Disturbance in Glucose Utilization

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Disturbance in Glucose Utilization

• Diabetes Mellitus- Gestational Diabetes-
  Impaired Glucose Tolerance- Hypoglycemia

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Diabetes Mellitus

• There are two types of diabetes mellitus
• Type I, or insulin dependent (IDDM)
• Type II, or non-insulin dependent (NIDDM)

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Gestational Diabetes

• A temporary type of diabetes that occurs during
  pregnancy

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Impaired Glucose Tolerance

• A higher than normal blood glucose level that is
  below the accepted value to diagnose diabetes
• Diet therapy is essential for all types of
  disturbance in glucose utilization

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The Goals of Diet Therapy for Diabetes

1. Attain and maintain desirable body weight.
2. Provide a normal growth rate in children and
   pregnant women.
3. Minimize glycosuria and keep the plasma glucose
   as near normal physiological range as possible.
4. Prevent and/or delay the development and/or
   progression of cardiovascular, renal, retinal,
   neurological, and other complications associated
   with diabetes.

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1. Modify the diet as necessary for complications of
   diabetes and for associated diseases
2. Improve the overall health of the patient by
   attaining and maintaining an optimal nutritional
   status.
3. Provide for each patient an individualized
   educational and follow-up program.

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Nutrition Guidelines

• Type 1 diabetes
• Take diet history usual pattern of food
  intake and physical activity
• Develop an individualized meal plan and schedule
  of insulin therapy
• Emphasize the need for regular meal and snack
  schedule SMBG

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1. Synchronize food intake with the time of action
   of the insulin used, and teach patient to change
   dosage and time of administration to compensate
   for changes in the meal plan

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• Type 2 diabetes
• Take diet history usual pattern of food
  intake and physical activity
• Aim to reduce weight
• Reduce fat intake
• Encourage physical activity
• Emphasize the need to control BG, lipid levels
  and BP by dietary means, explaining how to do so
• Develop an individualized meal plan

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• Diabetes in Pregnancy
• A- Diabetic women who become pregnant
• Intensive therapy is indicated
• SMBG must be conducted
• Changing meal plan with advancing pregnancy to
  maintain fatal growth
• Restrict energy intake for obese women (BMI gt 30)
  
• Encourage physical activity
• Monitor urine for ketones

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• B- GDM
• Provide adequate calories and nutrients to
  promote normal fetal growth
• Plan meal times to maintain FBG at 95 mg/dl or
  2h PPG at 120 mg/dl SMBG
• Bed time snack may be recommended to reduce risk
  of hypoglycemia at night
• Restrict energy intake for obese women (BMI gt 30)
  
• Encourage physical activity
• Monitor urine for ketones

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Dietary management of impaired glucose tolerance

1. Weight loss if needed
2. Avoidance of concentrated sweets and fats
3. Increase level of exercise
4. Increase intake of soluble fiber incase of
   hyper-triglyceridemia

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Nutritional Management of DM

• Meal planning
• Balanced meals are essential
• Meals should include a source of protein to slow
  digestion, and the increase in blood sugar
• Complex carbohydrates are preferred, while simple
  sugars avoided
• Carbohydrates should be divided carefully
  between meals and snacks

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Some Complications of Diabetes

• Nutritional Management

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Insulin Shock or Insulin Reaction Hypoglycemia

• Causes
• More insulin is injected or more oral
  hypoglycaemic agents are given than needed
• Foods are omitted from diet
• Increased physical activity
• An error in insulin injection in relation to
  exercise

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Symptoms

• Blood glucose decreases below acceptable level
  and patient sweats profusely
• If not treated promptly the patient experiences
• Mental confusion and disorientation
• If untreated seizures occur followed by
• unconsciousness and
• Death

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Prevention and Management

• Avoid precipitating factors
• Recognize signs
• Test BG
• Correct hypoglycaemia
• If the patient is unconscious glucagon injections
  must be given

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Coping with acute illness

• Check BG and urine ketones often
• Consume 10-15 gm CHO every 1-2 hours
• When vomiting, diarrhea or fever present consume
  liquids every 15-30 min.
• Notify health care provider if cannot retain food
  for 4h.

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Other complications of DM

• Heart disease- control fat cholesterol intake
• Kidney disease- control protein intake
• Diabetic retinopathy- control BG and take
  anti-oxidants
• Neuropathy- control BG and take vit.B1,B6 and B12
  supplement

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Coping with gastroparesis

• Give drugs to increase GI motility
• Correct hyperglycemia if present
• Keep record for food, BG, and symptoms to fit
  insulin to peak absorption time
• Use short and ultra-short insulin
• Decrease fat intake

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• Decrease intake of high fiber food
• Give small frequent meals
• Chew well
• Maintain upright posture for 30-60 min after meal

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Role of the nurse in nutritional management of
diabetes

1. Review previous history and diet
2. Give positive verbal reinforcement for any
   attempt at control
3. Identify areas of strength for positive
   reinforcement and areas of need for referral or
   personal assistance
4. Assess the patients knowledge about his/her
   condition, and explain appropriate action in
   various situations

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Reactive Hypoglycaemia

• Postprandial
• Second most common type of hypoglycaemia
• Caused by exaggerated insulin release following a
  meal leading to transient hypoglycaemia.
• Glucose returns to normal without food.

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Dietary management of reactive hypoglycemia

1. Limit the intake of simple sugars, and conc.
   Sweets
2. Emphasize complex carbohydrates
3. Eat small frequent meals and snacks (every 2 to 3
   hours)
4. Include a protein source with meals and snacks
5. Restrict intake of caffeine

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How to approximate the individual dietary needs
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Factors to consider

1. Weight and height
2. Caloric needs
3. Division into protein, carbohydrate and fat
4. Division into meals and snacks
5. Limitations (modifications for special condition)
6. Need for insulin
7. Individual food habits
8. Family food budget

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Weight and height
Children Men Women Build
Chart growth pattern on graph (Wetzel, Lowa, or Stuart) every 3-6 months Allow 106 Ib. for first 5 ft. of height, plus 6 Ib. for each additional inch Allow 100 Ib. for first 5 ft. of height, plus 5 Ib. for each additional inch Medium
Subtract 10 Subtract 10 Small
Add 10 Add 10 Large
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Determination of caloric needs

• For adults
• Basal calories equals desirable body weight (Ib.)
  x 10, or (Kgx 22)
• Add activity calories
• Sedentary equals desirable body weight (Ib.) x 3,
  or ( Kg x 6.6)
• Moderate equals desirable body weight (Ib.) x 5,
  or (Kg x11)
• Strenuous equals desirable body weight (Ib.) x
  10, or (Kgx22)

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• Add calories for indicated weight gain, growth
  (pregnant women), or lactation
• Subtract calories for indicated weight loss

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• For children
• Children vary markedly in their caloric needs
  depending on rate of growth and level of activity
• Estimate caloric requirement from chart of
  Recommended Daily Dietary Allowances
• Adjust caloric intake as needed to maintain
  normal rate of growth

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Determination of grams of protein, carbohydrate
and fat

1. Protein 20 of total calories for growing
   children and pregnant women, minimum of 0.5 gm
   per Ib.(1.1 gm/Kg)desirable body weight for other
   adults
2. Carbohydrate from 50-70 of non-protein calories
3. Fat from 30-50 of non-protein calories

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Example for diet order of 2000 kcal /day

• Protein 2000x0.15300 kcal 4(kcal/g)75g
• Carbohydrate 2000x0.61200 kcal 4(kcal/g)300g
• Fat 2000x0.25500 kcal 9(kcal/g)55g

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Suggested division into meals and snacks

• Meals usually contain 2/10 to 4/10 of the
  calories and carbohydrate, and
• snacks usually contain 1/10 of the calories
  and carbohydrate

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• b. In the non-insulin dependent individual, food
  is usually divided into three meals per day.
• In the insulin dependent individual, food is
  usually divided into three meals and a bedtime
  snack and occasionally a mid-afternoon and/or
  mid-morning snack, depending on plasma glucose
  levels

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Limitations (modifications for special conditions)

1. Protein
2. Saturated fat and/or cholesterol
3. Sodium
4. Potassium
5. other

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The GI Factor

• The increase in the area under the blood glucose
  curve after the ingestion of 50 gm of
  carbohydrate in the test food compared to the
  area under the curve when 50 gm of glucose or
  white bread is taken

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