(3) Chapter 15: Nutrition for Diabetes Mellitus
Diabetes Acute Complications: Hypoglycemia
- *Causes*: too much insulin, skipping meals, too much exercise without food replacement; occurs most commonly during insulin peak and at night during sleep - *Symptoms:* occur when blood glucose level falls below 50 mg/dL or if there is a significant drop in blood glucose level
15 gram carbohydrate examples for treatment
- 3-4 glucose tablets - 1 tube of glucose gel - 4 oz fruit juice - 4 oz sugar sweetened soda - 5 life savors
Four methods of diagnosis
- A1c >6.5% - Fasting plasma glucose level >126 mg/dl - Random or casual plasma glucose measurement ≥ 200 mg/dl plus symptoms - Two-hour OGTT level ≥ 200 mg/dl using a glucose load of 75g
Nutrition Therapy Goals
- Address individual nutritional needs, personal and cultural preferences, lifestyle, and willingness to change. - Medical team member responsible for providing nutrition therapy should be the registered dietitian. - Emphasize importance of nutrition assessment and individualization. - Address use of fructose and other nutritive and nonnutritive sweeteners.
Individualize nutrition therapy: Diabetes and Pregnancy
- Adequate kilocalories and nutrients - Self-monitoring of blood glucose level Goals: •Blood glucose fasting level: less than 95 mg/dL •1-hour postprandial glucose level: less than 140 mg/dL •2-hour postprandial glucose level: less than 120 mg/dL
Nursing Role in Nutrition Therapy
- Assess client's knowledge, understanding, and adherence to regimen. - Consider client's age and the setting. - Devise care plan. - Ensure that management goals are realistic. - Monitor glucose to check compliance. - Noncompliance may be explained by lack of knowledge versus lack of motivation.
Gestational Diabetes characteristics
- Associated with obesity, but weight loss not recommended during pregnancy - Goal: achieve good glucose control; insulin often prescribed to reduce complications - Oral hypoglycemic agents: teratogenic and not recommended Increased risk for later development of T2DM; occurs in 20% to 50% of women with gestational diabetes --- Increased risk for developing type 2 in 5 to 10 years
Goals of nutrition therapy
- Attain and maintain optimal metabolic outcomes: blood glucose, lipid, and lipoprotein profiles; and blood pressure - Prevent and treat chronic complications - Improve health through healthy food choices and physical activity
General guidelines for exercise in T1DM
- Avoid exercise if glucose levels exceed 250 mg/dL with ketosis or exceed 300 mg/dL. - Ingest added carbohydrate if glucose level is less than 100 mg/dL. - Monitor blood glucose levels before and after exercise, and learn to adjust food and insulin amounts. - Consume added carbohydrate as needed to avoid hypoglycemia; keep carbohydrate-based foods available during and after exercise.
Prediabetes
- BG not high enough for diabetes diagnosis - Increase risk for developing type 2 diabetes - If no preventive measure taken—usually develop diabetes within 10 years - Long-term damage already occurring --- Heart, blood vessels
Blood Glucose Level Goals
- Before meals: 70 to 130 mg/dL - Two hours after meals: less than 180 mg/dL (expect a 30- to 50-point rise from pre-meal glucose) - Bedtime: 90 to 150 mg/dL
Diabetes Nutritional Therapy: *Carbohydrates*
- Carbohydrates and monounsaturated fats should provide 45% to 65% of total energy intake - decrease Carbohydrate diets are not recommended for diabetics
DKA
- Caused by profound deficiency of insulin - Characterized by •Hyperglycemia > 250 •Ketosis •Acidosis •Dehydration - Most likely occurs in type 1diabetic - Occurs in absence of exogenous insulin - Precipitating factors: insufficient or interrupted insulin therapy, too much food, infection, other stresses
Diabetes Nutritional Therapy: *protein*
- Contribute 15-20% of total energy consumed - In diabetics, excessive consumption of protein and low insulin level can lead to a greater conversion of proteins to glucose, which may have a negative effect on the control of blood glucose.
Types of insulin
- Conventional/standard insulin therapy, flexible/intensive insulin therapy, continuous subcutaneous insulin infusion - Integration of insulin regimen with patient's lifestyle
Gestational Diabetes
- Develops during pregnancy - Detected at 24 to 28 weeks of gestation - Usually glucose levels back to normal at 6 weeks postpartum - Increased risk for cesarean delivery, perinatal death, and neonatal complications - Occurrence rate: 5% to 10% of pregnancies
Special Considerations: Illness
- Effect on blood glucose concentration: elevates - Effect on appetite: decreases How to manage: -- Monitor blood glucose level at least four times a day. -- Test urine for ketones. -- Do not omit medications to control blood glucose level (dose may need to be adjusted).
Leading cause of Diabetes Mellitus
- End-stage renal disease - Adult blindness - Non-traumatic lower limb amputations
Diabetes Exercise
- Essential part of diabetes management - ↑ Insulin receptor sites - Lowers blood glucose levels - Contributes to weight loss
Diabetes Nutritional Therapy
- For a 2,000 calories a day, the diabetic patient should consume about 250 grams of complex carbohydrates per day. - A good starting place for people with diabetes is to have roughly 45 to 60 grams of carbs per meal and 15 to 30 grams for snacks.
Type 1 Diabetes Mellitus (Immune-mediated)
- Formerly known as "juvenile onset" or "insulin dependent" diabetes - Most often occurs in people under 30 years of age - Peak onset between ages 11 and 13
Clinical Manifestation Type 1- Lack of insulin results in:
- Glucose molecules accumulate= hyperglycemia - Which causes hyper-osmolality (drawing H2O from •The intracellular spaces into circulation) - The increased blood volume increases renal blood flow Acting as a osmotic diuretic -INCREASES URINE OUTPUT= POLYURIA
Blood glucose monitoring
- Glycosylated hemoglobin: reflects blood glucose control for 100 to 120 days - Self-monitoring: useful for evaluating effectiveness of meal plans in meeting goals of nutrition therapy - Records: determine food, insulin, and exercise needs
Type 2 Diabetes Mellitus Onset of Disease
- Gradual onset - Person may go many years with undetected hyperglycemia - Osmotic fluid/electrolyte loss from hyperglycemia may become severe ---Hyperosmolar coma
Major contributing factor for Diabetes Mellitus
- Heart disease - Stroke
Diabetes Nutritional Therapy: Alcohol
- High in calories - No nutritive value - Promotes hypertriglyceridemia - Detrimental effects on liver - Can cause severe hypoglycemia
Type 1 Diabetes Mellitus Clinical Manifestation
- History of recent, sudden, weight loss - Classic symptoms --- Polydipsia --- Polyuria --- Polyphagia - Weakness - Fatigue
Diabetic Ketoacidosis (DKA) Consequences:
- Hyperglycemia - Osmotic diuresis - Dehydration-leads to lethargy - Lactic acidosis; lowered pH - Rapid respirations (Kussmaul's respirations) •Kussmaul respirations ---- Rapid deep breathing ---- Attempt to reverse metabolic acidosis - Fruity or acetone breath odor;
Exercise lowers blood glucose levels, assists in maintaining normal lipid levels, and increases circulation.
- Ideal: Exercise when blood glucose level is 100 to 200 mg/dL, 30 to 60 minutes after meals. - Avoid exercise when blood glucose level is greater than 250 ml/dL and ketones are in urine.
Type 2 Diabetes in Children
- Incidence and prevalence of T2DM in children: increased 30-fold since 1994 - Related to increase in childhood obesity - Other signs that may indicate risk for type 2 DM: acanthosis nigricans, polycystic ovarian syndrome, hypertension - Girls more susceptible than boys
Type 2 Diabetes in Elderly Adults
- Macro vascular and microvascular complications are common. - Overall risk for cardiovascular disease is higher. - Target for hemoglobin A1c level in fit elderly patients who have a life expectancy of more than 10 years should be <7.0%. - Hemoglobin A1c level should be somewhat higher (≤8.0%) in frail older adults with multiple medical and functional comorbid conditions.
Macrovascular and microvascular damage results in disability and premature death.
- Macrovascular complications: coronary artery disease, peripheral vascular disease, cerebrovascular disease - Microvascular complications: nephropathy, retinopathy, neuropathy, impaired healing leading to gangrene and amputation
Type 2 Diabetes Mellitus
- Most prevalent type of diabetes - Over 90% of patients with diabetes - Usually occurs in people over 35 years of age - 80% to 90% of patients are overweight
Drug Therapy Oral Agents
- Not insulin - Work to improve mechanisms by which insulin and glucose are produced and used by the body - Work on three defects of type 2 diabetes --- Insulin resistance --- Decreased insulin production --- Increased hepatic glucose production
Counter regulatory hormones
- Oppose effects of insulin - Increase blood glucose levels - Provide a regulated release of glucose for energy - Help maintain normal blood glucose levels - Examples •Glucagon, epinephrine, growth hormone, cortisol
Type 2 Diabetes Mellitus Pathophysiology
- Pancreas continues to produce some endogenous insulin - Insulin produced is either insufficient or poorly utilized by tissues Obesity (abdominal/visceral) - Most powerful risk factor Genetic mutations - Lead to insulin resistance - Increased risk for obesity
Pregnancy in Overt Diabetes
- Preconception counseling during puberty and childbearing years - Preconception achievement of blood glucose goals - Excellent glycemic control before conception and during early pregnancy to prevent fetal malformations - Individualizing meal plan to meet changing needs during pregnancy
Type 2 Diabetes etiology
- Prevalence increases with age - Genetic basis - Greater in some ethnic populations --- Increased rate in African Americans, Asian Americans, Hispanic Americans, and Native Americans --- Native Americans and Alaskan Natives: Highest rate of diabetes in the world
Normal insulin metabolism
- Produced by the b cells •Islets of Langerhans - Released continuously into bloodstream in small increments with larger amounts released after food intake - Stabilizes glucose range to 70 to 120 mg/dl - Average daily secretion 0.6 units/kg body weight
Gastroparesis
- Rate of occurrence: 20% to 30% - Manifestations: delayed gastric emptying associated with heartburn, nausea, abdominal pain, vomiting, early satiety, weight loss
Diabetes Team
- Registered nurse, physician or primary health care provider, registered dietitian, and the person with diabetes - Family members should be included for education and counseling
Gastroparesis Dietary management
- Replace carbohydrates with tolerated foods - Six small meals per day - Constipation or diarrhea: increase fiber - Dry mouth: increase fluids; add broth to moisten food - Low-fat (40 g) soft or liquid diet: may help
Insulin in diabetes T1DM and T2DM
- T1DM: Patients require exogenous insulin to maintain blood glucose level within normal limits. - T2DM: Some patients require insulin to optimize glucose control. Goal is to maintain glucose level as close to physiologic normal as possible; it is accomplished by varying timing and dosages of insulin.
Cultural Considerations
- Tailor educational sessions in culturally appropriate ways. - Group education programs help with problem solving. - Some cultures might require significant dietary changes
Glycemic index (GI)
- Term used to describe rise in blood glucose levels after consuming carbohydrate-containing food - Should be considered when formulating a meal plan
Type 1 Diabetes Mellitus Etiology and Pathophysiology causes
- Theories link cause to single/ combination of these factors - Genetic - Autoimmune - Viral - Environmental
Diets to improve weight status
- children aged 6-12 year: . 900 kcal/day - children aged 13-18 year: 1,200 kcal/day
General recommendations
- eat regular meals and snacks - reduce portion size - choose calorie-fre drinks (expect milk) - increase fruit and vegetable intake - consume 3-4 servings low fat dairy/day - limit --- juice to 1 cup/day --- high-fat food intake --- frequency, size of snacks - reduce calories from fast-food meals
Guidelines for children and adolescents with type 2 diabetes: weight loss
- formulate nutrition prescription as part of dietary intervention - increased intake of dietary fat and calorically sweetened beverages associated with increased risk of overweight - increased fruit and vegetable intake associared with decreased risk of overweight
Insulin Injection Sites
- lower abdomen - back of upper arm - outer thigh - gluteal
What is one serving of carbohydrates?
15 grams of carbs= 1 choice of carbohydrate - 1/2 cup of cooked beans, corn or peas - 1/3 cup cooked rice, pasta - 1 corn tortilla , 1 slice of bread - 8 oz milk, 1/2 cup ice cream - 1 small apple (4 oz), 1/2 cup fruit cocktail, 1/2 large banana
Nursing management DKA/HHS
Patient closely monitored •Administration --- IV fluids --- Insulin therapy --- Electrolytes •Signs potassium imbalance •Cardiac monitoring •Vital signs •Level of consciousness
Exercise T2DM:
Patients may be at risk for hypoglycemia when taking oral agents and exercising.
Glucose Regulation
Stress - Emotional and physical can increase BG levels Medications - Can potentiate hypo/hyper glycemic effects Exercise
Diabetes MellitusEtiology and Pathophysiology
Two most common types - Type 1 - Type 2 Other types - Gestational - Prediabetes - Secondary diabetes
Prediabetes symptoms
Usually present with no symptoms Must watch for diabetes symptoms - Polyuria - Polyphagia - Polydipsia
Clinical Manifestations
Weight loss - acute = loss of H2O, glycogen, triglyceride stores - chronic = decrease muscle mass Blurred vision - - effect of hyperosmolar fluid on lenses & retina Fatigue, Malaise & Dizziness - decrease fluid volume & K+, postural hypotension, - increase protein catabolism
Clinical Manifestation type 1- *Polydipsia*
When the BG level exceeds the renal threshold for glucose: about 180mg/dL - Glucose is excreted in the urine-glycosuria The decrease in intracellular volume & the increased urinary output cause dehydration - Thirst sensors are activated causing pt. to - Drink increased amounts of fluid= POLYDIPSIA
Type 1 Diabetes Mellitus Etiology and Pathophysiology
End result of long-standing process - Progressive destruction of pancreatic b cells by body's own T cells - Autoantibodies cause a reduction of 80% to 90% of normal b cell function before manifestations occur
Gastroparesis Bezoar
Hard ball vegetable fiber that may develop within the intestines; may be more common with intake of oranges, coconuts, green beans, apples, figs, potato skins, Brussels sprouts, sauerkraut
Diabetes Mellitus Diagnostic Studies
Hemoglobin A1C test (also called glycosylated hemoglobin) - Useful in determining glycemic levels over time - ADA recommends to diagnose (Feb 2010) - Shows the amount of glucose attached to hemoglobin molecules over RBC life span •90 to 120days Ideal goal •ADA 6.5% •American College of Endocrinology <6.5% Normal A1C reduces risk of retinopathy, nephropathy, and neuropathy
Diabetes Self-Management Education
Involves comprehensive nutrition assessment; self-care treatment plan; and client's health status, learning ability, readiness to change, and current lifestyle
Prediabetes types
Known as: Impaired fasting glucose (IFG) - Fasting glucose levels higher than normal (>100 mg/dl, but <126 mg/dl) OR Impaired glucose tolerance - 2 hour plasma glucose higher than normal (between 140 and 199 mg/dl)
blood glucose homeostasis: Low blood glucose
Low blood glucose causes the pancreas to release glucagon then the liver breaks fown glycogen and the blood glucose rises
Diabetes mellitus,
a chronic, lifelong disorder, necessitates lifestyle changes in both dietary intake and physical activity
Ketosis:
abnormal accumulation of ketones resulting from metabolism of fatty acids
Glycemic Index 30-50
coarse barley bread, strawberries, apples, pears and oranges, milk and soy milk, natural yoghurt, oatmeal beans
The plate methods
fill hald of a 9-inch plate with one cup of non-starchy vegetables; a quarter of the plate with high proteion foods and a quarter of the plate with carbohydrates foods. Add a small serving of fruit and a serving dairy
Type 2 Diabetes Mellitus symptoms
gradual onset of polyuria and polydipsia, frequent fatigue, frequent infections (especially of urinary tract) - Prolonged wound healing - Visual changes - Condition may exist for many years before complications lead to diagnosis. -- Caused by insulin resistance or failure of cells to respond to insulin
blood glucose homeostasis: High blood glucose
high glucose caues the pancrease to release insulin which leads to the cells taking up glucose from the blood and liver to produce glycogen which results in blood glucose falling
Glycemic Index 0-10
hummus, chickpeas, garlic, onion, green pepper, eggplant, broccoli, cabbage, tomatoes, mushrooms, lettuce
Major metabolic abnormalities
1. Insulin resistance •Body tissues do not respond to insulin Insulin receptors either unresponsive or insufficient in number •Results in hyperglycemia 2. Pancreas ↓ ability to produce insulin •β cells fatigued from compensating •β -cell mass lost 3. Inappropriate glucose production from liver •Liver's response of regulating release of glucose is haphazard •Not considered a primary factor in development of type 2
Clinical Manifestation type 1- *Polyphagia*
Because glucose cannot enter the cell without insulin, energy production decreases •Stimulates hunger •Person wants/eats more food=POLYPHAGIA
Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS)
Causes: insulin deficiency that results in severe hyperglycemia > 600 ; attributable to stress (e.g., trauma, infection) Enough insulin is present to prevent ketosis and acidosis, but not enough to prevent hyperglycemia - Life-threatening syndrome - Less common than DKA - Often occurs in patients over 60 years with type 2
Individuals with metabolic syndrome ("Syndrome X") are at increased risk for type 2:
Cluster of abnormalities that increase risk for cardiovascular disease and diabetes •Elevated insulin levels, ↑ triglycerides & LDLs, ↓ HDLs, hypertension Risk factors •Central obesity, sedentary lifestyle, urbanization, certain ethnicities
Management Issues
Control of blood glucose levels is the cornerstone of diabetes management. - Reduced rates of retinopathy, nephropathy, and neuropathy
Eating Disorders
Eating disorders in T1DM are somewhat common: --- Once insulin is initiated, weight gain occurs. - Insulin restriction to keep weight under control is dangerous. - Refer for both dietary and emotional counseling as needed
Exercise T1DM:
Glucose control can be compromised if food and insulin are not adjusted.
Diabetes Acute Complications
Hyperosmolar hyperglycemic syndrome (HHS) - Produces fewer symptoms in earlier stages - Neurologic manifestations occur due to ↑ serum osmolality - Consequences: hyperosmolar serum, osmotic diuresis, electrolyte depletion; death rate, 10% to 25%
Diabetes Nutritional Therapy: *Fats*
No more than 20% to 35% of meal plan's total calories •<7% from saturated fats, minimal trans fat
Fasting blood glucose
Normal: <100 mg/dL Prediabetes: 100-125 mg/dL Diabeters: >126 mg/dL
Oral glucose tolerance test
Normal:<140 mg/dL Prediabetes: 140-199 mg/dL Diabeters: >200 mg/dL
Guidelines for children and adolescents with type 2 diabetes
interventions to reduce obesity should include - diet, physical activity, nutrtition counseling, parent/caregiver participation
If regular foods are not tolerated, replace carbohydrates in the meal plan with
liquid, semiliquid, or soft foods. Carbohydrate: either of the following •15 g of every 1 to 2 hours •50 g of carbohydrate every 3 to 4 hours Less if blood glucose is greater than 240 mg/dL - Drink 8 to 12 oz. of liquid every hour. - Small amounts of salty foods may be needed after vomiting and diarrhea.
Gastroparesis medications
metoclopramide (Reglan) increases gastric contractions and relaxes pyloric sphincter; may result in dry mouth and nausea
Glycemic Index 10-30
pearled barley, lentils, greyfrut, cherry, apricot, plum, dark chocolate 70% cocoa, whole milk, cashews, walnuts
Children and adolescents: refer patients to registered dietician
provide nutrition education - consume 3 planned meals with snacks/day - no eating while watching TV,using computer - use smaller plates to make portions seem larger - leave small amounts of food on plate
Diabetes Mellitus Characteristics:
relative or complete lack of insulin secretion by beta cells or defects of insulin receptors - Results in disturbances of carbohydrate, protein, and lipid metabolism, and in elevated blood glucose levels
Glycemic Index 50-70
rye and wholegrain bread, muesli, corn, couscous, brown rice, spaghetti, popcorn, yams, ice cream, sweet yogurt, banana, grapes and kiwi
Desired weight gain:
same as in normal pregnancy; desired weight gain goals based on prepregnancy body mass index
Type 2 Diabetes in Children goals
to normalize blood glucose and glycated hemoglobin levels and control comorbid conditions - Nutrition therapy and exercise - Drug therapy - Comprehensive self-management education
Glycemic Index 70-100
white wheat bread, donuts, baguette, crackers, waffles, white rice, boiled potatoes and mash, french fries, watermelon and cornflakes
Insulin
•Decreases glucose in the bloodstream •Insulin ↑ after a meal •Stimulates storage of glucose as glycogen in liver and muscle •Inhibits gluconeogenesis •Enhances fat deposition •↑ Protein synthesis •Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell
Hypoglycemia Treatment
•If alert enough to swallow 15 to 20 g of a simple carbohydrate -4 to 6 oz. fruit juice -Regular soft drink Avoid foods with fat -Decrease absorption of sugar •Do not over treat •Recheck blood sugar 15 minutes after treatment •Repeat until blood sugar >70 mg/dl •Patient should eat regularly scheduled meal/snack to prevent rebound hypoglycemia •Check blood sugar again 45 minutes after treatment In acute care settings •20 to 50 ml of 50% dextrose IV push
