Week 11
What percent of Type 2 Diabetics are overweight?
85%
Dietary Fat
A Mediterranean-style dietary pattern that emphasizes unsaturated fats may benefit both glycemic control and cardiovascular disease (CVD) risk.36 In addition, increased intakes of omega-3 fatty acids from fatty fish or plant sources may improve the lipoprotein profile and various other CVD risk factors (see Chapter 4). Other guidelines related to fat intake are similar to those suggested for the general population: saturated fat should be less than 10 percent of total kcalories and trans fats should be avoided.
Excess Body Weight and Type 2 Diabetes
Because excessive body fat can worsen insulin resistance, weight loss is recommended for overweight or obese individuals who have diabetes. Even moderate weight loss (5 to 10 percent of body weight) can help to improve insulin resistance, glycemic control, blood lipid levels, and blood pressure. Weight loss is most beneficial early in the course of diabetes, before insulin secretion has diminished.
Medical Evaluation before Exercise
Before a person with diabetes begins a new exercise program, a medical evaluation should screen for problems that may be aggravated by certain activities. Complications involving the heart and blood vessels, eyes, kidneys, feet, and nervous system may limit the types of activity recommended. For individuals with a low level of fitness who have been relatively inactive, only mild or moderate exercise may be prescribed at first; a short walk at a comfortable pace may be the first activity suggested. People with severe retinopathy should avoid vigorous aerobic or resistance exercise, which may lead to retinal detachment and damage to eye tissue. Individuals with peripheral neuropathy should ensure that they wear proper footwear during exercise; those with a foot injury or open sore should avoid weight-bearing activity.
Treatment of Diabetes Mellitus
Diabetes is a chronic and progressive illness that requires lifelong treatment. Managing blood glucose levels is a delicate balancing act that involves meal planning, proper timing of medications, and physical exercise. Frequent adjustments in treatment are often necessary to establish good glycemic control. Individuals with type 1 diabetes require insulin therapy for survival. Type 2 diabetes may initially be treated with nutrition therapy and exercise, but most patients eventually need to add antidiabetic medications or insulin. Diabetes management becomes even more difficult once complications develop. Although the health care team must determine the appropriate therapy, the individual with diabetes ultimately assumes much of the responsibility for treatment and therefore requires education in self-management of the disease.
A major cause of death in people with diabetes is:
cardiovascular disease
autoimmune
refers to an immune response directed against the body's own tissues
prediabetes
the state of having plasma glucose levels that are higher than normal but not high enough to be diagnosed as diabetes; occurs in individuals who have metabolic defects that often lead to type 2 diabetes
diabetic coma
a coma that occurs in uncontrolled diabetes; may be due to diabetic ketoacidosis, the hyperosmolar hyperglycemic syndrome, or severe hypoglycemia. Diabetic coma was a frequent cause of death before insulin was routinely used to manage diabetes
peripheral vascular disease
a condition characterized by impaired blood circulation in the limbs
hyperosmolar hyperglycemic syndrome
a condition of extreme hyperglycemia associated with dehydration, hyperosmolar blood, and altered mental status; sometimes called the hyperosmolar hyperglycemic nonketotic state
acetone breath
a distinctive fruity odor on the breath of a person with ketosis
diabetes mellitus
a group of metabolic disorders characterized by hyperglycemia and disordered insulin metabolism
insulin
a pancreatic hormone that regulates glucose metabolism; its actions are countered mainly by the hormone glucagon
oral glucose tolerance test
a test that evaluates a person's ability to tolerate an oral glucose load
Type 1 Diabetes is associated with:
auto immune destruction
Sugars
A common misperception is that people with diabetes need to avoid sugar and sugar-containing foods. In reality, table sugar (sucrose), made up of glucose and fructose, has a lower glycemic effect than starch. Because moderate consumption of sugar has not been shown to adversely affect glycemic control,33 sugar recommendations for people with diabetes are similar to those for the general population, which advise minimizing foods and beverages that contain added sugars. However, sugars and sugary foods must be counted as part of the daily carbohydrate allowance. Although fructose has a minimal glycemic effect, its use as an added sweetener should be limited because excessive dietary fructose may adversely affect blood lipids and lipid metabolism (note that it is not necessary to avoid the naturally occurring fructose in fruits and vegetables).34 Sugar alcohols (such as sorbitol and maltitol) have lower glycemic effects than glucose or sucrose and may be used as sugar substitutes. Artificial sweeteners (such as aspartame, saccharin, and sucralose) contain no digestible carbohydrate and can be safely used in place of sugar.
Food Lists for Diabetes
A meal-planning system originally developed for persons with diabetes allows individuals to create an eating plan by choosing foods with specified portions from a variety of food lists. The different food lists group foods according to their proportions of carbohydrate, fat, and protein so that all items on a particular list have similar macronutrient and energy contents (see Appendix C, pp. C-1 to C-2). Thus, each food on a food list can be substituted for any other food on the same list without affecting the macronutrient balance in a day's meals. Although the food list system may be helpful for individuals who want to maintain a diet with specific macronutrient percentages, it is less flexible than carbohydrate counting and offers no advantages for maintaining glycemic control. However, the food lists may be helpful resources for individuals using carbohydrate-counting methods because the portions are similar to the portions used in carbohydrate counting, providing about 15 grams of carbohydrate per food item (see pp. C-3 to C-6; note that the carbohydrates in foods on the Milk and Milk Substitutes list can be rounded up to 15 grams).
Diabetic Ketoacidosis in Type 1 Diabetes
A severe lack of insulin causes diabetic ketoacidosis. Without insulin, glucagon's effects become more pronounced, leading to the unrestrained breakdown of the triglycerides in adipose tissue and the protein in muscle. As a result, an increased supply of fatty acids and amino acids arrives in the liver, fueling the production of ketone bodies and glucose. Ketone bodies, which are acidic, can reach dangerously high levels in the bloodstream (ketoacidosis) and spill into the urine (ketonuria). Blood pH typically falls below 7.30 (blood pH normally ranges between 7.35 and 7.45). Blood glucose levels usually exceed 250 mg/dL and rise above 1000 mg/dL in severe cases. The main features of diabetic ketoacidosis therefore include severe ketosis (abnormally high levels of ketone bodies), acidosis, and hyperglycemia.16 Patients with ketoacidosis may exhibit symptoms of both acidosis and dehydration (see Box 20-3). Acidosis is partially corrected by exhalation of carbon dioxide, so rapid or deep breathing is characteristic.* Ketone accumulation is sometimes evident by a fruity odor on a person's breath (acetone breath). Significant urine loss (polyuria) accompanies the hyperglycemia, lowering blood volume and blood pressure and depleting electrolytes. In response, patients may demonstrate marked fatigue, lethargy, nausea, and vomiting. The mental state may vary from alert to comatose (diabetic coma). Treatment of diabetic ketoacidosis includes insulin therapy to correct the hyperglycemia, intravenous fluid and electrolyte replacement, and, in some cases, bicarbonate therapy to treat acidosis. Diabetic ketoacidosis is sometimes the earliest sign that leads to a diagnosis of type 1 diabetes, but more often it results from inadequate insulin treatment, illness or infection, alcohol abuse, or other physiological stressors. The condition usually develops quickly, within one to two days. Mortality rates are generally less than 5 percent but may exceed 20 percent among very old individuals or patients with profound coma.17 Although diabetic ketoacidosis can occur in type 2 diabetes—usually due to severe stressors such as infection, trauma, or surgery—it develops less often because even relatively low insulin concentrations are able to suppress ketone body production
Insulin Regimen for Type 2 Diabetes
Although initial treatment of type 2 diabetes usually involves nutrition therapy, physical activity, and oral antidiabetic medications, long-term results with these treatments are often disappointing. As the disease progresses, pancreatic function worsens, and many individuals require insulin therapy to maintain glycemic control. Many possible regimens can be used to control type 2 diabetes.44 Most persons use insulin in combination with one or more antidiabetic drugs, although some individuals may be treated with insulin alone. Many patients need only one or two daily injections. In some cases, an injection of an intermediate- or long-acting form of insulin may be needed once or twice a day. Other regimens may involve two or more daily injections of an insulin mixture that includes both a rapid- or short-acting insulin and an intermediate- or long-acting insulin. Doses and timing are adjusted according to the results of blood glucose self-monitoring
Type 2 Diabetes in Children and Adolescents
Although most cases of type 2 diabetes are diagnosed in individuals who are over 40 years old, children and teenagers who are overweight or obese or have a family history of diabetes are at increased risk. Because type 2 diabetes is frequently asymptomatic, it is generally identified in youths only when high-risk groups are screened for the disease. Increased rates of both type 1 and type 2 diabetes have been documented in children in past decades and correlate with the rise in childhood obesity. Type 1 and type 2 diabetes are sometimes difficult to distinguish in children, however, and a few studies have found that some children diagnosed with one of these types of diabetes actually had the other type.12 Note that type 2 diabetes is still extremely rare in children; for example, its estimated incidence in 10- to 19-year-old African-American and Hispanic-American youths—two groups at high risk—is about 33 and 18 cases per 100,000 individuals per year, respectively.13 Its increasing prevalence, however, indicates that routine screening and diabetes prevention programs may be important safeguards for children at risk.
Which of these has the greatest potential to spike blood glucose levels?
Carbohydrate foods
Carbohydrate Counting
Carbohydrate-counting techniques are simpler and more flexible than other menu-planning approaches and are widely used for planning diabetes diets. Carbohydrate counting works as follows: After an interview in which the dietitian learns about the patient's usual food intake and calculates nutrient and energy needs, the patient is given a daily carbohydrate allowance, divided into a pattern of meals and snacks according to individual preferences. The carbohydrate allowance can be expressed in grams or as the number of carbohydrate portions allowed per meal (see Table 20-4). The user of the plan need only be concerned about meeting carbohydrate goals and can select from any of the carbohydrate-containing food groups when planning meals (see Table 20-5 and Figure 20-2). Although encouraged to make healthy food choices, the individual has the freedom to choose the foods desired at each meal without risking loss of glycemic control. Some people may also need guidance about consuming a diet that improves blood lipids or energy intakes. Box 20-8 shows how to implement carbohydrate counting in clinical practice. Carbohydrate counting is taught at different levels of complexity depending on a person's needs and abilities. The basic carbohydrate-counting method just described can be helpful for most people, although it requires a consistent carbohydrate intake from day to day to match the medication or insulin regimen. Advanced carbohydrate counting allows more flexibility but is best suited for patients using intensive insulin therapy. With this method, a person can determine the specific dose of insulin needed to cover the amount of carbohydrate consumed in a meal. The person is then free to choose the types and portions of food desired without sacrificing glycemic control. Advanced carbohydrate counting requires some training and should be attempted only after an individual has mastered more basic methods.
Prevention of Type 2 Diabetes Mellitus
Clinical trials have shown that intensive lifestyle changes can prevent or delay the development of type 2 diabetes in individuals at risk for as long as 10 to 20 years.14 Based on the results of these studies, guidelines for diabetes prevention include the following strategies: ● Weight management. A sustained weight loss of at least 7 percent of body weight is recommended for overweight and obese individuals with prediabetes. Individuals who cannot achieve weight loss should avoid gaining additional weight. ● Dietary modifications. Diets rich in whole grains, fruits, vegetables, legumes, and nuts and low in refined grains, red meat, and sugar-sweetened beverages may reduce diabetes risk.15 In addition, individuals who attempt weight loss may need to reduce dietary fat to avoid consuming excessive energy. ● Physical activity. At least 150 minutes of moderate physical activity (such as brisk walking) is recommended weekly; the activity should be conducted in at least three separate sessions during the week. ● Regular monitoring. Individuals with prediabetes should be monitored yearly to check for the development of diabetes.*
Evaluating Diabetes Treatment
Diabetes treatment is largely evaluated by monitoring glycemic status. Good glycemic control requires frequent testing of blood glucose levels using a glucose meter, referred to as selfmonitoring of blood glucose (see Box 20-5 and Photo 20-3). Glucose testing provides valuable feedback when the patient adjusts food intake, medications, and physical activity and is helpful for preventing hypoglycemia. Ideally, patients with type 1 diabetes should measure blood glucose levels prior to meals and snacks, at bedtime, prior to exercise or critical tasks such as driving, whenever they suspect hypoglycemia, and after treating hypoglycemia.28 Some patients may achieve better glycemic control by also using a continuous glucose monitoring system, which measures tissue glucose levels every few minutes using a tiny sensor placed under the skin. Although self-monitoring of blood glucose is also useful in type 2 diabetes, the recommended frequency varies according to the specific needs of individual patients.
Diabetic Neuropathy
Diabetic neuropathy often involves the peripheral nerves (peripheral neuropathy) and nerves that control body organs and glands (autonomic neuropathy). Peripheral neuropathy—the most common form of neuropathy in diabetes—may be experienced as pain, numbness, or tingling in the hands, feet, and legs or weakness of the limbs. Peripheral neuropathy also contributes to the development of foot ulcers because cuts and bruises may go unnoticed until wounds are severe. Autonomic neuropathy may be indicated by sweating abnormalities, disturbed bladder function, erectile dysfunction, delayed stomach emptying (gastroparesis), constipation, and cardiac arrhythmias. Neuropathy occurs in about 50 percent of patients with diabetes;26 the extent of nerve damage depends on the severity and duration of hyperglycemia.
Nutrition Therapy: Meal-Planning Strategies
Dietitians provide a number of meal-planning strategies to help people with diabetes maintain glycemic control. These strategies emphasize control of carbohydrate intake and portion sizes. Initial dietary instructions may include guidelines for maintaining a healthy diet, improving blood lipids, and reducing cardiovascular risk factors. Sample menus that include commonly eaten foods can help to illustrate general principles. People using intensive insulin therapy must learn to coordinate insulin injections with meals and to match insulin dosages to carbohydrate intake, as discussed later.
Glycemic Index
Different carbohydrate-containing foods have different effects on blood glucose levels after they are ingested; for example, consuming a portion of white rice causes blood glucose to increase more than would a similar portion of barley. A food's glycemic effect is influenced by the type of carbohydrate in a food, the food's fiber content, the preparation method, the other foods included in a meal, and individual tolerances (see Nutrition in Practice 3 for details). For individuals with diabetes, choosing foods with a low glycemic index (GI) over those with a high GI may modestly improve glycemic control.31 A food's glycemic effect is not usually a primary consideration when treating diabetes, however, because clinical studies investigating the potential benefits of low-GI diets on glycemic control have had mixed results.32 Nonetheless, high-fiber, minimally processed foods—which typically have lower glycemic effects than do highly processed, starchy foods—are among the foods frequently recommended for persons with diabetes
A con to the plate method is that it requires math and literacy skills.
False
If a diabetic is taking insulin, we can assume they are a Type 1 Diabetic.
False
Quinoa is a vegetable source of protein that can be included in the Vegan Diet.
False
Using the same dietary approach will affect all Type 2 Diabetics the same.
False
Alcohol Use in Diabetes
Guidelines for alcohol intake are similar to those for the general population, which recommend that women and men limit their average daily intakes of alcohol to one drink and two drinks per day, respectively. In addition, individuals using insulin or medications that promote insulin secretion should consume food when they ingest alcoholic beverages to avoid hypoglycemia (alcohol can cause hypoglycemia by interfering with glucose production in the liver).38 Conversely, an excessive alcohol intake (three or more drinks per day) can worsen hyperglycemia and raise triglyceride levels in some individuals. People who should avoid alcohol include pregnant women and individuals with advanced neuropathy, abnormally high triglyceride levels, or a history of alcohol abuse.
fasting hyperglycemia
hyperglycemia that typically develops in the early morning after an overnight fast of at least eight hours.
Which is not an example of a lean protein?
Greek Yogurt Salmon Sausage (Not) Cottage Cheese
Long-Term Glycemic Control
Health care providers periodically evaluate long-term glycemic control by measuring HbA1c levels. The glucose in blood freely enters red blood cells and attaches to hemoglobin in direct proportion to the amount of glucose present. The percentage of HbA1c in hemoglobin reflects glycemic control over the preceding two to three months, the average age of circulating red blood cells (Box 20-6 shows how HbA1c correlates with average plasma glucose levels). The goal of diabetes treatment is usually an HbA1c value less than 7 percent, but the percentage is often markedly higher in people with diabetes, even those who are maintaining nearnormal blood glucose levels. Less stringent HbA1c goals (for example, a value less than 8 percent) may be suitable for some patients, including those with limited life expectancy, advanced diabetic complications, or a history of severe hypoglycemia. HbA1c testing is typically conducted two to four times yearly. The fructosamine test is sometimes conducted to determine glycemic control over the preceding two to three weeks. This test determines the nonenzymatic glycation of serum proteins (primarily albumin), which have a shorter half-life than hemoglobin. Most often, the fructosamine test is used to evaluate recent adjustments in diabetes treatment or glycemic control during pregnancy. The test cannot be used if the patient has a liver or kidney disorder that lowers serum protein levels.
If a person does not produce enough insulin, he is prone to have:
Hyperglycemia
A diabetic patient with symptoms of shakiness, headache and confusion probably has:
Hypoglycemia
Insulin Therapy and Hypoglycemia
Hypoglycemia (blood glucose levels below 70 mg/dL) is the most common complication of insulin treatment, although it may also result from the use of some oral antidiabetic drugs. It most often results from intensive insulin therapy because the attempt to attain near-normal blood glucose levels increases the risk of overtreatment. Other potential causes include skipped meals or snacks or prolonged exercise. Hypoglycemia can be corrected by consuming glucose or a glucose-containing food. Usually, 15 to 20 grams of carbohydrate (see Box 20-9) can relieve hypoglycemia in about 15 minutes, although patients should monitor their blood glucose levels in case additional treatment is necessary.45 Foods that provide pure glucose yield a better response than foods that contain other sugars, such as sucrose or fructose. Individuals who use insulin are usually advised to carry glucose tablets or a source of carbohydrate that can be easily ingested. After blood glucose normalizes, patients should consume a meal or snack to prevent recurrence. Those at risk of severe hypoglycemia (blood glucose levels below 54 mg/dL) are often given prescriptions for the hormone glucagon, which can be injected by caregivers in case of unconsciousness.
Hypoglycemia
Hypoglycemia, or low blood glucose, is the most frequent complication of type 1 diabetes and may occur in type 2 diabetes as well. It is due to the inappropriate management of diabetes rather than to the disease itself, and is usually caused by excessive dosages of insulin or antidiabetic drugs, prolonged exercise, skipped or delayed meals, inadequate food intake, or the consumption of alcohol without food. Hypoglycemia is the most frequent cause of coma in insulin-treated patients and is believed to account for 4 to 10 percent of deaths in this population.20 Symptoms of hypoglycemia include sweating, heart palpitations, shakiness, hunger, weakness, dizziness, and irritability. Mental confusion may prevent a person from recognizing the problem and taking corrective action such as ingesting glucose tablets, juice, or candy (see Box 20-9 on p. 582). If hypoglycemia occurs during the night, patients may be completely unaware of its presence.
Sick-Day Management
Illness, infection, or injury can cause hormonal changes that raise blood glucose levels and increase the risk of developing diabetic ketoacidosis or the hyperosmolar hyperglycemic syndrome (see Box 20-11). During illness, individuals with diabetes should measure blood glucose and ketone levels several times daily. They should continue to use antidiabetic drugs, including insulin, as prescribed; adjustments in dosages may be necessary if they alter their diet or have persistent hyperglycemia. If appetite is poor, patients should select easy-to-manage foods and beverages that provide the prescribed amount of carbohydrate at each meal. To prevent dehydration, especially if vomiting or diarrhea is present, patients should make sure they consume adequate amounts of liquids throughout the day. The Case Study in Box 20-12 provides an opportunity to review the treatment for diabetes.
Maintaining Glycemic Control during Exercise
Individuals who use insulin or medications that increase insulin secretion must carefully adjust food intake and medication dosages to prevent hypoglycemia during physical activity. Medication dosages that precede exercise often need to be reduced substantially. Blood glucose levels should be checked both before and after an activity. If blood glucose is below 100 mg/dL, carbohydrate should be consumed before the exercise begins.* Additional carbohydrate may be needed during or after prolonged activity or even several hours after the activity is completed. Individuals with type 1 diabetes who have hyperglycemia and ketosis should delay exercise until blood glucose falls below 250 mg/dL, as even mild exercise may cause additional increases in blood glucose and ketone levels.
Monitoring for Long-Term Complications
Individuals with diabetes are routinely monitored for signs of long-term complications. Blood pressure is measured at each checkup. Annual lipid screening is suggested for adult patients. Routine checks for urinary protein (albuminuria) can determine whether nephropathy has developed. Physical examinations generally screen for signs of retinopathy, neuropathy, and foot problems.
Insulin Delivery
Insulin is most often administered by subcutaneous injection, either self-administered or provided by caregivers (note that insulin is a protein, and would be destroyed by digestive processes if taken orally). Disposable syringes, which are filled from vials that contain multiple doses of insulin, are the most common devices used for injecting insulin (see Photo 20-4). Another option is to use insulin pens, injection devices that resemble permanent marking pens. Disposable insulin pens are prefilled with insulin and are used one time only, whereas reusable pens can be fitted with prefilled insulin cartridges and replaceable needles. A rapid-acting inhalation powder is available for use before meals, although it cannot be used by patients with lung disease. Some individuals use insulin pumps, computerized devices that infuse insulin through thin, flexible tubing that remains in the skin; the pump can be attached to a belt or kept in a pocket (see Photo 20-5). Some of the newer insulin pumps include built-in continuous glucose monitoring systems.
Insulin Therapy
Insulin therapy is necessary for individuals who cannot produce enough insulin to meet their metabolic needs. It is therefore required by people with type 1 diabetes and those with type 2 diabetes who cannot maintain glycemic control with medications, diet, and exercise. The pancreas normally secretes insulin in relatively low amounts between meals and during the night (called basal insulin) and in much higher amounts when meals are ingested. Ideally, the insulin treatment should reproduce the natural pattern of insulin secretion as closely as possible.
Fasting Hyperglycemia
Insulin therapy must sometimes be adjusted to prevent fasting hyperglycemia, which typically develops in the early morning after an overnight fast of at least eight hours. The usual cause is a waning of insulin action during the night due to insufficient insulin dosing the evening before. A second possibility, known as the dawn phenomenon, is an increase of blood glucose in the morning due to the early-morning secretion of growth hormone, which reduces insulin sensitivity. Less frequently, fasting hyperglycemia develops as a result of nighttime hypoglycemia, which causes the secretion of hormones that stimulate glucose production; the resulting condition is known as rebound hyperglycemia (also called the Somogyi effect). Whatever the cause, fasting hyperglycemia can be treated by adjusting the dosage or formulation of insulin administered in the evening
A diabetic patient who is nauseated, hyperventilating and has fruity breath probably has:
Ketoacidosis
Ketone Testing
Ketone testing, which checks for the development of ketoacidosis, should be performed if symptoms are present or if risk has increased due to acute illness, stress, or pregnancy. Both blood and urine tests are available for home use, although the blood tests are generally more reliable. Ketone testing is most useful for patients who have type 1 diabetes or are pregnant. Individuals with type 2 diabetes may produce excessive ketone bodies when severely stressed by infection or trauma.
Microvascular Complications
Long-term diabetes is associated with detrimental changes in capillary structure and function, including the thickening of basement membranes, growth of fibrous tissue (scarring), increased capillary permeability, and proliferation of vessels that function abnormally. The primary microvascular complications involve the retina of the eye and the kidneys. In diabetic retinopathy, the weakened capillaries of the retina leak fluid, lipids, or blood, causing local edema or hemorrhaging. The defective blood flow also leads to damage and scarring within retinal tissue. New blood vessels eventually form, but they are fragile and bleed easily, releasing blood and proteins that obscure vision. About 60 to 80 percent of diabetes patients develop retinopathy 15 to 20 years after diagnosis.24 Retinopathy progresses most rapidly when diabetes is poorly controlled, and intensive diabetes management substantially reduces the risk. In diabetic nephropathy, damage to the kidneys' specialized capillaries prevents adequate blood filtration, resulting in abnormal urinary protein losses (albuminuria). As the kidney damage worsens, urine production decreases and nitrogenous wastes accumulate in the blood; eventually, the individual requires dialysis (artificial filtration of blood) to survive. Because the kidneys normally regulate blood volume and blood pressure, inadequate kidney function may also result in hypertension. At least 20 to 40 percent of persons with diabetes develop some degree of nephropathy, although a greater fraction of type 1 patients progress to kidney failure.25 As with diabetic retinopathy, intensive diabetes management can help slow the progression of kidney damage.
Micronutrients
Micronutrient recommendations for people with diabetes are the same as for the general population. Vitamin and mineral supplementation is not recommended unless nutrient deficiencies develop; those at risk include elderly individuals, pregnant or lactating women, strict vegetarians, and individuals on kcalorierestricted diets. Although various micronutrients (including chromium and antioxidant nutrients such as vitamins C and E) have been tested for their potential benefits in managing diabetes or diabetes complications, results have not been promising
Nutrition Therapy: Dietary Recommendations
Nutrition therapy can improve glycemic control and slow the progression of diabetic complications. As always, the nutrition care plan must consider personal preferences and lifestyle habits. In addition, dietary intakes must be modified to accommodate growth, lifestyle changes, aging, and any complications that develop. Although all members of the diabetes care team should understand the principles of dietary treatment, a registered dietitian is best suited to design and implement the nutrition therapy provided to diabetes patients. This section presents the dietary recommendations for diabetes; a later section describes meal-planning strategies.
All of the following are symptoms of diabetes except:
Polyuria Polydipsia Polyglycosuria (not) Polyphagia
Chronic Complications of Diabetes Mellitus
Prolonged exposure to high glucose concentrations can damage cells and tissues. Glucose nonenzymatically combines with proteins, producing molecules that eventually break down to form reactive compounds known as advanced glycation end products (AGEs); in diabetes, these AGEs accumulate to such high levels that they alter the structures of proteins and stimulate metabolic pathways that are damaging to tissues. In addition, excessive glucose promotes the production and accumulation of sorbitol, which increases oxidative stress within cells and causes cellular injury. Chronic complications of diabetes typically involve the large blood vessels (macrovascular complications), smaller vessels such as arterioles and capillaries (microvascular complications), and the nerves (diabetic neuropathy). Other tissues adversely affected include the lens of the eye and the skin; cataracts, glaucoma, and various types of skin lesions sometimes develop. Infections are common in diabetes, a possible consequence of hyperglycemia, impaired circulation, and/or depressed immune responses (see Box 20-4). Many of these complications appear 15 to 20 years after the onset of diabetes.21 In individuals with type 2 diabetes, complications often develop before diabetes is diagnosed.
Which food can be substantial source of saturated fat and cholesterol?
Protein Foods
Protein
Protein recommendations for people with diabetes are similar to those for the general population (see Box 20-7). In the United States, the average protein intake is about 16 percent of the energy intake. Although several small, short-term studies have suggested that higher protein intakes (28 to 40 percent of total kcalories) may improve glycemic control or lipoprotein levels in diabetic individuals, other studies did not show any benefit.37 In addition, high protein intakes are sometimes discouraged because they may be detrimental to kidney function in patients with nephropathy
Whole Grains and Fiber
Recommendations for whole grain and fiber intakes are similar to those for the general population. People with diabetes are encouraged to include fiber-rich foods such as whole-grain cereals, legumes, fruits, and vegetables in their diet. Although some studies have suggested that very high intakes of fiber (more than 50 grams per day) may improve glycemic control, many individuals have difficulty enjoying or tolerating such large amounts of fiber
Physical Activity and Diabetes Management
Regular physical activity can improve insulin sensitivity, muscle glucose uptake, and overall glycemic control and is therefore a central feature of diabetes management. Physical activity also benefits other aspects of health, including cardiovascular risk factors and body weight. Children with diabetes or prediabetes should engage in at least 60 minutes of aerobic activity each day. Adults with diabetes are advised to perform at least 150 minutes of moderate-to-vigorous aerobic activity each week, spread over at least three days of the week. Both children and adults should participate in two or three sessions of muscle-strengthening exercises weekly.
Gestational Diabetes
Risk of gestational diabetes is highest in women who have a family history of diabetes, are obese, are in a high-risk ethnic group (for example, African American, Hispanic/ Latino, Native American, or Pacific Islander), or have previously given birth to an infant weighing over 9 pounds. To ensure that appropriate treatment is offered, physicians routinely test women for gestational diabetes between 24 and 28 weeks of gestation. In high-risk women, testing may begin prior to pregnancy or soon after conception; note that some women may be found to have undiagnosed type 2 diabetes at the earlier time points. Even mild hyperglycemia can have adverse effects on a developing fetus and may lead to complications during pregnancy. Weight loss is not recommended during pregnancy. For women with gestational diabetes who are overweight or obese, a modest caloric reduction (about 30 percent less than the total energy requirement) may be recommended to slow weight gain.54 Limiting the carbohydrate intake to less than 45 percent of total energy intake may improve blood glucose levels after meals. Carbohydrate is usually poorly tolerated in the morning; therefore, restricting carbohydrate (to about 30 grams) at breakfast may be helpful. The remaining carbohydrate intake should be spaced throughout the day in several meals and snacks, including an evening snack to prevent ketosis during the night. Regular aerobic activity is recommended because it can help to improve glycemic control. Women who fail to achieve glycemic goals through diet and exercise alone may need to use insulin or an antidiabetic drug that is safe to use during pregnancy (such as metformin or glyburide).55 The Case Study in Box 20-15 reviews the connections between gestational diabetes and type 2 diabetes.
Diabetic ketoacidosis is characterized by all of the following except:
Severe ketoacidosis High blood glucose Low blood glucose (not) Low blood pH
Which is not an example of a fortified dairy substitute?
Skim Milk (Not) Soy Milk Coconut Milk Rice Milk
Symptoms of Diabetes Mellitus
Symptoms of diabetes are usually related to the degree of hyperglycemia present (see Table 20-1 and Box 20-2). When the plasma glucose concentration rises above about 200 milligrams per deciliter (mg/dL), it exceeds the renal threshold, the concentration at which the kidneys begin to pass glucose into the urine (glycosuria). The presence of glucose in the urine draws additional water from the blood, increasing the amount of urine produced. Thus, the symptoms that arise in diabetes may include excessive urine production (polyuria), dehydration, and excessive thirst (polydipsia). Some people lose weight and have excessive hunger (polyphagia) as a result of the nutrient depletion that occurs when insulin is deficient. Another potential consequence of hyperglycemia is blurred vision, caused by the exposure of eye tissues to hyperosmolar fluids. Increased infections are common in individuals with diabetes and may be due to weakened immune responses and impaired circulation. In some cases, constant fatigue is the only symptom and may be related to altered energy metabolism, dehydration, or other effects of the disease.
Types of Diabetes Mellitus
Table 20-2 lists features of the two main types of diabetes, type 1 and type 2 diabetes. Pregnancy can lead to abnormal glucose tolerance and the condition known as gestational diabetes (discussed later in this chapter), which often resolves after pregnancy but is a risk factor for type 2 diabetes. Diabetes can also be caused by medications that cause glucose intolerance (such as steroids) and medical conditions that damage the pancreas or interfere with insulin function.
Total Carbohydrate Intake
The amount of carbohydrate consumed has the greatest influence on blood glucose levels after meals—the more grams of carbohydrate ingested, the greater the glycemic response. The carbohydrate recommendation is based in part on the person's metabolic needs (which are related to the type of diabetes, degree of glucose tolerance, and blood lipid levels), the type of insulin or other medications used to manage the diabetes, and individual preferences. For optimal health, the carbohydrate sources should be vegetables, fruits, whole grains, legumes, and milk products, whereas foods made with refined grains and added sugars should be limited.
Macronutrient Intakes
The recommended macronutrient distribution (percent of kcalories from carbohydrate, fat, and protein) depends on food preferences and metabolic factors (for example, insulin sensitivity, blood lipid levels, and kidney function).29 Intakes suggested for the general population are often used as a guideline (see Box 20-7). Day-to-day consistency in carbohydrate intake is associated with better glycemic control, unless the patient is undergoing intensive insulin therapy that matches insulin doses to mealtime carbohydrate intakes.
Macrovascular Complications
The damage caused by diabetes accelerates the development of atherosclerosis in the arteries of the heart, brain, and limbs. Moreover, type 2 diabetes is frequently accompanied by multiple risk factors for cardiovascular disease, including hypertension and blood lipid abnormalities. People with diabetes also have increased tendencies for thrombosis (blood clot formation) and abnormal ventricle function, both of which can worsen the clinical course of heart disease. As a result of cardiovascular complications, the most common causes of death in individuals with long-term diabetes are heart attack and stroke.22 About 20 to 30 percent of individuals with diabetes develop peripheral vascular disease (impaired blood circulation in the limbs),23 which increases the risk of claudication (pain while walking) and contributes to the development of foot ulcers (see Photo 20-2). Left untreated, foot ulcers can lead to gangrene (tissue death), and some patients require foot amputation, a major cause of disability in individuals with diabetes.
Diagnosis of Diabetes Mellitus
The diagnosis of diabetes is based primarily on plasma glucose levels, which can be measured under fasting conditions or at random times during the day. In some cases, an oral glucose tolerance test is given: the individual ingests a 75-gram glucose load, and plasma glucose is measured at one or more time intervals following glucose ingestion. Glycated hemoglobin (HbA1c) levels, which reflect hemoglobin's exposure to glucose over the preceding two to three months, are an indirect assessment of blood glucose levels. The following criteria are currently used to diagnose diabetes:3 ● The plasma glucose concentration is 126 mg/dL or higher after at least 8 hours of fasting (normal fasting plasma glucose levels are 75 to 100 mg/dL). ● In a person with classic symptoms of hyperglycemia, the plasma glucose concentration of a random, or casual, blood sample (that is, obtained from a nonfasting individual) is 200 mg/dL or higher. ● The plasma glucose concentration measured two hours after a 75-gram glucose load is 200 mg/dL or higher. ● The HbA1c level is 6.5 percent or higher. Following a preliminary diagnosis of diabetes by clinical testing, confirmation is required either by the presence of overt symptoms or a follow-up blood test that yields similar results. The term prediabetes is used when an individual's blood glucose levels are above normal but not high enough to be classified as diabetes; that is, between 100 and 125 mg/dL when fasting or between 140 and 199 mg/dL when measured two hours after ingesting a 75-gram glucose load.4 HbA1c levels between 5.7 and 6.4 percent also suggest prediabetes. Although people with prediabetes are usually asymptomatic, they are at high risk of eventually developing type 2 diabetes (described in a later section) and cardiovascular diseases. Prediabetes affects approximately 34 percent of adults in the United States5 and 23 percent of adolescents aged 12 to 19 years,6 and it is especially prevalent among those who are overweight or obese. ● Excessive urine production (polyuria) ● Dehydration, dry mouth ● Excessive thirst (polydipsia) ● Weight loss ● Excessive hunger (polyphagia) ● Blurred vision ● Increased infections ● Fatigue
Insulin Preparations
The forms of insulin that are commercially available differ by their onset of action, timing of peak action, and duration of effects. Table 20-6 and Figure 20-3 show how insulin preparations are classified: they may be rapid acting (lispro, aspart, glulisine, and inhaled insulin), short acting (regular), intermediate acting (NPH), or long acting (glargine, detemir, and degludec), thereby allowing substantial flexibility in establishing a suitable insulin regimen.41 The rapid- and short-acting insulins are typically used at mealtimes, whereas the intermediate- and long-acting insulins provide basal insulin for the periods between meals and during the night. Thus, mixtures of several types of insulin can produce greater glycemic control than any one type alone. Several premixed formulations are also available; examples are listed in Table 20-6.
Hyperosmolar Hyperglycemic Syndrome in Type 2 Diabetes
The hyperosmolar hyperglycemic syndrome is a condition of severe hyperglycemia and dehydration that develops in the absence of significant ketosis. As mentioned earlier, the hyperglycemia that develops in poorly controlled diabetes leads to polyuria, which results in substantial fluid and electrolyte losses. In the hyperosmolar hyperglycemic syndrome, patients are unable to recognize thirst or adequately replace fluids due to age, illness, sedation, or incapacity. The profound dehydration that eventually develops exacerbates the rise in blood glucose levels, which often exceed 600 mg/dL and may climb above 1000 mg/dL. Blood plasma may become so hyperosmolar as to cause neurological abnormalities, such as confusion, speech or vision impairments, muscle weakness, abnormal reflexes, and seizures; about 10 percent of patients lapse into coma.18 Treatment includes intravenous fluid and electrolyte replacement and insulin therapy. The hyperosmolar hyperglycemic syndrome is sometimes the first sign of type 2 diabetes in persons with undiagnosed diabetes. It is usually precipitated by an infection, serious illness, or drug treatment that impairs insulin action or secretion. Unlike diabetic ketoacidosis, the condition often evolves slowly, over one week or longer; the absence of clinical symptoms can delay its diagnosis. The mortality rate may be as high as 20 percent, in part because the condition occurs more often in older patients with cardiovascular disease or other major illnesses.
Treatment Goals
The main goal of diabetes treatment is to maintain blood glucose levels within a desirable range to prevent or reduce the risk of complications. Several multicenter clinical trials have shown that intensive diabetes treatment, which keeps blood glucose levels tightly controlled, can greatly reduce the incidence and severity of some chronic complications.*27 Therefore, maintenance of near-normal glucose levels has become the fundamental objective of diabetes care plans. Other goals of treatment include maintaining healthy blood lipid concentrations, controlling blood pressure, and managing weight—measures that can help to prevent or delay diabetes complications as well. Table 20-3 provides examples of some major differences between conventional and intensive therapies for type 1 diabetes. For type 2 diabetes, intensive therapy involves the addition of certain medications or insulin to standard dietary and lifestyle modifications. Note that intensive therapy is recommended only if the benefits of therapy outweigh the potential risks, and it may be inappropriate for some individuals (including those with limited life expectancies, history of hypoglycemia, or previous heart disease). Diabetes education provides an individual with the knowledge and skills necessary to implement treatment. The primary instructor is often a Certified Diabetes Educator, a health care professional (often a nurse or dietitian) who has specialized knowledge about diabetes treatment and the health education process. To manage diabetes, patients need to learn about appropriate meal planning, medication administration, blood glucose monitoring, weight management, appropriate physical activity, and prevention and treatment of diabetic complications.
The Vegan Diet is linked to improved insulin sensitivity.
True
Overview of Diabetes Mellitus
The term diabetes mellitus refers to metabolic disorders characterized by elevated blood glucose concentrations and disordered insulin metabolism. People with diabetes may be unable to produce sufficient insulin or use insulin effectively, or they may have both types of abnormalities. These impairments result in defective glucose uptake and utilization in muscle and adipose cells and unrestrained glucose production in the liver. The result is hyperglycemia, a marked elevation in blood glucose levels that can ultimately cause damage to blood vessels, nerves, and tissues. Box 20-1 defines diabetes-related symptoms and complications.
Antidiabetic Drugs
Treatment of type 2 diabetes often requires the use of oral medications and injectable drugs other than insulin. As shown in Table 20-7, these drugs can improve hyperglycemia by various modes of action. Treatment may involve the use of a single medication (monotherapy) or a combination of several medications (combination therapy). By utilizing several mechanisms at once, combination therapy achieves more rapid and sustained glycemic control than is possible with monotherapy. Box 20-10 lists some nutrition-related effects of several antidiabetic drugs.
Complex carbohydrates are healthier than simple carbohydrates.
True
The Plate Method helps you get enough non-starchy vegetables and lean protein, and limits the amount of higher-carb foods.
True
Type 1 Diabetes
Type 1 diabetes accounts for about 5 to 10 percent of diabetes cases.7 It is usually caused by autoimmune destruction of the pancreatic beta cells, which produce and secrete insulin (see Photo 20-1). By the time symptoms develop, the damage to the beta cells has progressed so far that insulin must be provided exogenously, most often by injection. Although the reason for the autoimmune attack is usually unknown, environmental toxins or infections are likely triggers. People with type 1 diabetes often have a genetic susceptibility for the disorder and are at increased risk of developing other autoimmune diseases. Type 1 diabetes typically develops during childhood or adolescence, although it may occur at any age. Diagnosis often follows an unrelated illness, which increases insulin requirements and stresses the limited reserve of the defective pancreatic beta cells.8 Hence, classic symptoms of hyperglycemia (polyuria, polydipsia, weight loss, and weakness or fatigue) may appear abruptly in a previously healthy child or young adult. Disease onset tends to be more gradual in individuals who develop type 1 diabetes in later years. Blood tests that detect antibodies to insulin, pancreatic islet cells, and pancreatic enzymes can confirm the diagnosis and help to predict risk of the disease in close relatives.
Insulin Regimen for Type 1 Diabetes
Type 1 diabetes is best managed with intensive insulin therapy, which typically involves three or four daily injections of several types of insulin or the use of an insulin pump.42 Insulin pumps are usually programmed to deliver low amounts of rapid-acting insulin continuously (to meet basal insulin needs) and bolus doses of rapid-acting insulin at mealtimes. In persons who inject insulin, intermediate- or long-acting insulin meets basal insulin needs, and rapid- or short-acting insulin is injected (or in some cases, administered via inhalation*) before meals. Simpler regimens involve twice-daily injections of a mixture of intermediate- and short-acting insulin. Regimens that include three or more injections allow for greater flexibility in carbohydrate intake and meal timing. With fewer injections, the timing of both meals and injections must be similar from day to day to avoid periods of insulin deficiency or excess. A person using intensive therapy must learn to accurately determine the amount of insulin to inject before each meal. The amount required depends on the pre-meal blood glucose level, the carbohydrate content of the meal, and the person's body weight and sensitivity to insulin. To determine insulin sensitivity, the individual keeps careful records of food intake, insulin dosages, and blood glucose levels. Eventually, these records are analyzed by medical personnel to determine the appropriate carbohydrate-to-insulin ratio for that individual, which assists in calculating insulin doses at mealtime. Intensive therapy allows for substantial variation in food intake and lifestyle, but it requires frequent testing of blood glucose levels and a good understanding of carbohydrate counting. After insulin therapy is initiated, persons with type 1 diabetes may experience a temporary remission of disease symptoms and a reduced need for insulin, known as the honeymoon period. The remission is due to a temporary improvement in pancreatic beta-cell function and may last for several weeks or months. It is important to anticipate this period of remission to avoid insulin excess. In all cases, the honeymoon period eventually ends, and the patient must reinstate full insulin treatment.
Type 2 Diabetes
Type 2 diabetes is the most prevalent form of diabetes, accounting for 90 to 95 percent of cases.9 It is often asymptomatic for many years before diagnosis. The defect in type 2 diabetes is insulin resistance, the reduced sensitivity to insulin in muscle, adipose, and liver cells, coupled with relative insulin deficiency, the lack of sufficient insulin to manage glucose effectively. Normally, the pancreatic beta cells secrete more insulin to compensate for insulin resistance. In type 2 diabetes, insulin levels are often abnormally high (hyperinsulinemia) but the additional insulin is insufficient to compensate for its diminished effect in cells. Thus, the hyperglycemia that develops represents a mismatch between the amount of insulin required and the amount produced by beta cells. Beta cell function tends to worsen over time in people with type 2 diabetes, and insulin production gradually declines as the condition progresses. Although the precise causes of type 2 diabetes are unknown, risk is substantially increased by obesity (especially abdominal obesity), aging, and physical inactivity. More than 80 percent of individuals with type 2 diabetes are obese, and obesity itself can directly cause some degree of insulin resistance (see Nutrition in Practice 20).10 Prevalence increases with age and exceeds 25 percent in persons aged 65 years or older; however, many cases remain undiagnosed.11 Genetic factors strongly influence risk, as type 2 diabetes is more prevalent in certain ethnic groups, including African Americans, Hispanic/Latino populations, Native Americans, Asian Indians, and Pacific Islanders.
Acute Complications of Diabetes Mellitus
Untreated or poorly controlled diabetes may result in life-threatening complications. Insulin deficiency can cause significant disturbances in energy metabolism, and severe hyperglycemia can lead to dehydration and electrolyte imbalances. In treated diabetes, hypoglycemia (low blood glucose) is a possible complication of inappropriate disease management. Figure 20-1 presents an overview of some of the effects of insulin insufficiency on energy metabolism.
Which breakfast is not acceptable to eat according to the vegan diet?
Waffles Granola Bar Cheetos Yogurt (not)
Insulin Therapy and Weight Gain
Weight gain is sometimes an unintentional side effect of insulin therapy, especially in individuals undergoing intensive insulin treatment. Although the exact causes of the weight gain are unclear, it may partly be due to insulin's stimulatory effect on fat synthesis. Patients may be able to avoid weight gain by reducing the ratio of basal to mealtime insulin and improving carbohydrate-counting skills to obtain better estimates of mealtime insulin requirements.46 Concerns about weight should not discourage the use of intensive therapy, which is associated with longer life expectancy and fewer complications than occur with conventional therapy.
Diabetes Management in Pregnancy
Women with diabetes face new challenges during pregnancy. Due to hormonal changes, pregnancy increases insulin resistance and the body's need for insulin, so maintaining glycemic control may be more difficult. In addition, 4 to 14 percent of nondiabetic women in the United States develop gestational diabetes (the prevalence depends on the patient population).50 Women with gestational diabetes are at greater risk of developing type 2 diabetes later in life, and their children are at increased risk of developing obesity and type 2 diabetes as they enter adulthood. A pregnancy complicated by diabetes increases health risks for both mother and fetus (see Box 20-13). Uncontrolled diabetes is linked with increased incidences of miscarriage, birth defects, and fetal deaths. Newborns are more likely to suffer from respiratory distress and to develop metabolic problems such as hypoglycemia, jaundice, and hypocalcemia. Women with diabetes often deliver babies with macrosomia (abnormally large bodies), which makes delivery more difficult and can result in birth trauma or the need for a cesarean section. Macrosomia results because maternal hyperglycemia induces excessive insulin production by the fetal pancreas, which stimulates growth and fat deposition.51 Box 20-14 shows the glycemic goals for pregnant women with diabetes.
Pregnancy in Type 1 or Type 2 Diabetes
Women with diabetes who achieve glycemic control at conception and during the first trimester of their pregnancy substantially reduce the risks of birth defects and spontaneous abortion (see Photo 20-6). For this reason, women contemplating pregnancy should receive preconception care to avoid complications that can result from uncontrolled diabetes. Maintaining glycemic control during the second and third trimesters minimizes the risks of macrosomia and morbidity in newborn infants. Women with type 1 diabetes require intensive insulin therapy during pregnancy. Insulin adjustments may be necessary every few weeks due to changes in insulin sensitivity. Patients with type 2 diabetes are usually switched from their usual medications to insulin therapy to prevent possible toxicity to the fetus.52 Although metformin and the sulfonylurea glyburide may be safe to use at conception and during early pregnancy in pregnant women with type 2 diabetes, research data are limited in this population so physicians may be reluctant to prescribe the drugs.53 Nutrient requirements during pregnancy are similar for women with and without diabetes. In women with diabetes, however, carbohydrate intakes must be balanced with insulin treatment and physical activity to avoid hypoglycemia and hyperglycemia. To help with this goal, women should consume meals and snacks at similar times each day, and select carbohydrate sources that facilitate glucose control after meals, such as whole grains, fruits, and vegetables. An evening snack is usually required to prevent overnight hypoglycemia and ketosis. When insulin dosages are adjusted, the diabetic woman will need to modify her carbohydrate intake as well.
hypoglycemia
abnormally low blood glucose concentrations. In diabetes, hypoglycemia is treated when plasma glucose falls below 70 mg/dL
ketoacidosis
an acidosis (lowering of blood pH) that results from the excessive production of ketone bodies
gangrene
death of tissue due to a deficient blood supply and/or infection
gastroparesis
delayed stomach emptying, often caused by nerve damage in a person with diabetes
type 1 diabetes
diabetes that is characterized by absolute insulin deficiency, usually resulting from the autoimmune destruction of pancreatic beta cells
macrovascular complications
disorders that affect large blood vessels, including the coronary arteries and arteries of the limbs
microvascular complications
disorders that affect small blood vessels, including those in the retina and kidneys
hyperglycemia
elevated blood glucose concentrations. Normal fasting plasma glucose levels are less than 100 mg/dL. Fasting plasma glucose levels between 100 and 125 mg/dL suggest prediabetes; values of 126 mg/dL and above suggest diabetes
ketosis
elevated levels of ketone bodies in body tissues
polyphagia
excessive hunger or food intake
polydipsia
excessive thirst
polyuria
excessive urine production
rebound hyperglycemia
hyperglycemia that results from the release of counterregulatory hormones following nighttime hypoglycemia; also called the Somogyi effect.
hyperosmolar
having an abnormally high osmolarity; osmolarity refers to the concentration of osmotically active particles in solution. Hyperglycemia may cause some body fluids to become hyperosmolar
glycated hemoglobin (HbA1c)
hemoglobin that has nonenzymatically attached to glucose; the level of HbA1c in the blood helps to diagnose diabetes and evaluate long-term glycemic control. Also called glycosylated hemoglobin
The first sign of type 1 diabetes is often:
ketoacidosis
diabetic nephropathy
kidney damage that results from long-term diabetes
advanced glycation end products (AGEs)
reactive compounds formed after glucose combines with protein; AGEs can damage tissues and lead to diabetic complications.
dawn phenomenon
morning hyperglycemia that is caused by the early-morning release of growth hormone, which reduces insulin sensitivity
diabetic neuropathy
nerve damage that results from long-term diabetes
claudication
pain in the legs while walking; usually due to an inadequate supply of blood to muscles
diabetic retinopathy
retinal damage that results from long-term diabetes
renal threshold
the blood concentration of a substance that exceeds the kidneys' capacity for reabsorption, causing the substance to be passed into the urine
albuminuria
the presence of albumin (a blood protein) in the urine, a sign of diabetic nephropathy
glycosuria
the presence of glucose in the urine
ketonuria
the presence of ketone bodies in the urine
