NUTRITION AND DIABETES MELLITUS

Dr Sivakumar Gowder
INTRODUCTION

In the United States:

– 12.3% of adults aged 20 and older have diabetes
(about 29 million people)
– One of top ten leading cause of death in the world
(Ref: Science message-7)
– 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

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
SYMPTOMS -DIABETES MELLITUS

-Excessive urine production – polyuria

-Dehydration, dry mouth
-Excessive thirst (polydipsia)
-Weight loss
-Excessive hunger (polyphagia)
-Blurred vision
-Increased infections
-Fatigue
DIAGNOSIS OF DIABETES MELLITUS

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)

DIAGNOSIS OF DIABETES MELLITUS

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
TYPES - 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
TYPES OF DIABETES MELLITUS

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
TYPES OF DIABETES MELLITUS

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)
TYPES OF DIABETES MELLITUS

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
PREVENTIVE METHODS

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
PREVENTIVE METHODS

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
COMPLICATIONS OF DIABETES MELLITUS

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
COMPLICATIONS OF DIABETES MELLITUS

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
COMPLICATIONS OF DIABETES MELLITUS)

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
COMPLICATIONS OF DIABETES MELLITUS

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
COMPLICATIONS OF DIABETES MELLITUS

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
COMPLICATIONS OF DIABETES MELLITUS

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

– [Claudication: pain in the arms and legs;

Gangrene: death of body tissue due to lack of blood supply]
COMPLICATIONS OF DIABETES MELLITUS

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
COMPLICATIONS OF DIABETES MELLITUS

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

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

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
TREATMENT
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
TREATMENT
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
TREATMENT

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

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
TREATMENT

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
TREATMENT

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
TREATMENT

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
TREATMENT

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

Carbohydrate counting
– What is the advantage of advanced carbohydrate
counting?

Food lists for diabetes

– Meal plan created by choosing foods with specified
portions from the lists
– Less flexible than carbohydrate counting
– Lists are useful resources for CHO counting
TREATMENT

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

Insulin preparations:
– 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
TREATMENT

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
TREATMENT

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
TREATMENT

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
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
TREATMENT

Antidiabetic drugs:

– For type 2 treatment

– Oral medications and injectable drugs other than

insulin
TREATMENT

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

Medical evaluation before exercise:

- Screen for potential problems

- Exercise safety considerations
- Adjust insulin and/or medication doses
- Check glucose before and after exercise
- Avoid vigorous activity during ketosis
TREATMENT

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

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

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

-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

-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
 ASSIGNMENT / EXERCISE-4

Explain the following:

1- Life threatening diseases with two examples

2. Effects of diabetes

3. Hyperglycemia

4. Symptoms of diabetes

5. Treatment of diabetes
THANK YOU