NTR 103 exam 2 chapters 22 & 23

Hypertriglyceridemia

Elevated blood triglyceride levels

Symptoms

Usually related to the degree of hyperglycemia present. When plasma glucose level rises above 200 mg per deciliter, it exceeds renal threshold (concentration in which kidneys begin to pass glucose into urine. Presence of glucose in water draws water from blood, increasing amount of urine produced. This leads to • Frequent urination (polyuria) • Dehydration, dry mouth • Excessive thirst (polydipsia) • Weight loss • Excessive hunger (polyphagia) • Blurred vision • Increased infections • fatigue

Hypertension

People cannot feel physical effects of hypertension. Primary risk factor for atherosclerosis and cardiovascular disease. Hypertension has damaging effects on arteries, elevated bloof pressure forces heart to work harder and eject blood into arteries; this effort weakens heart muscle and increases risk of developing heart arrhythmias, heart failure, and even sudden death. Hypertension is primary cause of stroke and kidney failure, reducing blood pressure can dramatically reduce incidence of these diseases. Affects ~1/3 adults in US and ~18% people with hypertension are unaware they have it

Heart Healthy Diet

Dietary and lifestyle changes can improve most cases of mild hypertriglyceridemia. Excessive weight gain and inactivity may raise triglyceride levels. Dietary factors that increase triglyceride levels include high intakes of alcohol and refined carb; sucrose and fructose are carbs with strongest effect. Controlling body weight, being physically active and restricting alcohol and limting intakes of refined carbs (sweetened bev. And food items made with white flour and added sugars) are basic treatments for hypertriglyceridemia. High triglyceride levels associated with low HDL but the lifestyle changes listed are likely to improve HDL levels as well.

Diabetes:

: Diabetes mellitus is a chronic condition characterized by inadequate insulin secretion and/or impaired insulin action; diagnosis is based on indicators of hyperglycemia.

The Disease

Affects nearly 1/3 adults in US. Common n people with diabetes mellitus, obesity. And metabolic syndrome and may result from other disorders. Elevated triglycerides may coexist wieht elevated LDL cholesterol or occur separately. Mild to moderate hypertriglyceridemia is often associated with increased CHD risk, severe hypertriglyceridemia (blood triglyceride about 500 mg/dL) can cause additional complications, including fatty deposits in the skin and soft tissues and acute pancreatitis.

The Disease

CHD, Also called coronary artery disease, most common type of cardiovascular disease. CHD is most often caused by atherosclerosis leading to impaired blood flow through coronary arteries; possible outcomes incl. angina pectoris; heart attack, and sudden death. Most common symptm is pain or discomfort in chest region; pain may radiate to left neck and shoulder, arms, back, or jaw. Other symptoms incl. shortness of breath, unusual weakness or fatihgue, lightheadedness or dizziness, nausea, vomiting, and lower abdominal discomfort

Type 2 Diabetes: Define 3 Acute Complications

Type 2: diabetes that is characterized by insulin resistance coupled with insufficient insulin secretion. Most prevelant form accounting for 90-95% of cases. 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 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 the cells. Thus, hyperglycemia that develops represents 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 declines as the condition progresses. Precise cause of type 2 diabetes is unknown but risk is substantially increased by obesity (esp. abdominal obesity,) aging, and physical inactivity. Majority of individuals with type 2 diabetes are obese, and obesity itself can directly cause some degree of insulin resistance. Prevelance increases with age and ~25% in persons older than 65; however, many cases remain undiagnosed. Genetic factors strongly influence risk: type 2 more prevelant in certain ethnic populations, incl. African Americans, asian Americans, Hispanic populations, native Americans, and pacific islanders. Most often diagnosed in individuals over 40 years of age but children and teenagers who are overweight or obese or have a family history of diabetes are at increased risk. Frequently asymptomatic so generally identified in youths only when high-risk groups are screened for the disease. Increased rate of type 1 and 2 have been documented in children in past decade and correlate with rise in childhood obesity. Type 1 and 2 can be difficult to distinguish in children, some diagnosed type 1 end up actually type 2. Type 2 still extremely rare in children but indicates routine screening and diabetes prevention programs may be important safeguards fro children at risk. Untreated may lead to 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 is a possible complication of inappropriate disease management 3 acute complications incl: 1. diabetic ketacidosis in type 1 diabetes: a sever lack of insulin causes diabetic ketoacidosis. w/o insulin, glucagon's effects become more pronounced, leading to the unrestrained breakdown of the triglycerides in the adipose tissue and the protein in the 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 blood (ketoacidosis) and spill into urine (ketonuria). Blood pH typically falls below 7.3 (normal range between 7.35-7.45). blood glucose levels usually exceed 250 mg/dL and rise above 1,000 mg/dL in severe cases. Main features of ketoacidosis include severe ketosis, acidosis, and hyperglycemia. Patients with ketoacidosis may exhibit symptoms of acidosis and dehydration. Acidosis is partially corrected by exhalation of carbon dioxide, so rapid or deep breathing is characteristic. Ketone accumulation sometimes evident by fruity odor on person's breath (acetone breath). Significant urine loss (polyuria) accompanies hyperglycemia, lowering blood volume and blood pressure and depleting electrolytes. Patients may demonstrate fatigue, lethargy, nausea, and vomiting. Mental state varies from alert to comatose (diabetic coma). Treatment includes insulin therapy to correct hyperglycemia, intravenous fluid and electrolyte replacement, and, in some cases, bicarbonate therapy to treat acidosis. Diabetic ketoacidosis may result from inappropriate diabetes treatment (ex: missed insulin injections), illness or infection, alcohol abuse, or other physiological stressors. Usually develops quickly (1-2 days). Although can occur in type 2 diabetes-usually due to severe stressors such as infection, trauma, or surgery-it rarely develops because even relatively low insulin concentrations suppress ketone body production 2. hyperosmolar hyperglycemic syndrome in type 2 diabetes: hyperosmolar hyperglycemic syndrome is a condition of severe hyperglycemia and dehydration that develops in the absence of significant ketosis. Often evolves slowly (one week or longer). Usually precipitated by a serious illness or infection that worsens hyperglycemia and results in substantial fluid losses due to polyuria or diarrhea; in addition the patient in unable to recognize thirst or replace fluids adequately due to age, illness, sedation, or incapacity. Profound dehydration the eventually develops exacerbates the rise in blood glucose levels, which often exceed 600mg/dL and may climb above 1000 mg/dL. Blood plasma may become so hyperosmolar as to cause neurological abnormalities, confusion, speech or vision impairments, muscle weakness, abnormal reflexes, and seizures; ~10% of patients lapse into a coma. Treatment includes intravenous fluid and electrolyte replacement and insulin therapy. 3. Hypoglycemia: hypoglycemia/low blood glucose is due to the innapropriate management of diabetes rather than the disese itself. 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 the insulin-treated patients and is believes to account for 3-4 deaths in this population. Symptoms include sweating, heart palpitations, shakiness, hunger, weakness, dizziness, and irritability. Mental confusion may prevent a person from recognizing the problem and taking such corrective actions as ingesting glucose tablets, juice, or candy. If hypoglycemia occurs during the night, patients may be completely unaware of its presence.

Contributions

90-95% cases cause is unknown. Other cases, hypertension is caused by a known physical or metabolic disorder (abnormality in organ or hormones involved in blood pressure regulation) number of risk factors identified incl.: Aging: 2/3 people older than 65 have hypertension. People with normal blood pressure at 55 still have 90% risk of developing high blood pressure during lifetime. Genetic: risk is similar among family members. Also prevelant and severe in certain ethnic groups (41% in African American adults, 28% in whites and Mexican americans) Obesity: strong relationship between excess body fat and increased blood pressure. Obesity raises blood pressure partially by stimulating the sympathetic nervous system and activating hormonal processes that promote sodium retention and blood vessel constriction. Salt sensitivity: ~30-50% those w/ hypertension have blood pressure that is sensitive to salt intake. Salt (sodium) sensitivity may worsen due to aging, obesity, diabetes, kidney disease, or hypertension itself. Alcohol: heavy drinking increases incidence and severity of hypertension Dietary factors: person's diet may influence hypertension risk and diets that emphasize fruits, veggies, and whole grains and include low-fat milk products have been shown to reduce blood pressure

Heart Failure

Also called congestive heart failure; characterized by heart's inability to pump adequate blood, resulting in inadequate blood delivery and a buildup of fluids in the veins and tissues. Heart failure has various causes, but often a consequence of chronic disorders that create extra work for heart muscle., like CHD or hypertension. To accomadate extra workload, heart enlarges or pumps faster or harder but may eventually weaken enough to fail completely. Develops mostly in older adults and elderly; majority of cases occur in indicviduals 60+ Consequences: fluid may accumulate in liver and abdomen and in lower extremities causing chest pain, difficulty with digestion and absorption, and swelling in legs ankles and feet. Fluid can also build up in lungs (pulmonary edema) resulting in shortness of breath and limited oxygen for activity; severe cases can lead to respiratory failure. Inadequate blood flow leads to functions of various organs (kiney and liver) to become impaired. Effects of heart failure depend on severity of illness; mild cases may be asymptomatic, but severe cases may cause considerable damage to health. Often affects food intale and level of physical activity. Those with abdominal bloating and liver enlargement, pain and discomfort may worsen with meals. Limb weakness and fatigue can limit physical activity. End-stage heart failure is often accompanied with cardiac cachexia, condition of severe malnutroion characterized by significant weight loss and tissue wasting. Medical management: heart failure is chronic, profressive illness that may require frequent hospitalizations. Many patints face combination of debilitating symptoms, complex treatments, and an uncertain outcome. Important goals of medical therapy are to slow disease progression and enhance patients quality of life. Treatment depends on nature and severity of illness. Medications help to manage fluid retention and improve heart function. Dietary sodium and fluid restictions can help to prevent fluid accumulation. Vaccinations for influenza and pneumonia reduce risk of developing respiratory infections. Heart failure patients are encouraged to participate in exercsise programs to avoid becoming physically disabled and to improve endurance. Nutritional therapy: modest sodium restriction of 2000mg or less daily tor educe fluid retention. Patients with persistant recurrent fluid retention, fluid intakes may be restricted to 2 liters per day or less. People with difficulty eating due to abdominal or chest pain may tolerate small, frequent meals than large ones. Heart failure patients may be prone to constipation due to dieuretic use ad reduced physical activity. Maintaining adequate fiber can help minimize problems. Restrict or avoid alcohol beverages and patients on dieuretic therapy or restricted diets may benefit gtom daily multivitamin-mineral supplementation. No known therapies reverse cachexia, and prognosis is poor. Some patients, liquid supplements, tube feedings, or parenteral nutrion support can be supportive additions to treatment.

The Disease

Artery walls become progressively thickened due to an accumulation of fetty deposits, fibrous connective tissue, and smooth muscle cells, collectively known as plaque. Atherosclerosis initially arises in response to minimal but chronic injuries that damage inner arterial wall. First lesions tend to develop in regions where arteries branch due to disturbed blood flow in those areas. Subtle damage caused by disturbed blood flow or other factors elicit an inflammatory response, attracting immune cells and increasing permeability of artery walls. Low-density lipoproteins (LDL) slip under artery's thin layer of endothelial cells, become oxidized by local enzymes, and accumulate. Arterial macrophages engulf altered LDL and become foam cells; these fat-laden cells are visible as fatty deposits along artery walls, known as fatty streaks eventually plaque thickens an hardens as additional lipids, calcium, and cellular debris acumlates. Atherosclerosis begins to develop as early as childhood/adolescence and typically progresses over several decades before symptoms develop.

Consequences

As it worsens it eventully narrows the lumen of an artery and interferes with blood flow. Some types of plaque are highly susceptible to rupture, promoting blood clotting within the artery (thrombosis). A blood clot (thrombus) may enlarge over time and eventually obstruct blood flow. A portion of clot can also break free (embolus) and travel through the circulatory system until it lodges in a narrowed artery and shuts off blood flow to surrounding tissue (embolism). Most complications result from deficiency of blood and oxygen within the tissue served by an obstructed artery (ischemia). Can effect almost any organ/tissue in body and is major cause of disability or death. Obstructed blood flow in coronary arteries can cause pain or discomfort in chest and surrounding regions (angina pectoris) or lead to heart attack. Obstructed blood flow to the brain can injure or destroy brain tissue causing stroke. Imparired blood flow in arteries of legs (peripheral artery disease) can cause pain and weakness in legs and feet. Blockage of arteries that supply kidneys can result in kidney disease or even kidney failure. Atherosclerosis is most common cause of an aneurysm-abnormal dilation of blood vessels. Plaque can weaken blood vessel walls, eventually pressure of blood flow can cause damaged region to stretch and balloon outward. Aneurysms can rupture and lead to massive bleeding and death, particularly when large vessel such as aorta is affected. In arteries of the brain, an aneurysm may lead to brain bleed, coma, or stroke.

Influences

Blood pressure depends on volume of blood pumped by heaty (cardiac output) and resistance the blood encounters in arterioles (peripheral resistance). When either cardiac output or peripheral resistance increases, blood pressure rises. Cardiac output is raised when heart rate or blood volume increases; peripheral resistance is affected mostly by diameters of the arterioles and blood viscosity. Blood pressure is therefore influenced by nervous system, which regulates heart muscle contractions and arteriole diameters and hormonal signals, which may cause fluid retention or blood vessel contriction. The kidneys also play a role in regulating blood pressure by controlling secretion of hormones involved in vasocontriction and retention of sodium and water.

Risk Factors

CHD develops over many years so prevention should begin well before symptoms appear. The American Heart Association (AHA) and American College of Cardiology (ACC) recommend an assessment of traditional risk factors for atherosclerotic CVD (including CHD) every 4 to 6 years in individuals who are 20 to 79 years Major Nonmodifiable Risk Factors ❚ Increasing age ❚ Male gender ❚ Family history of early heart disease Major Modifiable Risk Factors ❚ High LDL cholesterol ❚ High blood triglyceride (VLDL) levels ❚ Low HDL cholesterol ❚ Hypertension (high blood pressure) ❚ Diabetes ❚ Obesity (especially abdominal obesity) ❚ Physical inactivity ❚ Cigarette smoking ❚ Alcohol overconsumption (≥3 drinks per day) ❚ An atherogenic diet (high in saturated fat and trans fats; low in fruits and veggies Risk assessment requires several key laboratory measures. typical lipoprotein profile (also called a blood lipid profile) includes measures of total cholesterol, LDL and HDL cholesterol, and blood triglycerides (VLDL). Some clinicians may use the ratio of total cholesterol to HDL cholesterol or LDL cholesterol to HDL cholesterol to help assess CHD risk. In persons with high blood triglycerides, the non-HDL cholesterol level (total cholesterol minus HDL) may be more accurate than the LDL level for predicting CHD risk. Blood pressure and body weight measurements are also regularly included in risk assessment. Some tests provide additional detail about blood lipids or suggest presence of atherosclerosis. Atherosclerosis may be evaluated using coronary artery calcium score. Levels of C-reactive protein (marker of inflammation) may identify patients at risk for CHD. The ankle-brachial index, a ratio of blood pressure measurements taken at the ankle and the upper arms, can help to determine the presence or severity of peripheral artery disease. Once person's level of risk is identified much of treatment focuses on lowering LDL cholesterol. Elevated LDL levels are directly related to development of atherosclerosis and studies confirmed LDL-lowering treatments can successfully reduce CHD mortality rates. CHD seldom seen in populations maintaining desirable LDL levels. HDL help protect ahainst atherosclerosis, low HDL levels ofen coexist with other lipid abnormalities so low HDL level is highly predictive of CHD risk. Low HDL levels usually associated with other CHD risk factors (obesity, smoking, inactivity, and insulin resistnace). Having adequate HDL is beneficial but HDL levels do not mean additional benefits.

Chapter 22: Fat-Controlled, Mineral Modified Diets for Cardiovascular Diseases

Cardiovascular disease (CVD) (group of disorders involving the heart and blood vessels) is responsible for approximately 32% of deaths in US. Many assume heart conditions are men's disease but more women die than men from CVD/year. CVD is global health issue-leading cause of death worldwide. The most common form of CVD is coronary heart disease (CHD), which is usually caused by atherosclerosis in the coronary arteries that supply blood to the heart muscle. If atherosclerosis restricts blood flow in these arteries, the resulting deprivation of oxygen and nutrients can destroy heart tissue and cause a myocardial infarction (MI)—a heart attack. When the blood supply to brain tissue is blocked, a stroke occurs. Both heart attack and stroke may result in disablement or death.

Type 1 Diabetes: Define

Diabetes that is characterized by absolute insulin deficiency, usually resulting from the autoimmune destruction of pancreatic beta cells. Accounts for about 5-10% diabetes cases. Usually caused by autoimmune destruction of the pancreatic beta cells. Which produce and secrete insulin. By the time symptoms develop, damage damage to beta cells has progressed so far that insulin must be provided, most often by injection. Reason for autoimmune attack often unknown, environmental toxins or infections are likely the trigger. People with Type 1 often have a genetic susceptibility for the disorder and are at increased risk of developing other autoimmune diseases. Usually develops during childhood or adolescence and symptoms may appear abruptly in previously healthy children. Most common symptoms incl. polyuria, polydipsia, weight loss or weakness and fatigue. Ketoacidosis- acidosis due to excessive production of ketone bodies- is sometimes the first sign of diabetes. Disease onset tends to be more gradual in those who develop type1 in later years. Blood tests that detect antibodies to insulin, pancreatic islet cells, and pancreatic enzymes can confirm the diagnosis and help to predict the development of the disease in close relatives.

Causes

Factors that initiate atherosclerosis either cause direct damage to artery wall or allow lipid materials to penetrate its surface. Factors inlc.: • Shear stress/hypertension: stress of blood flow along artery walls (shear stress) can cause physical damage to arteries. Hypertension (high blood pressure) intensifies stress of blood flow on arterial tissue, provoing a low-grade inflammatory state that may stimulate plaque formation or progression. • Abnormal blood lipids: when levels are high, LDL are actively taken up and retained in susceptible regions in artery wall. Elevated levels of very-low-density lipoproteins (VLDL) can also promote atherosclerosis, either influencing the production of other atherogenic lipoproteins or by causing molecular changed in endothelial cells and macrophages that promote inflammation or plaque development. HDLs remove cholesterol from circulation and contain proteins that inhibit inflammation, LDL oxidation, and plaque accumulation, low HDL levels can contribute to the development of atherosclerosis as well. • Cigarette smoking: chemicals in cigarette smoke (incl nicotine) are toxic to endothelial cells and contribute to arterial injury. Also causes inflammation, vasoconstriction, enhanced blood coagulation, increased LDL cholesterol, and decreased HDL cholesterol- all promote progression of atherosclerosis • Diabetes mellitus: chronic hyperglycemia leads to accumulation of advanced glycation end products (AGEs), which promote inflammation and oxidative stress, induce production of compounds that favor plaque progression, and disturb blood vessel function. Diabetes increases tendencies for vasoconstriction, blood clotting, and plaque rupture. • Age and gender: as person ages, arterial cells tend to degenerate and risk factors for CDV accumulate. Risk of atherosclerosis increases significantly in men and women older than 45-55. After menopause, women's risk increases partially because decline in estrogen has unfavorable effects on lipoprotein levels and arterial function. Levels of the amino acid homocysteine, which may impair endothelial cell function, rise with age and are generally higher in men

Drug Therapies

For severe hypertriglyceridemia: medications usually necessary necessary for lowering blood triglyceride levels about 500 mg/dL. If blood levels exceed 1000 mg/dL, very low-fat diet (less than 15% kcal from fat) may be required. Patients must also eliminate consumption of alcoholic beverages. Drug therapies for CVD prevention: those who cant improve CHD risk with dietary lifestyle changes alone may be prescribed one or more meds. Drugs usually prescribed for lowering LDL levels are statins (Lipitor and crestor) which reduced cholesterol synthesis in liver. Although less effective than statins, bile acid sequestrants (colestid or questran) can reduce LDL levels by interfering with bile acid reabsorption in small intestine. For lowering triglyceride levels and increasing HDL, both filtrates (Lopid) and nicotinic acid (form of niacin) are effective; nicotinic acid can also reduce LDL and lipoprotein levels. Medication use should be coupled with dietary and lifestyle modifications so they can use minimum effective doses of drugs. Some people may require drugs that suppress blood clotting (anticoagulants and aspirin) or reduce blood pressure. Nitroglycerine (a vasodilator) may be given to alleviate angina. Some meds may affect nutrition status or food intake and interaction can be even more complicated when multiple meds used.

Stroke

Fourth most common cause of death in US and leading cause of long-term disability in adults. • ~87% strokes are ischemia strokes, caused by obstruction to blood flow to brain tissue. • Hemorrhagic strokes occur in 13% of cases and result from bleeding within brain damaging brain tissue. Most strokes are consequences of atherosclerosis, hypertension, or both. • Strokes that occur suddenly and are short-lived (lasting several minutes to several hours) are called transient ischemic attaclks (TIAs) which is a warning sign that a more severe stroke may follow. Prevention:Largely preventable by recognizing its risk factors and making lifestyle changes to educe risk. Amny risk factors are similar to those for heart disease and include hypertension, elevated LDL cholesterol, diabetes mellitus, cigarette smoking, and history of cardiovascular disease. Medications that suppress blood clotting reduce risk of ischemic stroke, especially in people who suffered a first stroke or TIA. Drugs typically prescribed antiplatelet drugs (aspirin) or anticoagulants such as warfarin (coumadin). Anticoagulant therapy requires regular follow-up and occasional adjustments in dosage to prevent excessive bleeding. Management: effect of stroke vary according to area of the brain that has been injured. Body movements, senses, and speech are often impaired, and one side of the body may be weakened or paralyzed. Early diagnosis and treatment are necessary to preserve brain tissue and minimize long-term disability. Thrombolytic (clot-busting_ drugs should be used within 4.5 hours following an ischemic stroke to restore blood flow and prevent further blood damage. Focus of nutrition care is to help patients maintain nutrition status and overall health despite disabilities caused by stroke. Initially determine self-feeding (if any) difficulty and adjustments required for appropriate food intake. May need to learn dietary treatments that improve blood lipid levels and blood pressure. Dysphagia (difficulty swallowing) is a frequent complication and is associated with poorer prognosis. Difficulty with speech may prevent patients from describing problems they may have with eating. Coordination problems make it hard for patients to grasp utensils or bring food from toable to mouth. Tube feedings may be necessary until patient can regain skills/

Heart Attack Treatment

Heart attack occurs when blood supply to heart muscle is blocked, causing damage to or death of heart tissue. Drug therapies given immediately after a heart attack may include thrombolytic drugs (sometimes called clot-busting drugs) anticoagulants, aspirin, painkillers, and medications that regulate heaty rhythm and reduce blood pressure/ patients are not given food or beverages (except sips of water and clear liquids) until condition stabilizes. Once able to eat, they are initially offered small portions of foods that are low in sodium, sat. fat, and cholesterol. Sodium restriction help limit fluid retention but may be lifted after several days if patient shows no sign of heart failure. Heart attack patient needs to regain strength and learn strategies that can reduce risk of future heart attack; similar to lifestyle changes described earlier. Cardiac rehabilitation programs in hospitals and outpatient clinics include physical therapy, instruction about heart-healthy food choices, help with smoking cessation, and medication counseling

Gestational Diabetes

Highest in women who have a family history of diabetes, are obese, are in a high-risk ethnic group (African American, Asian American, Hispanic American, native American or pacific islander), or have previously given birth to an infant weighing over 9lbs. the ensure appropriate 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 at earlier time points. Weight loss is not recommended during pregnancy. Women with gestational diabetes who are overwight or obese, a modest caloric reduction (about 30% less than total energy needs) may improve glycemic control without increasing risk of ketosis. Limiting carb intake to 40-45% of total energy intake may improve blood glucose levels after meals. Carbs are usually poorly tolerated in the morning; therefore restricting carbs at breakfast may be helpful. Remaining carb intake should be spaced throughout day in several meals and snack including an evening snack to prevent ketosis during the night. Regular aerobic activity 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. Women with gestational diabetes may need to restrict energy and/or carbohydrate intakes to maintain appropriate glucose levels; insulin or an antidiabetic drug may be prescribed to help them maintain glycemic control.

Drug Therapies

Hypertension usually requires two or more medications to meet blood pressure goals. Using combination of drugs with different modes of action can reduce doses of each drug needed and minimize side effects. Drugs commonly prescribed include diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin-receptor blockers; some of these drugs are also used to treat various heart conditions. Drug dosages may need adjustment until blood pressure goal is reached.

Sick Day Management For Diabetics

Illness, infection, or injury can cause hormonal changed that raise blood glucose levels and increase risk of developing diabetic ketoacidosis or the hyperosmolar hyperglycemic syndrome. During illness, people with diabetes should measure blood glucose and ketone levels several times daily. They should continue to use antidiabetic drugs, including insulin, as prescribed; adjuestments in dosage may be necessary if they alter their diet ot have persistant hyperglycemia. If appetite is poor, patients should select easy-to-manage foods and beverages that provide the prescribed amount of carbs at each meal. To prevent dehydration, esp. if vomiting or diarrhea is present, patients should make sure they consume adequate amount of liquids throughout the day.

Coronary Heart Disease

LABORATORY MEASURE FOR CHD RISK ASSESSMENT see sheet

DASH Eating Plan

Lifestyle modifications and medications are used to treat hypertension incl. weight reduction if obese or overweight, adopting healthy dietary pattern, angaging in regular physical activity,a dn limiting alcohol intake (combing two or more can enchance results). Weight reduction may reduce blood pressure significantly. Systolic blood pressure can be reduced by 1 mm Hg for each kg weight loss and blood pressure reduction can be sustained for several years. Long term (3 years) blood pressure tends to revert to intial levels, even when weight loss is partially maintained. Therefore weight reduction most beneficial for blood pressure control during periods when body weight is actually decreasing. Dietary approaches: significant reduction in blood pressure can be achieved by following a diet that emphasized fruits, veggies, and whole grains and include low-fat milk products, poultry, fish, and nuts. DASH diet provides more fiber, potassium, magnesium, and calcium than typical American diet. Diet also limits red meat, sweets, sugar-containing beverages, sat. fat (7%kcal) and cholesterol(150mg/day) so its beneficial for reducing CHD risk as well. DASH eating plan even more effective when accompanied by a low sodium intake. In a research study testing blood pressure-lowering effects of DASH dietary pattern in combination with sodium restriction, best results we achieved when sodium was reduced to 1500mg/day-a level much lower than amounts typically consumed in US. Results suggest optimal sodium intake for people with hypertension may be far lower than amounts typically recommended for gen population (less than 2300 or 2400mg daily)

Nutrition Assessment Checklist: page 597 in text Be familiar with the information.

Medical History- Check the medical record for a diagnosis of: ■ Coronary heart disease ■ Stroke ■ Hypertension ■ Heart failure Review the medical record for complications related to cardiovascular diseases: ■ Heart attack ■ Transient ischemic attack ■ Cardiac cachexia Note risk factors for CHD or stroke that are related to diet, including: ■ Elevated LDL or triglyceride levels ■ Obesity or overweight ■ Diabetes ■ Hypertension Medications- For patients using drug treatments for cardiovascular diseases, note: ■ Side effects that may alter food intake ■ Medications that may interact with grapefruit juice ■ Use of warfarin, which requires a consistent vitamin K intake ■ Use of diuretics or other drugs associated with potassium imbalances ■ Potential diet-drug or herb-drug interactions Dietary Intake- For patients with CHD, a previous stroke, or hypertension, assess the diet for: ■ Energy intake ■ Saturated fat, trans fat, cholesterol, and sodium content ■ Soluble fiber and plant sterol or plant stanol content ■ Intake of fruit, vegetables, whole grains, legumes, and nuts ■ Alcohol content For patients with complications resulting from cardiovascular diseases: ■ Check physical disabilities that may interfere with food preparation or consumption following a stroke. ■ Check adequacy of food and nutrient intake in patients with heart failure. Anthropometric Data- Measure baseline height and weight, and reassess weight at each medical checkup. Note whether patients are meeting weight goals, including: ■ Weight loss or maintenance in patients who are overweight ■ Weight maintenance in patients with advanced heart failure Remember that weight may be deceptively high in people who are retaining fluids, especially individuals with heart failure. Laboratory Tests- Monitor the following laboratory tests in people with cardiovascular diseases: ■ LDL cholesterol, blood triglycerides, and HDL cholesterol ■ Blood glucose in patients with diabetes ■ Serum potassium in patients using diuretics, antihypertensive medications, or digoxin ■ Blood-clotting times in patients using anticoagulants ■ Indicators of fluid retention in patients with heart failure Physical Signs- Blood pressure measurement is routine in physical exams but is especially important for people who: ■ Have cardiovascular diseases ■ Have experienced a heart attack or stroke ■ Have risk factors for CHD or hypertension Look for signs of: ■ Potassium imbalances (muscle weakness, numbness and tingling, irregular heartbeat) in those using diuretics, antihypertensive medications, or digoxin ■ Fluid overload in patients with heart failure

Dietary Recommendations: Macronutrients Total Carbohydrates Glycemic Index Sugars Grains/Fiber Fat Protein Alcohol

Nutrition therapy can improve glycemic control and slow progression of diabetes compications. Must consider personal preferences and lifestyle habits. • Macronutrient intakes: recommended macronutrient distribution (percent kcal from carb, fat, and protein) depends on food preferences and metabolic factors (ex: insulin sensitivity, blood lipid levels, and kidney functions).intake suggested for gen population often used as a guideline. Day-to-day consistency of carb intake s associated with better glycemic control, unless patient in undergoing intensive insulin therapy that matches insulin doses to mealtime carb intakes. Macronutrient DRI for adults: carb=45-65% fat=20-35% protein+10-35% carb RDA=130g/day fiber AI=21-38g/day protein RDA=0.8g/kg body weight • Total carb intake: amount of carb consumed has greatest influence on blood glucose levels after meals- the more grams of carb ingested, the greater the glycemic response. Carb reccomndation is based in part on person's metabolic needs, type of insulin or other medications used to manage diabetes, and individual preference. For optimal health, carb sources should be whole grains, legumes, vegetables, fruits, milk products, whereas foods made from refined grains and added sugars should be limited. • Glycemic index: different carb containing foods have different effects on blood glucose levels after they are ingested; for ex: consuming 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 type of carb in a food, the food's fiber content, and preparation method, the other foods included in the meal, and individual tolerences. Individuals with diabetes, choosing foods with low glycemic index (GI) over those with high GI may modestly improve glycemic control. A food's glycemic effect not usually primary consideration when treating diabetes. High-fiber, minimally processed foods (typically lower glycemic effects than highly processed sarchy foods) are among the foods most frequently recommended for persons with diabetes. • Sugars: common misperception is people with diabetes need to avoid sugar and sugar-containing foods but table sugar (sucrose) made up of glucose and fructose has a lower glycemic effect than starch. Moderate consumption of sugar has not been shown to adversely affect glycemic control so sugar recommendations for people with diabetes are similar to those for gen population (suggest minimizing foods and beverages that contain added suagrs) suagrs and sugary foods must be counted as daily carb allowance. Fructose (naturally occurring monosaccharide in fruit) has minimal effects on blood glucose levels when compared with similar amounts of sucrose or starch. Some foods marketed to people with diabetes are sweetened with fructose but intakes of fructose should be limited- no more than 12% total kcal) to avoid excessive energy intakes or adverse effects on blood lipids (high fructose intakes may increase blood triglyceride levels in some individuals). Sugar alcohols have lower glycemic effect than glucose or sucrose and may be used as sugar substitutes. Artificial sweeteners contain no digestible carb and be safely used in place of sugar. • Whole grain & fiber: recommendations are similar to gen population. People with diabetes are encourages to include fiber-rich foods (whole grain, legumes, fruits, veggies) in diet. • Fat: Mediterranean-style dietary pattern that emphasizes monounsaturated fats may benefit both glycemic control and cardiovascular disease (CVD) risk. Increased intake of omega-3 fatty acids from fatty fish or plant sources may improve lipoprotein profile and various other CVD risk factors. Other guidelines related to fat intake are similar to those suggested for gen population: saturated fat should be less than 10% of total kcal, trans fat should be minimized, and cholesterol intake should be less than 300mg/day • Protein: similar to gen population. In US average protein intake is ~15% energy intake. High protein intakes sometimes discouraged because they may be detrimental to kidney function in patients with nephropathy • Alcohol: similar to gen population: men and women limit average daily intakes of alcohol to one drink and two drinks per day. 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 liver). Excessive alcohol intake (3 or more drink/day) can worsen hyperglycemia and raise triglyceride levels. People who should avoid incl. pregnant and individuals with advanced neuropathy, abnormally high triglyceride levels, or a history of alcohol abuse.

Lifestyle Management: Dietary Factors

People at sig. risk of heart attack, stroke, and other complications of atherosclerosis are typically advised to modify health behaviors to reduce risk (healthy dietary patter, regular physical activity, nonsmoking status, and maintaining healthy bodyweight. Dietary factors: people with elevated LDL levels benefit from diets that emphasize veggies, fruit, and whole grains; including low-fat milk, poultry, fish, legumes, non-tropical vegetable oils, and nuts; and limit intakes of sweets, sugar-sweetened beverages, and red meats. Acceptable diets incl. USDA food patter and DASH eating plan • Saturated fat: out of diatary lipids saturated fat has the strongest effect on blood cholesterol levels and replacing it wieht monounsaturated and polyunsaturated fats can generally lower LDL levels. People with high LDL suggested to limit saturated fat ~5-7% total kcal. Average saturated fat intake in US ~11% energy intake. Most people cutting down is hard since main source of sat fat in US is full-fat cheeses, pizza, grain-based and dairy-based desserts, chicken dishes, sausaged and bacon. Choosing fat-free/low-fat milk products, lean meat or fish, and avoiding certain desserts are more effective at reducing saturated fat. Some find limiting total fat intake indirectly helps reduce sat. fat intake. Replaceing sat. fat with carbs also can lower LDL cholesterol but the change may raise blood triglycerides (VLDL) levels. Effect on blood triglycerieds can be minimized by limiting added sugars and incl. fiber-rich foods; diet should incl. generous amounts of whole grains, legumes, fruits, and veggies. • Trans fat: can raise LDL levels and when replacing sat. fat in diet (margarine for butter) it may also reduce HDL levels. Aka trans fat intake should be kept low as possible. Most sources from partially hydrogenated vegetable oils (baked goods like crackers, cookies, doughnuts; snack food like potato chips and corn chips; fried foods like frnech fries). Trans fat has been cut out by many manufactures but also been replaced with sat. fat. • Dietary cholesterol: connection between dietary cholesterol and CHD unclear- so general recommendation for high-risk individuals is a cholesterol intake of less than 200mg/day (US average for women and men ~261-333mg/day. Eggs contribute about ¼ of cholesterol in US diet followed by chicken beef and cheese. Eggs not linked to CHD risk in healthy populations but found associated risk in diabetes. Optimal # of eggs to include ina heart-healthy diet is undertermined, and different guidelines may be necessary for healthy and high-risk populations. • Soluble fiber: soluble, viscous fiber can reduce LDL cholesterol levels by inhibiting cholesterol and bile absorption in small intestine and reducing cholesterol synthesis in liver. Good sources incl. oats, barley, legumes, and fruits. Soluble fiber in psyllium seed husks, frequently used to treat constipation, is effective for lowering cholesterol levels when used as a dietary supplement. • Plant sterols: foods or supplements contain significant amounts of plant sterols (or plant stanols) help lower LDL cholesterol levels by interfering with cholesterol and bile absorption. These plant compounds are added to various food products (margarine and OJ) or in dietary supplement. ~2g plant sterols daily can lower LDL cholesterol by up to 10% • Fish and omega 3 fatty acids: otherewise known as EPA and DHA may benefit people at risk for CHD by suppressing inflammation, lowering blood triglyceride levels, reducing blood clotting, and stabilizing heart rhythm. Incl. fish in diet can reduce CHD risk because fish is low in sat. fat and often replaces meat dishes than contain sat. fat. The American heart association (AHA) recommends consuming two or more servings of fish/week w/ emphasis on fatty fish. Use of fish oil supplmenets not been shown to reduce heart attacks or heart disease-related deaths in most clinical trials. • Alcohol: light to moderate alcohol consumption of alcohol has favorable effects on atherosclerosis, HDL levels, blodd clotting activity, insulin resistance, and overall CHD risk. Should be limited to one drink daily for women and two for men, higher intakes may promote plaque formation and increase triglyceride levels and blood pressure. Alcohol increases risk of various cancers and may have dentrimental effects on health. • Low sodium diet containing generous aounts of fruits and veggies, whole grains, nuts,and low-fat milk products have been found to substancially reduce blood pressure. Be physically active, avoid tobacco, prevent weight gain, reduce weight, and maintain lower body weight

Chronic Complications

Prolonged hyperglycemia can damage cells and tissue. 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. Chonic complications of diabetes typically involve large blood vessels (macrovascular complications), smaller vessels such as arterioles and capillaries (microvascular complications), and nerves (diabetic neuropathy). Complications may appear 15-20 years after diabetic onset. • Macrovascular: damage from diabetes accelerates development of atherosclerosis in arteries of the heart, brain, and limbs. Cardiovascular diseases are the leading cause of death in people with diabetes, accounting for up to 70% of deaths. Type 2 is often accompanied by mult. Risk factors for cardiovascular disease, incl. hypertension and blood lipid abnormalities. Have increased tendencies for thrombosis (blood clot formation) and abnormal ventricle function (both worsen clinical course of heart disease). Peripheral vascular disease (impaired blood circulation in limbs) increases risk of claudication (pain while walking) and contributes to the development of foot ulcers. Left untreated, foot ulcers can lead to gangrene (tissue death) and some patients require foot amputation (major cause of disability in diabetes) • Microvascular comlications: long-term diabetes causes progressive damage to capillaries in the retina (diabetic retinopathy), leading to visual impairments and sometimes blindness. Damage to kidneys' specialized capillaries (diabetic neuropathy) prevents adequate blood filtration, and kidney failure often develops requiring use of dialysis (artificial filtration of blood) for survival. Retinopathy and nephrpathy progresses most rapidly when diabetes is poorly controlled, and intensive diabetes management can help slow progression of these conditions. • Diabetic neuropathy: symptoms vary and may be experienced as deep pain or burning in legs and feet, weakness of arms and legs or numbness and tingling in hands and feet. Pain and cramping (esp. in legs) often severe during night and may interrupt sleep. Neuropathy also contributes to development of foot ulcers because cuts and bruises may go unnoticed until wounds are severe. Other manifestations of neuropathy include sweating, abnormalities, disturbances in bladder and bowel function, sexual dysfunction, constipation, and delayed stomach emptying (gastroparesis)

How to Reduce Sodium Intake

Select fresh, unprocessed foods. Packaged foods, canned goods, and frozen meals are often high in sodium. • Do not use salt at the table or while cooking. Salt substitutes may be useful for some people. Salt substitutes often contain potassium, however, and are not appropriate for people using diuretics that promote potassium retention in the blood. • Avoid eating in fast-food restaurants; most menu choices are very high in sodium. • Check food labels. The labeling term low sodium is a better guide than the terms reduced sodium (contains 25 percent less sodium than the regular product) or light in sodium (contains 50 percent less sodium). To be labeled low sodium, a food product must contain less than 140 milligrams of sodium per serving. Keep your sodium goal in mind when you read labels. • Recognize the high-sodium foods in each food category, and purchase only unsalted or low-sodium varieties of these products if they are available. High-sodium foods include the following: • Snack foods made with added salt, such as tortilla chips, popcorn, and nuts. • Processed meat, such as ham, corned beef, bologna, salami, sausage, bacon, frankfurters, and pastrami. • Processed fish, such as salted fish and canned fish. • Tomato-based products, such as tomato sauce, tomato juice, pizza, canned tomatoes, and catsup. • Canned soup or broth; note that even reduced-sodium varieties may contain excessive sodium. • Cheese, such as cottage cheese, American cheese, and Parmesan and most other hard cheeses. • Bakery products made with baking powder or baking soda (sodium bicarbonate), such as cake, cookies, doughnuts, and muffins. • Condiments and relishes, such as bouillon cubes, olives, and pickled vegetables. • Flavoring sauces, such as soy sauce, barbecue sauce, and steak sauce. • Check for the word sodium on medication labels. Sodium is often an ingredient in some types of antacids and laxatives. • About 75 percent of the sodium in a typical diet comes from processed foods, about 10 percent from unprocessed natural foods, and about 15 percent from table salt therefore o select fresh foods, which are usually low in sodium. o Select frozen and canned food products that have been prepared without added salt. o Avoid adding salt to foods while cooking or at the table. o When dining in restaurants, ask that meals be prepared without salt.

Treatment Goals

Strategies for diabetes prevention: • lose weight if overweight, or prevent additional weight gain • perform at least 150 minutes of moderate physical activity weekly • increase intake of whole grains and dietary fiber; limit intake of sugar-sweetened foods and beverages • monitor health status with yearly check-ups A chronic and progressive illness that requires lifelong treatment. Managingblood glucose levels is a delicate balancing act involving meal planning, proper timing of meds, and physical exercise. Frequenct adjustments in treatment often necessary to establish good glycemic control. Type 1 requires insulin therapy for survival, type 2 may initially be treated with nutrition therapy and exercise but often eventually need antidiabetic meds or insulin. Individual with diabetes ultimately assumes much of responsibility for treatment therefore requiring education in self-managemtn of disease. MAIN GOAL: for diabetes treatment is to maintain blood glucose levels within a desirable rainge to prevent or reduce risk of complications. (intensive diabetes treatment may be innapropriate for some incl. those with limited life expectations, history of hypoglycemia, or previous heart disease). Other goals include maintaining healthy blood lipid concentrations, controlling blood pressure and managing weight (cant also prevent or delay diabetes). Intensive therapy also associated with some risks (increased risk of hypoglycemia) but benefits most often outweigh risks. Diabetes education important for implementing treatment. Primary intstructor often called certified diabetes educator (CDE). Patients must learn appropriate meal planning, medication administration, blood glucose monitoring, weight management, appropriate physical activity, and prevention and treatment of diabetic complications. 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. 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 increases 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.

The Dash Eating Plan: What is it? What benefit does it have?

a diet that emphasizes vegetables, fruit, and whole grains; includes low-fat milk products; and limits sugars and red meats. DIEATRY APPROACH TO ATOP HYPERTENSION: This plan emphasizes whole grains, fruits, vegetables, fat-free or low-fat dairy, seafood, poultry, beans, seeds, and nuts. It contains less salt and sodium, sweets, added sugars, fats, and red meats than the typical American eats. Dash serving equals: Grains—one ounce or equivalent Fruits—half cup cut-up fruit or equivalent Vegetables—half cup cooked vegetables or equivalent Meats, poultry, and fish—one ounce cooked meats, poultry, or fish or one egg Nuts, seeds, and legumes—foods like two tablespoons peanut butter, third cup or 1-1/2 ounces of nuts, half cup cooked beans, or one cup bean soup Fats and oils—one teaspoon soft margarine or vegetable oil, one tablespoon mayonnaise, and one tablespoon regular salad dressing or two tablespoons low-fat dressing Sugars—one tablespoon jam or jelly, half cup regular Jell-O, or one cup regular lemonade

Atherosclerosis

an arterial disease characterized by a buildup of lipids and fibrous scar tissue on the inner walls of arteries.

Diagnosis

based primarily on plasma glucose levels measured under fasting conditions or at random times during day. Some cases involve an oral glucose tolerance test. Following criteria are currently used for diagnosing diabetes: • plasma glucose concentration is 126mg/dL or higher after fast of at least eight hours (normal fasting plasma glucose levels=75-100mg/dL) • in a person with classic symptoms of diabetes, the plasma glucose concentration of a random, or casual, blood sample (obtained from non-fasting indiv.) is 200 mg/dL or higher • plasma glucose concentration measured two hours after a 75-gram glucose load is 200mg/dL: or higher • the HbA level is 6.5% or higher overt symptoms of hyperglycemia help to confirm the diagnosis, otherwise diagnosis of diabetes is only confirmed is a subsequent test yields similar results. People with prediabetes have blood glucose levels that are at a high risk of eventually developing type 2 diabetes and cardiovascular disease. Prediabetes effects ~37% adults in US and 23% adolescence 12-19yrs. Especially prevelant among those who are obese or overweight Prediabetes: The state of having plasma glucose levels that are higher than normal but not high but not high enough to be diagnosed as a diabetes. Occurs in individuals that have metabolic defects that often lead to type 2 diabetes

Insulin Therapy for Type 1 Diabetics

insulin therapy necessary for those who cannot produce enough insulin to meet their metabolic needs. 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. Type 1 best managed with intensive insulin therapy typically involving three or four daily injections of several types of insulin or use of insulin pump (insulin pump 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. Those who inject insulin: intermediate or long acting insulin meets basal insulin needs, and rapid or short cting insulin is injected before meals. Simpler regimens involve twice-daily injections of a mixture of intermediate and short acting insulin. Regimens including three or more allow for greater flexibility in carb intake and meal timing. Fewer injections make timing of both meals and injections be similar from day to day to avoid periods of insulin deficiency or excess. Intensice therapy requires patient to learn to accurately determine amount of insulin to inject before each meal. Amount required depends on pre-meal blood glucose level, carb content of meal, and person's body weight and sensitivity to insulin. To determine insulin sensitivity, individuals keep careful records of foods intakes, insulin dosages, and blood glucose levels. Records are then analyzed by medicaly personnel to determine carb-to-insulin ratio. Intensive therapy allows for substantial variation in food intake and lifestyle \, but requires frequent testing of blood glucose levels and a good understanding of carb counting. After insulin therapy begins, type 1 diabetes patients may experience temporary remission of disease symptoms and a reduced need for insulin (honeymoon period) remission due to temporary improvement in pancreatic beta cell function and may last for several weeks or months. Important to anticipate this period od remission to avoid insulin excess. All cases honeymoon phase eventually ends and patient must reinstate full insulin treatment

Lifestyle Modification Diet: What is it? What benefit does it have?

modified diet: a diet that contains foods altered in texture, consistency, or nutrient content or that includes or omits specific foods; may also be called a therapeutic diet. a healthy dietary pattern, appropriate physical activity, nonsmoking status, a healthy body weight, total blood cholesterol ,200 mg/dL, blood pressure ,120/,80 mm Hg, and fasting plasma glucose ,100 mg/dL. Limits dietary sodium; degree of restriction depends on symptoms and disease severity. To help lower blood pressure or prevent fluid retention; dietary modifications may relieve disease symptoms or prevent certain types of complications should be adjusted to satisfy individual preferences and tolerances and may need to be altered as a patient's condition changes.

Physical Activity for Diabetics

regular physical activity can improve glycemic control significantly and is therefor a central feature of disease management. Physical acitivtiy also benfits other aspects of health, including cardiovascular risk factors and body weight. Children with diabetes or prediabetes should engage in at least 60 min activity per day. Adults with diabetes are advised to at least 150 min of moderate-intensity aerobic activity per week, also incl resistance exercises at least twice weekly (aerobic and resistance exercise can improve insulin sensitivity. Before person with diabetes begins new exercise program, a medical evaluation should screen for problems that may be aggrevated by certain activities. Complications involving hearts and blood vessels, eyes, kidneys, feet, and nervous system may limit type of activities recommended. People with low levels of fitness who have been relatively inactive, only mild or moderate exercise may be prescribed at first; short walk at comfortable pace may be first activity suggested. People w/ severe retinopathy should avoid rigorous aerobic or resistance exercise, which may lead to retinal detatchment and damage eye tissue. People with peripheral neuropathy should ensure they wear proper footwear during exercise. Proper hydration recommended before and during exercise People 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 preceed exercise often need to be reduced substantially. Blood glucose levels should be checked before and after activity. If blood glucose is below 100mg/dL, carbs should be consumed before exercise begins. Additional carbs may be needed during or after prolonged activity or even several hours after. Individuals with type 1 who have ketosis should avoid vigorous activity, which increases ketone body production and can worsen ketosis.

Insulin Therapy for Type 2 Diabetics

~30% type 2 patients can benefit form insulin therapy. Although initial treatment usually involves nutrition therapy, physical activity, and oral antidiabetic meds, long-term results with these treatments are often disappointed. As disease progresses, pancreatic function worsens, and many individuals require insulin therapy to maintain glycemic control. Man regimes can be used to control type 2 diabetes. Some may be treated with insulin alone, whereas others may use insulin in combination with other antidiabetic drugs. Many need only one or two daily injections. Some regimens involve a mixture of intermediated-acting and rapid- or short-acting insulin in the morning and an injection of intermediate- or long-acting insulin at dinner or before bedtime. In other cases, only a sinlge injection of intermediate- or long-acting insulin may be needed at bedtime. Doses and timing are adjusted according to the results of blood glucose self-monitoring.