Nutrition and Diabetes

1
Nutrition and Diabetes

• Chapter 19 Nelms, Sucher Long
• Insert some of my slides from Nursing course

2
Diabetes Mellitus (DM)

• Most common endocrine disorder
• Defects in insulin production, insulin action, or
  both
• All types characterized by hyperglycemia (excess
  blood glucose)
• A chronic disease of major public health
  significance amongst Canadians
• Affecting 1.8 million Canadians (5.5 of
  population)
• For every diabetic known, is one not yet
  diagnosed -- likely prevalence is 10 of
  population
• WHO says over 300 million people will have
  diabetes by year 2025

3
A Serious Health Problem

• Major cause of coronary artery disease (CAD) --
  leading cause of mortality
• Leading cause of blindness and kidney disease
• People with diabetes tend to have more health
  problems in middle adult years and die younger
• Financial costs to individual and society

4
Canadian Diabetes Association Website

• http//www.diabetes.ca
• CDA 2008 Clinical Practice Guidelines for the
  Prevention Management of Diabetes in Canada
• http//www.diabetes.ca/files/cpg2008/cpg-2008.pdf
  
• Purchase from bookstore Beyond the Basics Poster

5
Characteristics of Diabetes

• Either not enough insulin is produced and/or body
  does not use insulin properly
• Glucose in blood cannot enter cells so it cannot
  be used for energy
• Glucose accumulates in the blood (hyperglycemia)
• Body burns protein and fat -- produces ketones
• Ketoacidosis results can cause death

6
Types of Diabetes

• Type 1
• Diabetes that is primarily the result of
  pancreatic beta-cell destruction and is prone to
  ketoacidosis
• Usually leads to absolute insulin deficiency

• Type 2
• Diabetes that may range from predominant insulin
  resistance with relative insulin deficiency to a
  dominant secretory defect with insulin resistance

7
Types of Diabetes

• Type 1
• 5-10 of diabetics are Type 1
• Rapid onset usually during youth (before 30
  years)
• Must take insulin daily
• Used to be called Insulin Dependent Diabetes
  Mellitus (IDDM) or juvenile onset diabetes

• Type 2
• 90 - 95 of diabetics are Type 2
• Progressive onset (usually over 40), often occurs
  in obese
• May or may not need insulin
• Used to be called Non-Insulin-Dependent Diabetes
  Mellitus (NIDDM) or adult onset diabetes

8
Types of Diabetes

• Gestational Diabetes Mellitus (GDM)
• Glucose intolerance experienced first during
  pregnancy

9
Etiology of Type 1

• Immune mediated loss of pancreatic beta-cells
• Due to genetic and environmental factors
• Diabetes related auto-antibodies
• Viruses
• At present, no preventive measures are known to
  be effective

10
Etiology of Type 2 Diabetes

• Factors associated with type 2 diabetes include
• older age, family history, certain ethnic
  backgrounds, overweight/obesity (especially
  central adiposity), metabolic syndrome
  (hypertension, dyslipidemia, ), physical
  inactivity, history of GDM, overt CAD, polycystic
  ovary syndrome, history of impaired fasting
  glucose, and impaired glucose tolerance
• Growing evidence justifies promotion of weight
  reduction/control, diet exercise

11
Long-term Complications of Diabetes

• Macrovascular disease
• coronary heart disease, peripheral vascular
  disease, cerebrovascular disease
• Microvascular Disease
• eyes, kidneys
• Aim to maintain tight blood glucose control to
  avoid long-term vascular damage

12
Macrovascular DiseaseDyslipidemia

• Elevated serum lipids increase risk of
  atheroscelorosis and cardiovascular disease
• Diabetics are more likely to have elevated serum
  triglycerides and VLDL cholesterol, and lower
  levels of HDL cholesterol
• Justification behind reducing total fat and
  saturated fat intake

13
Macrovascular DiseaseHypertension

• Need vigorous treatment of diabetics with
  hypertension to avoid macro - and micro vascular
  diseases
• Develops with the onset of nephropathy
• Sodium restriction, weight reduction and
  restricted alcohol intake

14
Microvascular DiseaseRetinopathy

• Major cause of adult blindness
• Associated with higher glycemic levels
• Improved glucose control slows progression of
  retinopathy
• Elevated blood pressure high blood lipids are
  added risk factors
• Need for careful follow-up by ophthalmalogist

15
Microvascular DiseaseNephropathy

• Occurs in 20-40 of diabetics reason for 44 of
  new CKD cases
• Renal dysfunction begins with increased albumin
  excretion (gt 30 mg/24h) and increased glomerular
  filtration rate (GFR)
• Presents shortly after diagnosis but renal
  function can return to normal once glycemic
  control is restored
• May progress to microalbuminuria (30-300 mg/24h)
  - indicates diabetic nephropathy
• Macroalbuminuria (gt300 mg/24h) indicates overt
  nephropathy

16
Microvascular DiseaseNeuropathy

• Functional pathologic changes in the peripheral
  nervous system
• Effects 40-50 of Type 1 and Type 2 diabetics
  within 10 years of onset of diabetes
• Increased risk of foot ulceration
• need for good foot care

17
Adjustments in Metabolism

• Diabetes causes the body to behave as if it were
  in starvation modeeven when large amounts of
  food are consumed.
• Diabetes is due to a lack of insulin activity,
  and intensified by hypersecretion of catabolic
  hormones.

18
Action of Insulin on CHO Metabolism

• Activates the transport system of glucose in
  muscles and adipose cells
• Reduces breakdown and output of glucose from the
  liver glycogen
• Enables the conversion of glucose to glycogen for
  storage in liver and muscle

19
Action of Insulin on Fat Metabolism

• Promotes fatty acid synthesis in the liver
• Promotes TG storage in adipose tissue
• Reduces lipolysis in adipose tissue
• Reduces ketogenesis in liver

20
Action of Insulin on Protein Metabolism

• Promotes amino acid uptake into muscle adipose
  tissue lowers blood amino acid levels
• Reduces amino acid catabolism
• Promotes protein synthesis in muscle and adipose
  tissue to lesser extent in the liver
• Reduces protein degradation in muscle adipose
  tissue and liver

21
Effect of Catabolic Hormones

• Glucagon, adrenal glucocorticoids, and growth
  hormone are called catabolic hormones because
  they are antagonistic to insulin
• Thus the diabetic is in hormonal imbalance

22
Diagnostic Criteria

• Fasting Plasma Glucose (FPG) level of gt7.0
  mmol/L
• or
• Casual PG gt11.1 mmol/L symptoms of diabetes
• Casual any time of the day, without regard to
  the interval since the last meal
• Classic symptoms of diabetes polyuria,
  polydipsia and unexplained weight loss
• or
• 2hPG in a 75-g OGTT gt11.1 mmol/L
• Must have two confirmatory test results

23
Diagnostic Criteria

• Pre-diabetes
• People with Fasting Plasma Glucose levels between
  6.1 and 6.9 mmol/L are considered to have
  impaired fasting glucose (IFG) and have a higher
  risk of developing diabetes and CVD
• Need for screening and lifestyle changes
• Plasma glucose measured 2 hours after a 75 g oral
  glucose load (2hPG) 7.8 - 11.0 mmol/L indicates
  impaired glucose tolerance (IGT)
• Can have IFG IGT

24
Oral Glucose Tolerance Test (OGTT)

• 150 g CHO/ day for 3 days prior to test
• 10 to 16 hour fast, then a glucose load of 75 g
  in 300 mL beverage consumed within 5 minutes of
  fasting blood sample
• Repeat blood samples every 30 min for 2 to 5
  hours

25
SummaryGlucose Levels for Diagnosis
26
Gestational Diabetes (GDM)

• GDM occurs in 3.7 of all pregnancies (8-18 in
  aboriginal populations)
• Justifies screening for all pregnant women
• GD Screen between 24-28 weeks
• 50 g glucose load with FPG 1 hour later
• Diagnosis if PBG gt 10.3 mmol/L
• Increased infant morbidity macrosomia (with
  increased risk of trauma) and neonatal
  hypoglymemia
• Increased risk of later diabetes in mother

27
Glycated Hemoglobin Assays (A1C)

• Blood test that measures an individuals average
  blood glucose levels for preceding 3-4 months
• Expressed as a percentage of total hemoglobin
  that has glucose attached to it
• A1C test not used in diagnosis
• Measure every 3 months when glycemic targets not
  being met or when therapy adjusted
• Every 6 months when targets achieved

28
Screening for Type 2 Diabetes

• Mass screening in general population not
  recommended
• Testing every 3 years for those gt 40 years
  recommended
• More frequent for those in high risk groups
• Overweight youth with two risk factors (family
  hx, member of certain ethnic groups, signs of
  insulin resistance) screen at 10 years of age
  every 2 years

29
Hypoglycemia

• Low blood glucose level (lt4.0 mmol/L)
• caused by excessive insulin or oral
  anti-hyperglycemic agents, too little food,
  delayed or skipped meals/snacks, exercise, or
  alcohol intake without food
• Also called insulin reaction or insulin shock
• Symptoms
• headache, blurred vision, mood changes, seizures,
  coma
• Corrected by ingesting glucose tablets or
  glucagon injection

30
Diabetic Ketoacidosis

• Severe, uncontrolled diabetes, resulting from
  insufficient insulin for glucose utilization
• Causes severe disturbances in CHO, fat and
  protein metabolism
• Ketone bodies (acids) build up in the blood
• Symptoms
• Polyuria, polydipsia, dehydration, fatigue,
  vomiting, fruity odor to breath, labored
  breathing (Kussmaul respiration)
• If not treated with insulin and fluids
  immediately, can result in coma and death

31
Management of Diabetes

• Goal to maintain persons health
• Prevent or delay micro and macro vascular
  complications
• Quality of life and overall sense of well-being
• All aspects of everyday life affected by
  treatment ? client key member of DHC team
• Includes
• food intake
• medication
• insulin
• oral anti-hyperglycemic drugs
• exercise
• self-monitoring of blood glucose (SMBG)
• laboratory tests
• self-management training

32
Oral Glucose-Lowering Medications

• Also referred to as oral hypoglycemic agents/oral
  anti-hyperglycemic agents
• Used to help control blood glucose levels in Type
  2 diabetes
• Initiated when lifestyle changes have failed to
  achieve target glucose levels in 2 to 3 months
• Aim to attain target A1C within 6-12 months
• May use 2 or more in combination
• As endogenous insulin declines, can use insulin
  along with oral medications

33
Oral Glucose-Lowering Medications

• Sulfonylureas
• stimulate pancreas to release insulin
• Meglitinide
• new class which increases pancreatic secretion of
  insulin, quick acting and can be taken before
  meals
• Biguanides
• decrease liver glucose production, delay glucose
  absorption and enhance glucose uptake
• Alpha-glucosidase inhibitors
• slows down absorption of starch and sucrose in
  small intestine
• Thiazolidinediones
• Lowers insulin resistance and enhances insulin
  action in cells

34
Insulin Therapy

• Insulin formulations classified according to
  their duration of action as well as time of onset
  peak activity.
• Types of Insulin Preparations
• Long acting insulin best used as background
  (basal) insulin
• NPH, Lente, Ultralente
• Short acting insulin
• Regular, Toronto quickly absorbed and best
  used at mealtime
• Rapid acting insulin
• Novorapid, lispro (Humalog) rapidly absorbed and
  best used at mealtime

35
Types of Insulin and Their Actions
36
Insulin Protocols

• Adapt to tx goals, lifestyle, diet, age, general
  health, motivation, capacity for hypoglycemia
  awareness, social/financial circumstances
• Multiple daily injections (3-4)
• basal-bolus I.e. regular or lispro insulin
  before each meal and NPH or lente for basal
  action
• Insulin pen devices
• Continuous Subcutaneous Insulin Infusion (CSII)
  or Insulin Pump Therapy
• 2 Injections per day
• split-mixed i.e. mixture of regular and NPH
  before breakfast and bedtime
• Single injection
• NPH at bedtime with oral agents during day (type
  2 only)

37
Target Glucose Levels
Ideal Optimal (target goal) Suboptimal (action may be req.) Inadequate
Glycated Hb lt100 (.04-.06) lt115 (lt0.07) 116-140 (0.07-0.084) gt 140 (gt0.084)
FBG mmol/L 3.8-6.1 4-7 7.1-10 gt10
Post-prandial 4.4-7 5.0-11 11.1-14 gt14
38
Self Blood Glucose Monitoring (SBGM)

• Monitoring daily changes
• Improves blood glucose control
• Help ID hypoglycemia
• Assess effects of diet, exercise, and treatment
  changes
• Frequency weigh benefits to costs
• Type 2 diet OHA fasting and postmeal
• Type 1 premeal and bedtime intermittent
  postmeal

39
Dietary Management of Diabetes

• Goals
• Maintain or improve quality of life nutritional
  physiological health
• Achieve recommended serum blood lipid levels
• Nutrition therapy reduces A1C by 1-2
• Prevent and treat acute long-term
  diabetes-related complications, associated
  conditions disorders
• Enhance over all health

40
Dietary Management of Diabetes

• Approaches
• Diabetes Self Management Education
• Comprehensive nutrition assessment essential
• Self-care treatment plan
• Consider
• health status
• learning ability
• readiness to change
• current lifestyle

41
Nutrition Goals for Type 1

• Consider intensive insulin therapy to allow
  flexibility in meal patterns
• Integrate insulin therapy with usual food
  intake/eating pattern
• May need consistent mealtime/carbohydrate amounts
  depending on insulin regime (conventional
  therapy)
• Monitor blood glucose levels before bed
  pre-meal
• gt3 times daily correlated with best control

42
Nutrition Goals for Type 2

• Weight loss for those with BMI gt25kg/m2
• Space meals throughout day
• Avoid excessive CHO intake at one meal
• May need consistent mealtime depending on insulin
  use or insulin secretagogues
• Physical activity

43
Dietary Management of Diabetes Guidelines

• CHO gt45 of energy
• gt 60 from low GI high-fibre CHO
• Total fat lt 35
• Saturated -- lt 7 of total energy trans to
  minimum
• Emphasize monounsaturated fats
• Protein 10 - 20 of total energy intake
• Fibre 25-50 grams/day (higher than general
  population)

44
Dietary Management of Diabetes Guidelines

• Carbohydrates and Sweeteners
• Amount and source have effect on postprandial
  blood glucose
• Emphasis on total CHO rather than simple or
  complex
• Different foods have different effects on blood
  sugar level -- glycemic index
• Can have sucrose as part of CHO allotment up to a
  maximum of 10 of calories
• Replacement not addition
• Low nutrient value

45
CHO Source Glycemic Index (GI)

• An indicator ranking carbohydrate rich foods by
  how much they raise blood glucose levels compared
  to a standard food (glucose or white bread)
• Foods with a low GI are digested and absorbed
  more slowly than foods with a high GI
• Low GI foods increase amount of CHO entering
  colon and increase fermentation
• Used for making food choices by diabetics and
  people with impaired glucose tolerance

46
CHO Source Glycemic Index (GI)

• Low GI (55 or less)
• Medium GI (56-69)
• High GI (70 or more)

47
Glycemic Index Value Examples

• Food
• bread
• milk
• sucrose
• orange juice

• Glycemic Index
• 100
• 39
• 87
• 74

48
CHO Counting

• Identify foods that contain CHO
• Count CHO eaten (subtract dietary fibre from
  total CHO)
• Add total CHO provided at each meal/snack
• Keep consistent CHO to determine insulin bolus
• Establish a CHOinsulin ratio
• Label reading is an essential skill

49
Artificial Sweeteners

• Sugar alcohols (sorbitol, mannitol, xylitol)
  cause less rise in blood glucose
• gt10g/day may cause GI upset
• Non-nutritive Sweeteners
• Aspartame (Equal, Nutrasweet)
• Sucralose (Splenda)
• Acesulfame Potassium (Sunet)
• Saccharin (Sweetn Low, Sugar Twin)
• Cylamates (Sucaryl)
• Both of these not recommended during pregnancy

50
Individualized Menu Planning

• Client needs individualized menu and education
• Dietitian completes nutritional assessment and
  formulates a meal plan
• Stress flexibility
• Canadian Diabetes Association Just the Basics,
  Healthy Eating for Diabetes Management
  Prevention

51
Diabetic Exchange System

• Are tools for enabling food choices based on
  categories of foods and serving sizes
• Patients need to be fairly literate
• Carbohydrate containing foods are provided in
  serving sizes containing 15g of CHO
• Grains and starches
• Fruits
• Milk Alternatives
• Other Choices
• Non-CHO containing foods
• Meat alternatives
• Fats
• Extras
• Canadian Diabetes Association Beyond the Basics

52
Priorities for Meal Planning

• Type 2 diabetes with no insulin
• Gradually reduce total saturated fat
• Spread calories throughout the day
• Avoid large amount of food at one time
• Space meals at least 4-5 hours apart
• Aim for healthy body weight
• Promote appropriate exercise

53
Priorities for Meal Planning

• If require insulin
• Timing of meals and snacks important
• Quantity and quality of food important
• Watch CHO content
• Snacks at time of peak insulin action
• With more intensive use of insulin (including
  regular
• insulin before meals)
• Have more flexibility in food and timing
• Match insulin to CHO consumed (CHO counting)

54
Alcohol Intake

• Alcohol
• Moderate amounts can be consumed when diabetes is
  well controlled
• No more than two drinks per day
• lt 14 standard drinks/week for men
• lt 9 standard drinks/week for women
• Should always take alcohol with food
• Risk for hypoglycemia often delayed
• Blocks gluconeogenesis interferes with
  counter-regulatory mechanisms for insulin
• Further compounded by masking hypoglycemia
  symptoms impairing judgement

55
Some Special Situations

• Delayed meals
• Eat a snack if expect meal will be delayed
• Carry available source of CHO i.e. Glucose
  tablets or hard candy to avoid hypoglycemic
  reaction

56
Some Special Situations

• Strenuous exercise
• Eat extra food before activity and take 15-30
  grams of CHO for every 30 min of strenuous
  activity (15 g CHO for each hour of less
  strenuous exercise)
• Eat hearty snack after activity
• If activity is pre-planned may reduce insulin
  dosage prior to activity

57
Some Special Situations

• Illness
• Lack of appetite often with illness
• Substitute foods that are well tolerated
• Drink sugar containing liquids
• For each missed meal give 45-60 g CHO in small
  frequent feedings over 3-4 hours
• I.e. soup, Jello, pop, juices, ice cream
• Continue taking insulin!
• Monitor blood glucose test urine ketones

58
Hypoglycemia Treatment

• 151515 rule
• Give quickly absorbed CHO immediately (1/2 cup
  pop or juice, 2 sugar cubes, 6-7 lifesavers, 15 g
  glucose tablets)
• Check blood glucose after 15 minutes if still
  low repeat treatment
• If blood glucose normalizes but individual not
  going to eat within hour, has recently exercised
  or will go to bed additional food will be needed
• If unconscious give intravenous glucose or
  glucagon injection

59
Diabetes in Children

• 75 of Type 1 diabetes occurs before 18 years
• Peak onset is 6 -11 years
• Balance between allowing for normal growth and
  development, need for glycemic control
• Need meal plan that fits childs lifestyle and
  promotes optimal compliance

60
Management Goals in Children

• Support normal growth and development
• Control blood glucose
• Prevent acute and chronic complications
• Achieve optimal nutritional status

61
Gestational Diabetes

• Nutrition management similar to Type 1 and Type
  2.
• Diet tends to be slightly lower in CHO and higher
  in protein and fat (30-35)
• Requires individualized approach

62
Reactive Hypoglycemia

• Hypoglycemia following a meal due to rapid
  release of insulin
• Often associated with GI surgery, particularly
  gastrectomy with dumping syndrome
• Treatment
• Slow gastric emptying intestinal motility
• Small, frequent meals of complex CHO, fibre, a
  protein source
• Avoid simple carbohydrates alcohol

63
Psychological Aspects

• Adjustment problems
• Beliefs regarding how serious and controllable
  disease is
• Depression
• Twice as common in diabetics than general
  population
• Anxiety
• Some evidence to show prevalence elevated
• Eating Disorders
• Adolescent females young women with Type 1

64
Diabetes Care

• Diabetes Health Care (DHC) Team
• Physician and diabetes educators
• Other health professionals
• Shared care ongoing communication
  participation of team members
• Organizational aspects
• Centralized, computerized database
• Reminders recalls

65
Diabetes Care

• Models of Care
• Patient centred
• Self-management
• Ongoing education
• Comprehensive care

66
Diabetes Care

• Diabetes education
• One-on-one, group, sustained
• Interactive
• Solutions focused
• Based on experience of learner
• Tailored to individual needs abilities

67
Diabetes Care

• Counseling
• Motivational Interviewing explore resolve
  ambivalence self generated arguments for change
• Express empathy
• Develop discrepancies
• Roll with resistance
• Support self-efficacy