma glucose

 Glucagon

 Epinephrine

     CortisolGrowth hormone

               

Definition of DM

DM is a chronic complex syndrome induced by absolute or relative deficit of insuline which is characterized by metabolic disorders of carbohydrates, lipids and proteins.

The metabolic disturbances are accompanied by loss of carbohydrate tolerance, fasting hyperglycaemia, ketoacidosis, decreased lipogenesis, increased lipolysis, increased proteolysis and some other metabolic  disorders

                                 Classification of DM 

Base for the classification are etiopathogenetic mechanisms

involved in onset and development of DM

Types of DM

I. Diabetes mellitus - type 1: due to destruction of beta cells of pancreatic  islets

                Consequence: absolute deficit of insulin

                A. subtype: induced by autoimmunity processes

                B. subtype: idiopathic mechanism

 II.Diabetes mellitus -type 2: at the beginning-predomin of insulin resistance  and relative deficit of insulin(normo-hyper -insulinemia), later on - combination of impaired insulin secretion and simultaneous insulin resistance (hypoinsulinemia, insulin resistance)

III. Other specific types of DM

               

    · DM due to genetic defects of beta cells of pancreas islets

      and due to genetic defect of insulin function

               

     · DM due to diseases influencing exocrine functions of pancreas –

        - secondary is damaged endocrine function, too.

               

     · DM due to endocrinopathies, drugs, chemicals, infections,

        metabolic and genetic disturbances

IV. Gestational DM -

glucose intolerance which onsets for the first time  during pregnancy

WHO Diagnostic Criteria DM

􀂄 Fasting blood glucose > 126 mg/dl

􀂄 Random blood glucose > 200 mg/dl

􀂄 One value is diagnostic in symptomatic

individuals

􀂄 Two values are needed in    asymptomatic people

• Population Doubling Time in
  Some Mediterranean Countries
• (HYPOGLYCEMIA (INSULIN REACTIONS
  
   The blood glucose falls to less than
    50 -60 mg/dL.
   It can be caused by too much insulin or  oral hypoglycemic agents, too little    food, or excessive physical activity.
  
   It often occurs before meals,      
   especially if meals are delayed or  
   snacks are omitted.
• 
  
   The blood glucose falls to less than
    50 -60 mg/dL.
   It can be caused by too much insulin or  oral hypoglycemic agents, too little    food, or excessive physical activity.
  
   It often occurs before meals,      
   especially if meals are delayed or  
   snacks are omitted.
• 
  Clinical Manifestations
  
   The clinical manifestations of hypoglycemia  
   may be grouped into two categories:
   1-adrenergic symptoms
   2-central nervous system (CNS) symptoms.
   In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in a rise of epinephrine or nor epinephrine.
   This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness, and hunger
• 
  Clinical Manifestations
   In moderate hypoglycemia, the fall in blood glucose level
  deprives the brain cells of needed fuel for functioning.
   Signs of impaired function of the CNS may include inability to
  concentrate, headache, lightheadedness, confusion, memory
  lapses, numbness of the lips and tongue, slurred speech, impaired
  coordination, emotional changes, irrational or combative
  behavior, double vision, and drowsiness.
   In severe hypoglycemia, CNS function is so impaired. Symptoms
  may include disoriented behavior, seizures, difficulty arousing
  from sleep, or loss of consciousness
• Diabetic Ketoacidosis (DKA)
• Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. DKA occurs mostly in type 1 diabetes. It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia.
• Nonketotic Hyperosmolar Syndrome (NKHS)
• Nonketotic hyperosmolar syndrome (NKHS) is a metabolic complication of diabetes mellitus (DM) characterized by hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. It most often occurs in type 2 DM, often in the setting of physiologic stress. NKHS is diagnosed by severe hyperglycemia and serum hyperosmolarity and absence of significant ketosis. Treatment is IV saline solution and insulin. Complications include coma, seizures, and death
• Nutrition and diabetes
  􀂄 Nutritional management of DM should
  start with nutritional assessment.
  􀂄 Food for diabetic people should be:
  􀂄 High in starchy carbohydrates
  􀂄 High in NSP (fibre)
  􀂄 Low in salt and sugar (not sugar free)
  􀂄 Low in fat (mainly saturated fat)
• Nutrition and diabetes
  􀂄 Having diabetes doesn't mean that you
  have to start eating special foods.
  􀂄 Rather than a restrictive diet, a diabetic
  diet is a healthy-eating plan that is
  rich in nutrients and doesn’t differ
  from diet considered healthy for
  everyone.
  􀂄 Establish a routine for eating meals.
  Consistency is a key.
• Artificial sweetening
  agents
  􀂄 Sugar substitutes that contain little or
  no calories are called artificial
  sweeteners, non-nutritive sweeteners or
  non-caloric sweeteners.
  􀂄 Well-known artificial sweeteners include
  saccharin, sucralose and aspartame.
  􀂄 Nutritive sweeteners include sucrose
  and fructose.
• Artificial sweetening
  agents(cont)
  􀂄 Moderate use of nutritive (sucrose and
  fructose) and non-nutritive sweeteners
  (saccharin, aspartame and cyclamate)
  can be part of a well-balanced diet for
  diabetics.
  􀂄 However, diabetic patients, as other
  people, should accustom themselves to
  the low-sweetness taste.
• 
  

The Carbohydrates

• * Simple Carbohydrates
• * Complex Carbohydrates
• * Starches
• * Fiber

• Carbohydrate metabolism disorder
• First we will talk about the normal Carbohydrate metabolism in the body
• Carbohydrate metabolism:
• Carbohydrate metabolism begins with digestion in the small intestine where monosaccharides are absorbed into the blood stream. Blood sugar concentrations are controlled by three hormones: insulin, glucagon, and epinephrine. If the concentration of glucose in the blood is too high, insulin is secreted by the pancreas. Insulin stimulates the transfer of glucose into the cells, especially in the liver and muscles, although other organs are also able to metabolize glucose
• In the liver and muscles, most of the glucose is changed into glycogen by the process of glycogenesis (anabolism). Glycogen is stored in the liver and muscles until needed at some later time when glucose levels are low. If blood glucose levels are low, then eqinephrine and glucogon hormones are secreted to stimulate the conversion of glycogen to glucose. This process is called glycogenolysis (catabolism).
• If glucose is needed immediately upon entering the cells to supply energy, it begins the metabolic process called glycoysis (catabolism). The end products of glycolysis are pyruvic acid and ATP
• During strenuous muscular activity, pyruvic acid is converted into lactic acid rather thatn acetyl CoA. Durlng the resting period, the lactic acid is converted back to pyruvic acid. The pyruvic acid in turn is converted back to glucose by the process called gluconeogenesis (anabolism). If the glucose is not needed at that moment, it is converted into glycogen by glycogenesis
• Carbohydrate Metabolism Disorders
• The metabolism of the carbohydrates galactose, fructose, and glucose is intricately linked through interactions between different enzymatic pathways, and disorders that affect these pathways may have symptoms ranging from mild to severe or even life-threatening. Clinical features include various combinations of hypoglycemia (low blood sugar), liver enlargement, and muscle pain.
• Glycogen Storage Diseases 1-
• Glycogen storage diseases are caused by deficiencies of enzymes involved in glycogen synthesis or breakdown; the deficiencies may occur in the liver or muscles and cause hypoglycemia or deposition of abnormal amounts or types of glycogen (or its intermediate metabolites) in tissues
• Defects in glycolysis (rare) may cause syndromes similar to GSDs.
• 2-Galactosemia
• Galactosemia is caused by inherited deficiencies in enzymes that convert galactose to glucose. Symptoms and signs include hepatic and renal dysfunction, cognitive deficits, cataracts, and premature ovarian failure. Diagnosis is by enzyme analysis of RBCs. Treatment is dietary elimination of galactose.
• Galactose is found in dairy products, fruits, and vegetables .
• 3-Disorders of Fructose Metabolism
• Deficiency of enzymes that metabolize fructose may be asymptomatic or cause hypoglycemia, nausea and vomiting, abdominal pain, sweating, tremors, confusion, lethargy, seizures, and coma.
• Fructose is a monosaccharide that is present in high concentrations in fruit and honey and is a constituent of sucrose and sorbitol.
• 4-Disorders of Pyruvate Metabolism
• Inability to metabolize pyruvate causes lactic acidosis and a variety of CNS abnormalities.
• Pyruvate is an important substrate in carbohydrate metabolism
• Pyruvate dehydrogenase deficiency: Pyruvate dehydrogenase is a multi-enzyme complex responsible for the generation of acetyl CoA from pyruvate for the Krebs cycle. Deficiency results in elevation of pyruvate and thus elevation of lactic acid levels
• OTHER DISORDERS OF CARBOHYDRATE METABOLISM

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Nutrition Therapy in Diabetes Mellitus type 2

Introduction

Diabetes is a chronic disease that requires changes that last a lifetime. The management of diabetes includes medical nutrition therapy (MNT), medications, exercise, blood glucose monitoring, and self-management education/behavior modification.

 Type 2 diabetes should not be viewed as a less severe version of type 1 as it is a highly malignant condition with 50% of affected individuals dying within 10 years of the diagnosis.

A major contributing factor to the development of Type 2 diabetes is body weight and the incidence of type 2 diabetes begins to rise at a BMI of 23 kg/m2.

The overall goal of diabetes management is to help individuals with diabetes and their families gain the necessary knowledge, life skills, resources and support needed to achieve optimal health. This requires a team effort that includes diabetes health care professionals and the individuals who must deal with this chronic condition on a daily basis. The dietitian is a key member of the health care team, who plays an integral role in the individualization of management strategies for people with diabetes and those at risk for developing it.

General Principles

 In general, nutrition advice for people with diabetes is the same as that for all people, and follows the principles for healthy eating:

The optimum healthy choice of food for people with diabetes is the same for the general population

Enjoy a variety of foods. .

A regular meal pattern based on starchy carbohydrate foods such as bread, potatoes, rice, and pasta .Choose wholegrain foods where possible. Replace fried food with grilled or steamed

Emphasize cereals, breads and other whole grain products, vegetables and fruits.

Choose lower-fat dairy products, leaner meats and foods prepared with little or no fat. replacing saturated fat with monounsaturated rich fats and oils

Achieve and maintain a healthy body weight by enjoying regular

       physical activity and healthy eating.

General Principles

The goals of medical nutrition therapy

Achieve and maintain optimal blood glucose and lipid levels through appropriate food choices.

Improve quality of life and overall health.

Empower persons to self-manage their diabetes by providing information to increase their knowledge and skills.

Teach prevention and treatment of the acute complications of hypoglycemia, hyperglycemia

The goals of medical nutrition therapy

Provide adequate energy and nutrients for attaining and or maintaining a reasonable weight for adults and normal growth and development rates for children and adolescents, and meeting increased needs during pregnancy, lactation, or recovery from illness (reasonable weight is considered the weight an individual and health care professional agree upon to be achievable and maintainable; both short term and long term this weight may be different than desirable body weight).

Reduction of weight in obese patient to reduce insulin resistance.

Prevent or delay the long-term complications of diabetes such as retinopathy, nephropathy, and cardiovascular disease (secondary prevention).

     Weight management and monitoring glycaemic conttrol

More than 80% of people diagnosed with type 2 diabetes are overweight.  Weight management in type2 diabetes is important to help to reduce insulin resistance, control blood glucose levels, and lower the risk of long-term complications. Although preventing weight gain and/or reducing excess body weight can be very challenging, it is central to optimizing diabetes care and is a cornerstone in the dietary management of diabetes.

Monitoring of glycaemic control

Glycosylated hemoglobin (HbA1) should be measured at least annually. values ≤7% are considered a desirable target for most patients with type 1 and type2 diabetes, and are associated with a reduced risk of complications.

     3. Diet therapy

Energy Intake

 - Daily requirements to non-obese diabetic patient are the same needs of healthy person at the same age, sex, height and type of effort. Obese Diabetic (type II) must follow a reduced total Kcal by 500 kcal per day.

-          Resting Energy Expenditure (REE) method:

(Men) = 66.5 + [(wt x 13.75) + (ht x 5.0) – (age x 6.78)]

(Women) =655.1 + [(wt x 9.56) + (ht x 1.85) – (age x 4.68)]

Protein

 Typically, protein accounts for approximately 12 to 20% or more of total calories consumed. At present, scientific evidence does not support either a higher or lower protein intake for the person with diabetes, and protein intakes in the range of 10 to 20% of daily calories are recommended (RDA). In the presence of diabetic nephropathy, protein should not exceed 0.8 g/kg or 10% of total calories.

Protein intake should not go below 0.6 g/kg/day

Fat

 Fat intake generally should not exceed 30% of energy. Most importantly, saturated fats, because of their atherogenic potential, should be held at a maximum of 10% of energy needs.

      Polyunsaturates, with their tendency to lower HDL-cholesterol values and their susceptibility to oxidation, should also be held under 10%.

      monounsaturated, should be at or  more 10% ; sources such as: canola or olive oils.

 Cholesterol intake, though less influential than saturated fats on serum lipid values, should be held under 300 mg/day. These are consistent with those of the American Heart Association and other groups.

Fat

If LDL cholesterol level elevated

-Saturated fat 7% of kcal

-Cholesterol < 200 mg daily

FISH OILS (n-3)

evidence showing that fish oils can reduce plasma triglycerides and VLDL concentrations in the diabetic population, as well as reducing blood pressure.

there are also potential effect of fish oils on LDL cholesterol and glycaemic control in people with diabetes.

Types of fat

CHO

Carbohydrate depends on the state of the patient's case, food habits and nutritional goals. CHO should provide 50 to 60% of energy intake. Simple CHO (not as severely restricted in the past) should make  less than 1/3 of total CHO intake. Addressing a sufficient quantity of carbohydrates is important for all individuals, as well as for diabetics.

Total carbohydrate – more important than the type of carbohydrate consumed

Choose foods and beverages with little added sugar or kcaloric sweeteners

Artificial sweeteners (aspartame, saccharin) used in  place of sugar.

Food Sources

Grains, vegetables and fruits are a good source of Carbohydrates, it also provides us with vitamins, minerals and fiber. And  diabetic’s attention for Carbohydrates must be on total quantity rather than rely on food sources.

             Vitamins and Minerals:

There is a need for more conclusive evidence on the benefits of vitamins and antioxidant nutrients in terms of protection from cardiovascular disease and general health benefits for the diabetic and non-diabetic population.

Pharmacological doses of supplements are therefore not advised. However, it is recommended that a diet rich in foods which naturally contain significant quantities of antioxidants, especially fruit and vegetables, is followed.

 When food is balanced for diabetics there is no need for the

 use of vitamins and minerals supplements.

Alcohol use in DM

May use in moderation

Women – 1 drink/day   

Men – 2 drinks/day

Should consume food with alcoholic beverages – to avoid hypoglycemia

Interfering with gluconeogenesis in the liver

Excessive alcohol intakes can worsen hyperglycemia – raise triglyceride levels in some individuals

Abstention recommended with:

Pregnancy

Pancreatitis

Advanced neuropathy

Abnormally high triglyceride levels

          Table Salt :

             Often  diabetic Patients suffer from hypertension, where the salt plays role in that. Therefore, diabetic patients are advised not to eat more than 3000 mg of sodium daily. And in the event of a  high blood pressure for patients with diabetes ,patient must  reduce the proportion of sodium to 2400 mg or less daily. And for patients who suffer from high blood pressure in addition to the renal failure,  reducing the deal to 2000 mg sodium or less per day.

Fiber: 

The intake of an adequate amount of dietary fiber is considered very important.

the daily fiber requirements  for diabetic patients   is similar to the requirements of healthy people,  20- 30 g of fiber daily to  prevent constipation and reduce cholesterol and glucose levels.

Insoluble fiber:  (cellulose, hemicelluloses)

Soluble fiber: (gums and pectin)

      found in fruits and vegetables is more beneficial than insoluble fiber in DM, because it decreases the post-prandial glycaemia and acts favorably on blood lipids.

                    Micronutrient intakes

Folate supplements during pregnancy – prevent neural tube defects

Calcium supplements to reduce osteoporosis risk in older adults

Chromium supplementation not recommended for persons with DM2

Physical Activity

There is now unequivocal evidence that physically fit people are less likely to develop Type 2 diabetes and some intervention trials have shown that encouraging people with impaired glucose tolerance (IGT) to increase their physical activity significantly reduces their risk of developing diabetes .

This benefit is independent of body mass index (BMI) and there is some evidence that physical activity has a greater protective effect as BMI increases . It may be of more importance for people at risk of Type 2 diabetes to increase their physical fitness rather than concentrate on weight reduction.

Physical Activity

The practice of sport is very important for diabetics. Programme activities include exercise average of 20-30 minutes of air activities such as walking and scrambling at least three times a week:

Improves the ability of the body to make use of glucose and increase insulin sensitivity.

 Adjusts the level of lipids in the blood and helps to increase weight loss.

 Reduces the requirements for insulin up of 10 - 20%.

They also improve blood circulation and

       stimulate the muscles and give a sense

      of vitality and pay the morale of the patient.

Physical Activity

• Blood glucose levels drop during activity.
• Don’t inject insulin prior to exercise.
• If blood glucose below 100 mg consume carbohydrate prior to exercising
• During exercise:

.20–30 min of light/moderate activity should not require extra CHO

.30–60 min of moderate activity may require an extra 10–20g CHO

.30–60 min of strenuous activity may require an extra 30–50g CHO

•  Remember to consume adequate fluid to prevent dehydration And Proper footwear.

Nutritional Status Assessment in Diabetic Patients 

q  Anthropometric measurements recorded:

. Height (m)                              . Weight (kg)

. BMI (kg/m2)                            .  Waist circumference (cm)

Clinical finding

Laboratory which might include:

. Blood pressure

. Fasting/random blood glucose (mmol/l)

. HbA1c (%)

. Total, HDL and LDL cholesterol levels (mmol/l)

. Triglycerides (mmol/l)

and where appropriate indicators of renal function (and liver function).

Meal Planning

To help the patient meals plan better, options include:

exchange lists

carbohydrate counting

Menu approach. (See Sample menu

   for a diabetic patient)

Exchange lists

Exchange lists serve as the basis for a meal-planning system recommended by the ADA. The lists simplify meal planning, help the need for daily calculations, and ensure a consistent intake.

 Sorts foods according to their proportions of carbohydrate, fat, and protein – each item in the group is similar in macronutrient and energy content

Exchange lists Table

Carbohydrate counting

Carbohydrate information on food labels has simplified carbohydrate counting. The system is easier to learn than the exchange lists system, gives the patient more flexible food choices, and provides a better estimate of how much the blood glucose level will rise after a meal or snack. Also, if the patient takes insulin, carbohydrate counting can be helpful in determining insulin dosages.

Menu approach

In the menu approach, the patient and dietitian collaborate to develop menus tailored to the patient’s needs and preferences. As the patient desires, menus may be relatively flexible, dictating specific foods and the amounts that the patient must eat at specific times.

The menu approach is best for patients who have fairly regimented eating habits or who want to be told exactly what and how much to eat.

Example

  - Gender: female – (non pregnant)      

       - Age: 45 years

       - Height: 170 cm

       - Weight: 95 kg

       - Diagnosis: DM (type 2)

       - Activity level: sedentary

Method 1:

         655.1 + [(wt * 9.56) + (ht * 1.85) – (age * 4.68)] * AF

         655.1 + [(65 * 9.56) + (170 * 1.85) – (45 * 4.68)] * AF

         655.1 + [(621.4) + (314.5) – (210.6)] * AF 

        (655.1 + 725.3) = 1380.4 kcal per day

  

Method 2:     Add activity factor

      1380.4* 1.2 = 1656.48 = 1650   Kcal per day

CHO = 60 %         -   1650  * 0.60 =  990 kcal  / 4 gm=  247.5 gm                                      

Protein = 20 %      -  1650 * 0.20 =  330 kcal  / 4 gm =  82.5gm                                      

Fat = 20%             -  1650* 0.60 =  330kcal  / 9 gm =  82.5gm                         

 Diabetes in special groups

Nutrition therapy for pregnant women with diabetes and GDM:

      is individualized on the basis of the nutrition history, pre-pregnancy weight, and physical activity levels. Generally, an additional 100 to 300 cal/day is added to the meal plan at the beginning of the second trimester. Three main meals and 3 snacks are recommended.

Adequate nutrition for mother and fetus, this should meet all the nutrient requirements of pregnancy through the provision of regular meals that include a large component of slowly absorbed carbohydrate.

Energy intake that limits unnecessary maternal weight gain

Nutrition therapy for pregnant women with diabetes and GDM

Recommended pregnancy weight gain in women with gestational diabetes :

  BMI             Weight gain(kg)

                 <25                   10-12.5

                 25-30                  7-11.5

                 30-34                  7

                 >34                    0    

Limiting weight gain in pregnancy is controversial but in obese women with GDM is associated with decrease risk of hypertension, CS, large for gestational age babies but no increase in risk of preterm delivery or small for gestational age babies , and Blood sugar level should be monitored regularly and insulin dose and frequency adjusted to maintain capillary between 4.4-6.1 mmol/l before meals and<8.6mmol/l after meals.

  Diabetes in children and adolescents

The nutrition prescription is based on the nutrition assessment. Newly diagnosed children often present with weight loss and hunger, and as a result the initial meal plan must be based on adequate calories to restore and maintain appropriate body weight. Several formulas can be used to confirm that a child or adolescent is receiving the minimum number of             calories necessary for growth and development.

Diabetes in children and adolescents

Height and weight should be recorded on growth charts every 3 to 6 months to make sure children are growing normally. If not, the overall diabetes management needs to be assessed. Caloric needs in children change continuously, and, therefore, food intake should be evaluated every 3 to 6 months.

Daily eating patterns in children generally require three meals and three snacks, depending on the length of time between meals and physical activity level. The purpose of the snacks is to prevent hypoglycemia between meals.

Estimating Caloric Requirements for Youth

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