Nutrition - Ch. 19 -- Nutrition for Patients with Diabetes Mellitus

Fasting blood glucose levels of ____________ indicate prediabetes.

100 to 126 mg/dL

A rise in postprandial blood glucose levels stimulates the pancreas to secrete ______.

insulin

Exchange Lists for meal planning

"Choose Your Foods: Exchange Lists for Meal Planning" (now referred to as Food Lists for Diabetics) is a framework for choosing a healthy diet. -- *This groups foods into lists that, per serving size given, are similar in carbohydrate, protein, fat, and calories, based on rounded averages* -- Three major categories are carbohydrates, meat and meat substitutes, and fats. -- Sample meal pattern is designed for clients based on their usual pattern of eating. -- Clients are encouraged to eat a variety of foods within each list and to make healthy choices. -- Food should be weighed or measured until portion sizes can be accurately estimated. -- Eliminates the need for daily calculations (if they get on task with MyPlate) -- Some items on some lists are counted as more than just one choice or one exchange. -- Some items appear on more than one list and in different amounts. -- Best suited to people who want or need structured meal-planning guidance and are able to understand complex details

Type 1 Diabetes

"insulin-dependent diabetes mellitus" - *Characterized by the absence of insulin* Risk factors for type 1 diabetes may be: Autoimmune Genetic Environmental -- No known way to prevent type 1 diabetes All people with type 1 diabetes require *exogenous insulin* to control blood glucose levels. Most often detected in children, adolescents, and young adults Classic symptoms of polyuria, polydipsia, and polyphagia -- Urinating a lot, eating a lot, thirsty a lot

Type 2 Diabetes

*A slowly progressive disease that usually begins as a problem of insulin resistance* Insulin resistance is strongly linked to obesity. Occurs most often after the age of 45 years -- Accounts for 90% to 95% of diagnosed cases of diabetes Type 2 diabetes is often asymptomatic. Risk factors for type 2 diabetes - Age 45 years or older - Overweight (BMI ≥25 kg/m2) - First-degree relative with diabetes - Physically inactive or exercises fewer than three times per week - Member of high-risk ethnic group: African American, Latino, Native American, Asian American, Pacific Islander - Previously identified with factors such as impaired fasting glucose or impaired glucose tolerance - History of gestational diabetes or giving birth to a baby weighing more than 9 pounds - Hypertensive - Polycystic ovary syndrome - HDL <35 mg/dL and/or triglyceride level ≥ 250 mg/dL ---- If the HDL (good cholesterol) is less than 35, we rather see it being 100; The good cholesterol is not doing the job it's supposed to

Sick-Day Management for Diabetics

*Acute illnesses can significantly raise blood glucose levels* - Maintain normal medication schedule, monitor blood glucose levels every 2 to 4 hours, and maintain an adequate fluid intake - A daily intake of 150 to 200 g of carbohydrates, approximately 50 g every 3 to 4 hours, is recommended.

Diabetic ketoacidosis (DKA)

*Type 1 Diabetes* - A life-threatening complication of diabetes mellitus that develops when a severe insulin deficiency occurs. - Because there is not enough insulin, the body produces ketones - Characterized by hyperglycemia (glucose levels >250 mg/dL) and ketonemia (ketones in the blood)

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

*Type 2 Diabetes* - Characterized by hyperglycemia (>600 mg/dL; Life threatening number) without significant ketonemia - Occurs most commonly in people with type 2 diabetes

Hypoglycemia

- Blood glucose level less than 70 mg/dL - Commonly referred to as "insulin reaction"

Life Cycle Considerations: Children and adolescents

- Children with diabetes appear to have the same nutrient needs as their age-matched peers. - Managing diabetes in children and adolescents is complicated by the impact of growth on nutrient needs, irregular eating patterns, and erratic activity levels. - Failure to provide adequate calories and nutrients results in poor growth, as does poor glycemic control and inadequate insulin administration. - Individualized meal plans and intensive insulin regimens can provide flexibility for erratic eating, activity, and growth. Increasingly larger numbers of American youths are diagnosed with type 2 diabetes. - Weight control is key to preventing type 2 diabetes in children.

Causes of hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

- Dehydration and heat exposure increase the risk. - Illness or infection is usually the precipitating factor in the elderly. Older people may be particularly vulnerable. Develops symptoms relatively slowly Best protection against HHNS is regular glucose monitoring. - Treatment includes insulin and fluid and electrolyte replacement.

Managing Diabetes

- Primary goal of diabetes management is *to keep blood glucose levels as near normal as possible* -Secondary goals: Attain and maintain control of blood lipid levels and blood pressure. Prevent or delay the development of complications. Meet the individual's cultural and personal needs. Maintain the pleasure of eating by not limiting any foods unless indicated by scientific evidence. Nutrition therapy is an essential component of diabetes management.

Sweeteners in Diabetes

- Sucrose and sucrose-containing foods are not restricted. - Sugar-free foods - Foods high in sugar are usually nutrient poor. - False sugars have no nutritional value, so stay away from them mostly - Use of fructose as an added sweetener is not recommended. ➢May adversely affect serum lipid levels ➢No reason for people with diabetes to avoid naturally occurring fructose in fruit and vegetables

Preventing Diabetes

- Weight loss through a combination of healthy eating and exercise is the primary focus of diabetes prevention. - Diabetes Prevention Program (DPP) - A low saturated fat intake may reduce the risk for diabetes by improving insulin resistance and promoting weight loss. - Several studies show that an increased intake of whole grains and fiber lowers the risk of diabetes.

Carbohydrate counting

-- Easier and more flexible alternative to using the exchange system -- *Clients are given an individualized meal pattern that specifies the number of carbohydrate "choices" for each meal and snack* -- Carbohydrate choice lists -- Protein and fat cannot be disregarded. -- Appropriate for people who understand the importance of consuming a consistent carbohydrate intake to match insulin or medication peaks -- Feel more in control and benefit from improved glucose control -- Keeping records of blood glucose tests and food intake helps

Metabolic syndrome (MetS)

-A group of metabolic conditions occurring together that increases a person's risk of heart disease, stroke, and diabetes People with MetS are 3x as likely to develop heart disease and 5x as likely to develop diabetes compared to those without. - Type 2 diabetes demonstrate similar characteristics associated with MetS Even modest weight loss can lessen the risks associated with metabolic syndrome. - Suggest to go on a weight training or weight loss program Modifiable risk factors for metabolic syndrome include excess body fat, a sedentary lifestyle, and a high-saturated fat diet.

Is the following statement true or false? Diabetic ketoacidosis is characterized by glucose levels greater than 250 mg/dL.

Answer: True. Rationale: People with type 1 diabetes are susceptible to diabetic ketoacidosis (DKA), characterized by hyperglycemia (glucose levels >250 mg/dL) and ketonemia. **for HHNS, glucose is > 600**

Is the following statement true or false? Sugar alcohols produce a smaller rise in postprandial glucose levels and insulin secretion than sucrose

Answer: True. Rationale: Sugar alcohols do produce a smaller rise in postprandial glucose levels and insulin secretion than sucrose

Type 1 diabetes, once referred to as insulin- dependent diabetes, is caused by what? Hyperinsulinemia Absence of insulin Sensitivity to insulin Metabolic syndrome

Answer: b. Absence of insulin Rationale: Type 1 diabetes, formerly known as insulin-dependent diabetes mellitus, is characterized by the absence of insulin.

_____________________________ is the leading cause of death among people with diabetes.

Atherosclerotic cardiovascular disease (ASCVD)

Atherosclerotic cardiovascular disease (ASCVD)

Blood vessels around the heart becoming plaqued and narrow; Risk of cardiac issues increases

Total carbohydrates - Acceptable Macronutrient Distribution Range (AMDR):

Carbohydrates take up 45% to 65% of total calories.

Causes of diabetic ketoacidosis (DKA)

Caused by a severe deficiency of insulin or from physiologic stress, such as illness or infection -- When you think of diabetic patients and they are sick, such as a stomach virus/ketoacidosis (vomiting), they can throw themselves into diabetic complications easily -- Their insulin deficiency can increase when sick → ketoacidotic state Hyperventilation, fatigue, nausea, vomiting, and confusion develop. Diabetic coma and death are possible. DKA is treated with electrolytes, fluid, and insulin

Changing behaviors in diabetics:

Diagnosis of diabetes often triggers anxiety and uncertainty. Before recommending dietary changes, it may be useful to ask the client: - What are your goals for nutrition counseling? - What behaviors do you want to change? - What changes can you make in your present lifestyle? - What obstacles may prevent you from making changes? - What changes are you willing to make right now? - What changes would be difficult for you to make? Ideally, positive changes occur progressively. - Patient actively involved in goal setting, self-monitoring, and record keeping. - Periodic and ongoing follow-up improves compliance.

Exercise for type 1 diabetics

Exercise in insulin users - Has been shown to improve glycemic control - May worsen hyperglycemia It is not clear whether physical activity offers the same benefits in people with type 1 diabetes Physical activity may cause hypoglycemia; source of readily absorbable carbohydrate should be carried at all times

Protein in Diabetes

For people with diabetic kidney disease, the Recommended Dietary Allowance (RDA) for protein (0.8g/kg) should be maintained.

Gestational diabetes + Risk factors

Hyperglycemia that develops during pregnancy Risk factors: - A history of gestational diabetes - A history of giving birth to an infant weighing more than 9 pounds - Like type 2 diabetes... Obesity, Being a member of a certain ethnic population (African American, Latino/Hispanic, Asian American, and Native American)

Insulin therapy for people with type 1 diabetes

Insulin preparations vary in how quickly they act, when their peak action occurs, and how long their effects last. - *Intermediate* or Long-acting insulin is used to meet basal needs. - *Rapid* or Short-acting insulin is used before each meal. Rapid = Gets in there quick Closely resembles how insulin is normally secreted Nighttime hypoglycemia can be a problem with NPH peaking during the night. -- NPH is the normal insulin

Alcohol in Diabetes

Moderate use of alcohol (1 drink/day or less in women and 2 drinks/day or less in men) by people who have well-controlled diabetes minimally affects blood glucose and insulin levels. Risk of hypoglycemia if taken without food

Meal Planning Approaches for Diabetics

Monitoring carbohydrate intake is essential for controlling blood glucose levels Meal plans should reflect the individual's lifestyle, preferences, and willingness/ability to make dietary changes. *Exchange Lists for meal planning* and *Carbohydrate Counting*

Causes of hypoglycemia

Occurs from taking too much insulin, inadequate food intake, delayed or skipped meals, extra physical activity, or consumption of alcohol without food Symptoms: - Blood glucose <70 mg is treated with 15g of ingested glucose. - Symptoms normally improve in 15 minutes. If not, repeat process If they get those 15g of glucose in (ex. Candy, juice, milk) to raise glucose levels, symptoms usually go away; If not, increase intake Hypoglycemic unawareness - Consistent monitoring of blood glucose is especially important.

Exercise for type 2 diabetics

Offers substantial benefits - Helps to maintain long-term weight reduction - Monitor blood glucose levels Insulin may need to be adjust their pre-exercise carbohydrate intake or insulin dose to void hypoglycemia Stop activity if signs and symptoms of hypoglycemia develop

Glucose-lowering medications

Oral glucose-lowering medications vary in their mechanism of action and food concerns. Considered adjunct to nutrition therapy and exercise, not a sole mode of therapy

Pharmacologic Management of Diabetes

People with type 1 diabetes rely on exogenous insulin for survival. Due to the progressive nature of the disease, most people with type 2 diabetes eventually require oral agents, insulin, or a combination of both to manage blood glucose levels. -- Metformin (name of a medication for type 2)

Tertiary Prevention: Controlling diabetes complications

Progression of microvascular diabetes (vessels are being narrowed → risk of hypertension) complications may be modified by *improving glycemic control* and *lowering blood pressure*

Sugar alcohols in Diabetes

Provide fewer calories and cause a smaller increase in glucose Nonnutritive sweeteners ➢Saccharin, aspartame, acesulfame, and sucralose ➢May safely be used by people with diabetes Caution with these, but if the patient is trying their best to eat low sugar diets and

Fiber in Diabetes

Recommendations for fiber are the same as for the general population. Foods rich in fiber provide other benefits such as increasing satiety; providing vitamins, minerals, and phytochemicals; and lowering serum cholesterol levels.

Long term complications of diabetes

Retinopathy Nephropathy Neuropathy Myocardial infarction Stroke Peripheral vascular disease Mild to severe forms of nervous system damage Impaired wound healing** Periodontal disease Pregnancy complications: Because the babies grow at excessive rates, maturing faster in size than they should be Increased susceptibility to other illnesses

What are the primary determinants of how quickly and how high blood glucose levels rise after eating?

The *amount* of carbohydrate consumed and, to a lesser extent, the *type* of carbohydrate eaten

Glucose

The source of ready fuel for body cells

Fat in Diabetes

The type of fat is more important than the amount of fat consumed. The amount of saturated fat, trans fat, and cholesterol recommended for the general public is also appropriate for people with diabetes.

Diabetes Management: Type 1 diabetes Type 2 diabetes

Type 1 diabetes: Managed by a coordinated regimen of nutrition therapy and insulin Type 2 diabetes: Diet and exercise -- INITIALLY; Can be reversed initially

Acute Diabetes Complications

Untreated or poorly controlled diabetes can lead to acute life-threatening complications. Conversely, hypoglycemia caused by overuse of medication, too little food, or too much exercise, can also be life-threatening. Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) Hypoglycemia

Glycemic control depends on ___________________________________.

matching carbohydrate intake with the action of insulin or other medication A low glycemic index diet may provide a modest benefit in controlling postprandial hyperglycemia.

Many of the risks for type 2 diabetes are characteristics of ____________________.

metabolic syndrome (MetS)