Diabetes Melitus Diabetes Melitus dan dan Komplikasinya.Komplikasinya.

Jossep Frederick William,dr.Jossep Frederick William,dr.

Diabetes.Diabetes.

Natural History of Type 1 DiabetesNatural History of Type 1 Diabetes

CELLULAR (T CELL) AUTOIMMUNITYCELLULAR (T CELL) AUTOIMMUNITY

LOSS OF FIRST PHASE LOSS OF FIRST PHASE INSULIN RESPONSEINSULIN RESPONSE

(IVGTT)(IVGTT)

GLUCOSE INTOLERANCEGLUCOSE INTOLERANCE(OGTT)(OGTT)

HUMORAL AUTOANTIBODIESHUMORAL AUTOANTIBODIES(ICA, IAA, Anti-GAD(ICA, IAA, Anti-GAD6565, IA, IA22Ab, etc)Ab, etc)

PUTATIVEPUTATIVEENVIRONMENTALENVIRONMENTAL

TRIGGERTRIGGER

CLINICALCLINICALONSETONSET

TIMETIME

BE

TA

CE

LL

MA

SS

BE

TA

CE

LL

MA

SS

DIABETES

GENETIC PREDISPOSI

TION

INSULITISBETA CELL

INJURY“PRE”-

DIABETESDIABETES

Symptoms of diabetesSymptoms of diabetes

• Polyuria (Sering kencing)Polyuria (Sering kencing)• Polydipsia (Sering merasa haus)Polydipsia (Sering merasa haus)• Penurunan Berat Badan.Penurunan Berat Badan.

Gejala lainnya dari Diabetes.

• Rasa lapar. Rasa lapar. • Letih. Letih. • Kulit yang kering.Kulit yang kering.• Mudah terkena infeksi. Mudah terkena infeksi. • Feet ulcerationFeet ulceration• Hilangnya sensasi di kaki. Hilangnya sensasi di kaki. • Erectile dysfunction.Erectile dysfunction.

Diagnosing Diabetes

• Fasting Blood Glucose (FBG):Fasting Blood Glucose (FBG):– Blood Glucose Level is measured after a fastBlood Glucose Level is measured after a fast

• Oral Glucose Tolerance Test (OGTT)Oral Glucose Tolerance Test (OGTT)– Blood glucose level is measured fasting and two hours Blood glucose level is measured fasting and two hours

after drinking a glucose-rich beverageafter drinking a glucose-rich beverage

From http:// www.diabetes.org

DiagnosisDiagnosis FBGFBG OGTTOGTT

Pre-Pre-DiabetesDiabetes

100-125100-125 140-199140-199

DiabetesDiabetes ≥ ≥ 126126 ≥ ≥ 200200

Pathophysiology Pathophysiology of Type 2 Diabetes of Type 2 Diabetes

• Insulin resistance.Insulin resistance.

• Beta cell dysfunction.Beta cell dysfunction.

Pathophysiology of Type 2 DiabetesInsulin Resistance

• Insulin Resistance pada saat awal dari Insulin Resistance pada saat awal dari penyakit.penyakit.

• Insulin resistance saja tidak akan Insulin resistance saja tidak akan menghasilkan seseorang terkena diabetes. Bila menghasilkan seseorang terkena diabetes. Bila fungsi dari beta sell norma, maka orang fungsi dari beta sell norma, maka orang tersebut akan dapat mengkompensasikan tersebut akan dapat mengkompensasikan terjadinya insulin resistansi dengan terjadinya insulin resistansi dengan meningkatkan produksi dari insulin. meningkatkan produksi dari insulin.

Pathophysiology of Type 2 Pathophysiology of Type 2 Diabetes Diabetes Beta cell defectBeta cell defect

• Semua penderita diabetes tipe 2 setidaknya Semua penderita diabetes tipe 2 setidaknya akan mengalami defek baik dalam fungsi dari akan mengalami defek baik dalam fungsi dari beta sel dan juga jumlah dari beta sel yang beta sel dan juga jumlah dari beta sel yang berfungsi dalam pancreas. berfungsi dalam pancreas.

• Function:Function: in the (UKPDS), newly diagnosed in the (UKPDS), newly diagnosed

people with diabetes had, on average, only people with diabetes had, on average, only about 50% of normal beta-cell functionabout 50% of normal beta-cell function..[Diabetes. 1995;44:1249-1258 , Diab Res Clin Pract. [Diabetes. 1995;44:1249-1258 , Diab Res Clin Pract. 1998;40(suppl):S21-S25.]1998;40(suppl):S21-S25.]

• Mass:Mass: Autopsy studies comparing the Autopsy studies comparing the

volume of beta cells in nondiabetic volume of beta cells in nondiabetic individuals with that of people with diabetes individuals with that of people with diabetes found a 41% decrease in beta-cell mass found a 41% decrease in beta-cell mass among people with type 2 diabetes among people with type 2 diabetes

Pathophysiology of Type 2 Diabetes Beta cell defect

IV glucose infusion to a nondiabetic individual IV glucose infusion to a nondiabetic individual results in a biphasic insulin response: results in a biphasic insulin response:

- Immediate first-phase insulin response in - Immediate first-phase insulin response in the first few minutes. the first few minutes.

- Second-phase response, more prolonged. - Second-phase response, more prolonged.

Pathophysiology of Type 2 Diabetes Beta cell defect

• This first-phase insulin response is absent in type This first-phase insulin response is absent in type 2 diabetic patients contributing to the excessive 2 diabetic patients contributing to the excessive and prolonged glucose rise after a meal in those and prolonged glucose rise after a meal in those with diabetes with diabetes Diabetologia. 2004;47(suppl 1):A279. Diabetologia. 2004;47(suppl 1):A279.

• Infusing insulin can only partially improve this Infusing insulin can only partially improve this condition. condition.

Pathophysiology of Type 2 Pathophysiology of Type 2 DiabetesDiabetes Other FactorsOther Factors

• Historically, hyperglycemia in diabetes has Historically, hyperglycemia in diabetes has been viewed as a failure of insulin-mediated been viewed as a failure of insulin-mediated glucose disposal into muscle and adipose glucose disposal into muscle and adipose tissue.tissue.

• This looks to be an over simplification of a This looks to be an over simplification of a

more complicated issue.more complicated issue.

Normal IGT Type 2 DM Kecacatan Dan Kematian

Komplikasi

Primary Secondary Primary Secondary TertiaryTertiaryprevention prevention preventionprevention prevention prevention

Progres dari Diabetes.Progres dari Diabetes.

Pengendalian terjadinya komplikasi dan Pengendalian terjadinya komplikasi dan penanganan kerusakkan yang terjadi. penanganan kerusakkan yang terjadi.

Pencegahan terjadinya komplikasi dari diabetes. Pencegahan terjadinya komplikasi dari diabetes. Pencegahan terjadinya diabetes pada mereka Pencegahan terjadinya diabetes pada mereka

yang memiliki resiko tinggi.yang memiliki resiko tinggi.

Macrovascular Microvascular

Stroke

Heart disease and hypertension

2-4 X increased risk

Foot problems

Diabetic eye disease(retinopathy and cataracts)

Renal disease

Peripheral Neuropathy

Peripheral vascular disease

Diabetes: Komplikasi.

Meltzer et al. CMAJ 1998;20(Suppl 8):S1-S29.

Erectile Dysfunction

Nephropathy Diabeticum.

Peripheral arterial Peripheral arterial disease.disease.

Diabetic Neuropathy.Diabetic Neuropathy.

The Good News… • By managing the ABCs of diabetes, people with By managing the ABCs of diabetes, people with

diabetes can reduce their risk for heart disease and diabetes can reduce their risk for heart disease and stroke.stroke.

– A stands for A1CA stands for A1C– B stands for Blood pressureB stands for Blood pressure– C stands for CholesterolC stands for Cholesterol

– PLUS More B’s…PLUS More B’s…• BMIBMI• Blood SugarsBlood Sugars

Body Mass IndexBody Mass Index

• Being overweight or obese is a leading risk Being overweight or obese is a leading risk factor for type 2 diabetes. factor for type 2 diabetes.

• A healthy weight is measured by your body A healthy weight is measured by your body mass index (BMI). mass index (BMI).

BMIBMI CategoryCategory

Below 18.5Below 18.5 UnderweightUnderweight

18.5-24.918.5-24.9 HealthyHealthy

25-29.925-29.9 OverweightOverweight

Over 30Over 30 ObeseObese

BMI Goal = less thanBMI Goal = less than2525

Memonitor kadar gula Memonitor kadar gula darah.darah.

GLUCOSE GLUCOSE ABSORPTIONABSORPTION

GLUCOSE GLUCOSE PRODUCTIONPRODUCTION

MetforminMetformin ThiazolidinedionesThiazolidinediones

MUSCLEMUSCLE

PERIPHERAL PERIPHERAL GLUCOSEGLUCOSEUPTAKEUPTAKE ThiazolidinedionesThiazolidinedionesMetforminMetformin

PANCREAS

INSULIN SECRETION Sulfonylureas: Glyburide, Gliclazide, Glimepiride Non-SU Secretagogues: Repaglinide, Nateglinide

ADIPOSE ADIPOSE TISSUETISSUELIVER

Alpha-glucosidase inhibitors

INTESTINE

Tempat kerja dari berbagai macam obat diabetes.

Gliclazide 2+ + 0 Gliclazide 2+ + 0 0 0 + +

Glimepiride 2+ + 0 Glimepiride 2+ + 0 0 0 + +

Repaglinide 1+ + 0 0 0 0 +Repaglinide 1+ + 0 0 0 0 +

Nateglinide 1+ ? 0 0 0 0 +Nateglinide 1+ ? 0 0 0 0 +

Metformin 0 0 0 2+ + 0 -Metformin 0 0 0 2+ + 0 -

Acarbose 0 0 0 3+ 0 Acarbose 0 0 0 3+ 0

Rosiglitazone 0 + + 0 0 Rosiglitazone 0 + + 0 0 * +* +

Pioglitazone 0 + + 0 0 Pioglitazone 0 + + 0 0 * +* +

Hypoglycemia Wt. Gain Edema GI Lactic Liver Use in effects Acidosis Toxicity Renal Failure

Adapted from Lebovitz H: Endocrinol & Metab Clinics of NA; 30 (4)909-933Adapted from Lebovitz H: Endocrinol & Metab Clinics of NA; 30 (4)909-933

* * Liver enzyme monitoring recommended in product monographsLiver enzyme monitoring recommended in product monographs

Glyburide 4+ + 0 0 -

DrugDrug TradeTrade DoseDose CostCost ODBODB

GlyburideGlyburide DiabetaDiabeta Start 1.25-5 mg odStart 1.25-5 mg od

Spit dose bid > 10mg/dSpit dose bid > 10mg/d

Max 10 mg bidMax 10 mg bid

$14/mos$14/mos YesYes

GliclazideGliclazide DiamicronDiamicron Start 80 mg bidStart 80 mg bid

Max 160 mg bidMax 160 mg bid$90/mos$90/mos NoNo

GliclazideGliclazide

MRMRDiamicronDiamicron

MRMR

Start 30 mg odStart 30 mg od

Max 120 mg odMax 120 mg od$30/mos$30/mos Exp Sect 8Exp Sect 8

GlimepirideGlimepiride AmarylAmaryl Start 1-2 mg odStart 1-2 mg od

Max 8 mg odMax 8 mg od$30-40/mos$30-40/mos NoNo

RepaglinideRepaglinide GluconormGluconorm Start 0.5 mg tid-qidStart 0.5 mg tid-qid

Max 4 mg qidMax 4 mg qid$45/mos$45/mos Exp Sect 8Exp Sect 8

NateglinideNateglinide StarlixStarlix Start 60-120 mg tidStart 60-120 mg tid

Max 180 mg tidMax 180 mg tid$45/mos$45/mos NoNo

MetforminMetformin GlucophageGlucophage Start 500 mg od-bidStart 500 mg od-bid

Max 1000 mg bidMax 1000 mg bid$14/mos$14/mos YesYes

PioglitazonePioglitazone ActosActos Start 15-30 mg odStart 15-30 mg od

Max 45 mg odMax 45 mg od$92/mos$92/mos Exp Sect 8Exp Sect 8

RosiglitazoneRosiglitazone AvandiaAvandia Start 4 mg odStart 4 mg od

Max 4 mg bidMax 4 mg bid$ 60/mos$ 60/mos

$ 120/mos$ 120/mos

Exp Sect 8Exp Sect 8

Prinsip kerja Sulfonil Urea

Prinsip kerja Metformin.

Summary of availableinsulin preparations

Agent Type / Administration

Glucose lowering

Basal Post-meal

NPH Intermediate-acting humanOnce or twice daily at bedtime ± breakfast

Detemir Long-acting analogueOnce or twice daily at bedtime ± breakfast

Glargine Long-acting analogueOnce daily at bedtime or before breakfast

Premixed Human or analogue mixTwice daily before breakfast and dinner

Regular Fast-acting humanBefore meals

Aspart, glulisine, lispro

Rapid-acting analogueBefore meals

Inhaled insulin

Rapid-acting humanBefore meals

Penggunaan Pen InsulinPenggunaan Pen Insulin

Evidence-based guideline-derived treatment algorithm

DiagnosisDiagnosis

Lifestyle intervention then metforminLifestyle intervention then metformin

HbAHbA1c1c 6.5 %6.5 %

Add sulfonylurea Add sulfonylurea

Meal-time + basal insulin + metformin Meal-time + basal insulin + metformin ±± thiazolidinedione thiazolidinedione

Add insulin

Start insulinStart insulin

Add thiazolidinedione*Add thiazolidinedione*

HbAHbA1c1c 6.5 %6.5 %

HbAHbA1c1c 7.5 %7.5 % HbAHbA1c1c 7.0 %7.0 %

HbAHbA1c1c 6.5 %6.5 %

IDF. IDF. Global Guideline for Type 2 Diabetes.Global Guideline for Type 2 Diabetes. 2005 2005

*Alternatively, start *Alternatively, start thiazolidinedione before thiazolidinedione before sulfonylurea,sulfonylurea,and sulfonylurea later.and sulfonylurea later.

intensify insulinintensify insulin

DM Tahap I Tahap II Tahap III

GHSGHS

+Monoterapi

Catatan :1. GHS = Gaya Hidup Sehat2. Dinyatakan gagal bila terapi selama 2 -3 bulan pada tiap tahap tidak mencapai target terapi HbA1C < 7 %3. Bila tidak ada pemeriksaan HbA1C dapat dipergunakan pemeriksaan glukosa darah rata2 hasil pemeriksaan beberapa kali glukosa darah sehari yang dikoversikan ke HbA1C menurut kriteria ADA, 2010

GHS+

Kombinasi 2 OHO+

Basal Insulin

GHS+

Kombinasi 2 OHO

Insulin IntensifGHS

+Kombinasi 3 OHO

Jalur Pilihan Alternatif, bila :-Tidak terdapat insulin-Diabetisi betul-betul menolak insulin-Kendali Glukosa belum Optimal

GHS+

MonoterapiMet, SU,

AGI, Glinid, TZD, DPP-IV

GHS+

Kombinasi 2 Obat

Met, SU, AGI, Glinid, TZD, DPP-

IV

GHS+

Kombinasi 3 Obat

Met, SU, AGI, Glinid, TZD, DPP-IV

GHS+

Kombinasi 2 Obat

Met, SU, AGI, Glinid, TZD

+Basal Insulin

Kadar HbA1C

GHS

Gaya Hidup Sehat Penurunan Berat badanMengatur diit latihan jasmani teratur

Catatan :1. Dinyatakan gagal bila dengan terapi 2-3 bulan tidak mencapai target HbA1C < 7 %2. Bila tidak ada pemeriksaan HbA1C dapat digunakan pemeriksaan glukosa darah. Rata2 glukosa darah sehari dikonversikan ke HbA1C menurut kriteria ADA 2010

< 7 % 7-8 % 8-9 % >9 % 9-10 % >10 %

GHS+

Insulin Intensif

Efek samping dari TZD• EdemaEdema

• 4-5% of patients get mild-moderate edema4-5% of patients get mild-moderate edema• 15% if TZD used in combo with insulin15% if TZD used in combo with insulin

• Mild anemia (dilutional)Mild anemia (dilutional)• Weight gainWeight gain

• Increase in subcutaneous not visceral fatIncrease in subcutaneous not visceral fat

• Myalgia (pioglitazone only)Myalgia (pioglitazone only)• Myalgia 5.4% pioglitaz. versus 2.7% placeboMyalgia 5.4% pioglitaz. versus 2.7% placebo• Few patients with unexplained CK > 10x ULNFew patients with unexplained CK > 10x ULN

• Contraindicated in class II, III and IV CHFContraindicated in class II, III and IV CHF

• Contraindicated if ALT > 2.5x ULN or active liver diseaseContraindicated if ALT > 2.5x ULN or active liver disease

TZDs: effect on Metabolic Syndrome

• Reduce insulin resistance/blood sugarReduce insulin resistance/blood sugar• Mild decrease in diastolic BP (2-4 mmHg)Mild decrease in diastolic BP (2-4 mmHg)• Lipids:Lipids:

– ↓↓TG ↑HDL (pioglitazone > rosiglitazone?)TG ↑HDL (pioglitazone > rosiglitazone?)

– ↓↓LDL (pioglitazone)LDL (pioglitazone)

– ↑↑LDL (rosiglitazone)LDL (rosiglitazone)• No change in ApoB so ↑ due to larger less atherogenic particle No change in ApoB so ↑ due to larger less atherogenic particle

sizesize

• Decrease in carotid artery intimal-media thickness (IMT)Decrease in carotid artery intimal-media thickness (IMT)

Add additional meal-time injections if HbAAdd additional meal-time injections if HbA1c1c ≥≥7.0% after 3 months7.0% after 3 months

Bagaimana kita memberikan insulin kepada mereka yang terkena diabetes tipe 2 ?

Nathan DM et al. Nathan DM et al. Diabetes CareDiabetes Care. 2006;29:1963-1972. 2006;29:1963-1972

Algorithm driven dose titration – basal regimen*Algorithm driven dose titration – basal regimen*

HbAHbA1c1c ≥≥7.0% after 3 months7.0% after 3 months

Check pre- breakfast, lunch, dinner, and bedtime PG Check pre- breakfast, lunch, dinner, and bedtime PG

Add rapid-acting insulin to the meal with the highest excursionAdd rapid-acting insulin to the meal with the highest excursion

Begin 4 U and adjust by 2 U every 3 days based on PG changeBegin 4 U and adjust by 2 U every 3 days based on PG change††

*Insulin regimens should be designed taking lifestyle and meal schedule into account; this *Insulin regimens should be designed taking lifestyle and meal schedule into account; this algorithm provides a basic guideline for initiation and adjustment of insulin. Regimens with once- algorithm provides a basic guideline for initiation and adjustment of insulin. Regimens with once- or twice-daily premixed insulins are also possible.or twice-daily premixed insulins are also possible.

Once daily intermediate or long-acting insulinOnce daily intermediate or long-acting insulin

Begin 10 U or 0.2 U/kg, titrate by 2 U every 3 days using pre-breakfast plasma Begin 10 U or 0.2 U/kg, titrate by 2 U every 3 days using pre-breakfast plasma glucose (PG) until in target range (100 – 110 mg%)glucose (PG) until in target range (100 – 110 mg%)

††Inhaled insulin dosing in 1 mg (≈ 3 U) steps.Inhaled insulin dosing in 1 mg (≈ 3 U) steps.

Time of dayTime of day

20

40

60

80

100

0600 06000800 18001200 2400

μU

/ml

Basal-bolus insulin treatment: matching insulin administration to insulin needs

B = breakfast; L = lunch; D = dinnerB = breakfast; L = lunch; D = dinnerRiddle MC. CADRE Core Slide Kit. 2003Riddle MC. CADRE Core Slide Kit. 2003

Polonsky KS et al. Polonsky KS et al. N Engl J Med.N Engl J Med. 1988;318:1231-1239 1988;318:1231-1239

B L D

Normal patternNormal pattern

Rapid-acting insulinsRapid-acting insulins

Basal insulinsBasal insulins

Dosing of dry powderDosing of dry powderinhaled insulin inhaled insulin

Exubera (insulin human [rDNA origin]) inhalation powder [prescribing Exubera (insulin human [rDNA origin]) inhalation powder [prescribing information]. New York: Pfizer Inc; 2006information]. New York: Pfizer Inc; 2006

DoseDose Dose of Regular Dose of Regular SC InsulinSC Insulin

1-mg Blisters 1-mg Blisters per Doseper Dose

3-mg Blisters 3-mg Blisters per Doseper Dose

1 mg1 mg 3 U3 U 11 ——

2 mg2 mg 6 U6 U 22 ——

3 mg3 mg 8 U8 U —— 11

4 mg4 mg 11 U11 U 11 11

5 mg5 mg 14 U14 U 22 11

6 mg6 mg 16 U16 U —— 22

Tipe dari insulin.Tipe dari insulin.

Diagnosis dari Metabolik Diagnosis dari Metabolik Syndrome.Syndrome.

Terdapat 3 hal dibawah ini:Terdapat 3 hal dibawah ini:• Abdominal obesity (M > 102 cm, F > Abdominal obesity (M > 102 cm, F >

88 cm)88 cm)• TG > 200mg%TG > 200mg%• Low HDL (M < 45mg%, F < 50mg%)Low HDL (M < 45mg%, F < 50mg%)• BP > 130/85BP > 130/85• FPG > 120 mgr%/dlFPG > 120 mgr%/dl

Hyperglycemia

• Terjadi karena gula darah yang tinggi dengan sel Terjadi karena gula darah yang tinggi dengan sel dalam tubuh mengalami kekurangan glukosa. dalam tubuh mengalami kekurangan glukosa.

• Menyebabkan terjadinya dehidrasi yang serius. Menyebabkan terjadinya dehidrasi yang serius. • Saat kadar gula dalam sel tubuh terus menurun Saat kadar gula dalam sel tubuh terus menurun

tubuh akan mulai menghasilkan keton dan produksi tubuh akan mulai menghasilkan keton dan produksi dari asam akan meningkat. dari asam akan meningkat.

• Biasanya terjadi pada kadar gula darah 180mg/dl Biasanya terjadi pada kadar gula darah 180mg/dl yang terjadi selama 3 hari terus menerus atau yang terjadi selama 3 hari terus menerus atau 240mg/dl240mg/dl

Hyperglycemia

• Penyebab :Penyebab :– Pasien lupa menggunakan insulin. Pasien lupa menggunakan insulin. – Pasien makan berlebihan, membebani tubuh Pasien makan berlebihan, membebani tubuh

dengan karbohidrat. dengan karbohidrat. – Pasien mengalami infeksi yang menganggu Pasien mengalami infeksi yang menganggu

keseimbangan insulin dan glukosa. keseimbangan insulin dan glukosa.

Hyperglycemia

• Signs and SymptomsSigns and Symptoms– Polyuria (frequent urination)Polyuria (frequent urination)– Polydypsia (excessive thirst)Polydypsia (excessive thirst)– Polyphagia (excessive hunger)Polyphagia (excessive hunger)– Nausea/VomitingNausea/Vomiting– Kussmaul’s Respiration's (Deep and Rapid)Kussmaul’s Respiration's (Deep and Rapid)– Warm, Dry SkinWarm, Dry Skin– Fruity Odor on BreathFruity Odor on Breath– Abdominal PainAbdominal Pain

Hyperglycemia

• Signs and Symptoms Cont..Signs and Symptoms Cont..– Falling Blood PressureFalling Blood Pressure– FeverFever– Decreased LOCDecreased LOC

Hyperglycemia

• Treatment BLSTreatment BLS– AirwayAirway– BreathingBreathing– CirculationCirculation– DisabilityDisability– Asses for trauma:protect C-spine if indicatedAsses for trauma:protect C-spine if indicated– Administer O2 per Pt assessmentAdminister O2 per Pt assessment– Suction airway if needed Suction airway if needed

Hyperglycemia

• Treatment BLSTreatment BLS– Obtain Hx if possibleObtain Hx if possible– Check finger stickCheck finger stick– Protect airwayProtect airway– Call for ALS if Available (don’t delay transport)Call for ALS if Available (don’t delay transport)– TransportTransport

ComparisonComparison

• HypoglycemiaHypoglycemia– Onset SuddenOnset Sudden

– Skin cold, pale, Skin cold, pale, moistmoist

– Normal Normal

– Weak, rapid Weak, rapid pulsepulse

– Weakness/ Weakness/ uncoordinationuncoordination

– HeadacheHeadache

– Irritable/Nervous Irritable/Nervous BehaviorBehavior

• HyperglycemiaHyperglycemia– Slower onsetSlower onset

– Skin warm, red, drySkin warm, red, dry

– Acidic BreathAcidic Breath• Kussmaul Kussmaul

Respiration's Respiration's

– Rapid PulseRapid Pulse

– Polyuria, Polyuria, polydypsia, polydypsia, polyphagiapolyphagia

– Nausea/VomitingNausea/Vomiting

– Falling Blood Falling Blood PressurePressure

Preprandial Preprandial glucose mg/dlglucose mg/dl

Additional units Additional units (regular insulin)(regular insulin)

<100<100 00

100-140100-140 22

140-160140-160 33

160-180160-180 44

180-200180-200 55

200-250200-250 66

250-300250-300 88

>300>300 1010

supplemental regular supplemental regular insulin scaleinsulin scale

CATEGORY RECOMMENDATIONS

Weight managementAttain & maintain desirable body weight (BMI≤25)

Carbohydrate(% of energy) 55-65%

PolysaccharidesEmphasixe whole grains, legumes, vegetables

Monosaccharides and discharides

Use in moderation

Glycemic indexIncorporate into exchanges and teaching material

Fiber, total 25-50 g/d (15-25 g/1000 kcal)

NUTRITION RECOMMENDATIONNUTRITION RECOMMENDATIONFOR PERSONS WITH DIABETESFOR PERSONS WITH DIABETES

Nutrition Recommendation for Persons with DiabetesNutrition Recommendation for Persons with Diabetes

NutrientNutrient ADAADA HCF Nutrition FdnHCF Nutrition Fdnb,cb,c

Carbohydrate,Carbohydrate, about 50%about 50% 50-60%50-60%% of kcal% of kcalProteins, %Proteins, % 10-20%10-20% 10-15% (0.8 g/kg)10-15% (0.8 g/kg)Fat, total, %Fat, total, % 30% 30%dd 30% 30%ee

Saturated, % Saturated, % <10%<10% <10%<10% Monounsaturated% Monounsaturated% 10-20%`10-20%` 10-15%10-15% Polyunsaturated % Polyunsaturated % <10%<10% <10%<10% Cholesterol, Cholesterol, <300 mg/day<300 mg/day <200 mg/day <200 mg/day Fiber, g/dayFiber, g/day 20-35 g/day20-35 g/day about 35 g/dayabout 35 g/day

(15-25 g/1000 kcal(15-25 g/1000 kcalSodium, mg/daySodium, mg/day <2400 mg if<2400 mg if <1000 mg/1000 kcal<1000 mg/1000 kcal

hypertensive hypertensiveAlcoholAlcohol drinks/day drinks/day Men Men 2 drinks/day2 drinks/day

Women Women 1 drink/day1 drink/dayVitamin supplementsVitamin supplements Not recommendedNot recommended Multivitamin-mineral dailyMultivitamin-mineral daily

antioxidant supplementsantioxidant supplements

American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus. JADA American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus. JADA 1994;94-9051994;94-905Anderson JW, Geil PB. Nutrition management of diabetes mellitus. In Shils M. Modern Nutrition in Health and Anderson JW, Geil PB. Nutrition management of diabetes mellitus. In Shils M. Modern Nutrition in Health and Disease, 8Disease, 8thth edition. Philadelphia: Lea & Febiger, 1994;1259-86. edition. Philadelphia: Lea & Febiger, 1994;1259-86.Anderson JW, Professional guide to high fiber fitness plan. Lexington, KY: HCF Nutrition Research Fdn. 1995;10.1-Anderson JW, Professional guide to high fiber fitness plan. Lexington, KY: HCF Nutrition Research Fdn. 1995;10.1-10.2210.22Individualization recommended. More fat permitted and less carbohydrate acceptable.Individualization recommended. More fat permitted and less carbohydrate acceptable.Up to 35%of energy from fat can be used for nonobese individuals with acceptable serum triglyceride values if the Up to 35%of energy from fat can be used for nonobese individuals with acceptable serum triglyceride values if the additional fat comes from monounsaturated sources and saturated and polyunsaturated fats remain under 10% additional fat comes from monounsaturated sources and saturated and polyunsaturated fats remain under 10% each.each.

Glycemic Index (GI) Ranking of Selected Starchy FoodsGlycemic Index (GI) Ranking of Selected Starchy Foods

Class IClass I Class II Class II Class IIIClass III(Higher: GI >90)(Higher: GI >90) Intermediate:Intermediate: (Lower: GI <70)(Lower: GI <70)

GI = 70–90 GI = 70–90

Most breadsMost breads Oat branOat bran Pumpernickel breadPumpernickel breadPlain crackersPlain crackers OatmealOatmeal Most pastaMost pastaMost breakfastMost breakfast Most cookies orMost cookies or Boiled riceBoiled rice cereals cereals biscuits biscuitsMost potatoesMost potatoes polished ricepolished rice Most dried legumesMost dried legumesPancake & wafflesPancake & waffles Whole-wheat breadWhole-wheat bread NutsNutsCorn chipsCorn chips Boiled Sweet cornBoiled Sweet corn BarleyBarleyMost cakesMost cakes Boiled new potatoesBoiled new potatoes Dry beans & lentilsDry beans & lentils

YamsYamsSweet potatoesSweet potatoes

www.themegallery.com

Glycemic response of nondiabetic individuals to 50 g carbohydrate from new Glycemic response of nondiabetic individuals to 50 g carbohydrate from new potatoes or kidney beans. B. Glycemic response of healthy individuals to 50 potatoes or kidney beans. B. Glycemic response of healthy individuals to 50 g of glucose, sucrose, or fructoseg of glucose, sucrose, or fructose

Factors affecting the Glycemic Response to food

Rate of ingestionRate of ingestionFood formFood formFood componentsFood components

Fat contentFat contentFiber contentFiber contentProtein contentProtein contentStarch characteristicStarch characteristic

Methods of cooking and processingMethods of cooking and processing Physiologic effectsPhysiologic effects

Pregastric hydrolysisPregastric hydrolysisGastric hydrolysisGastric hydrolysisGastric emptying rateGastric emptying rateIntestinal responseIntestinal responseIntestinal hydrolysis and absorptionIntestinal hydrolysis and absorptionPancreatic and gut hormone responsePancreatic and gut hormone responseColonic effectsColonic effects

High Fiber Intakes Advantages and DisadvantagesAdvantagesAdvantages

Slow nutrition digestion and absorptionSlow nutrition digestion and absorptionDecrease postprandial plasma glucoseDecrease postprandial plasma glucoseIncrease tissue insulin sensitivityIncrease tissue insulin sensitivityStimulate glucose useStimulate glucose useAttenuate hepatic glucose outputAttenuate hepatic glucose outputDecrease counterregulatory hormone release (e.g.,glucagon)Decrease counterregulatory hormone release (e.g.,glucagon)Lower serum cholesterolLower serum cholesterolLower fasting and postprandial serum triglyceridesLower fasting and postprandial serum triglyceridesMay attenuate hepatic cholesterol synthesisMay attenuate hepatic cholesterol synthesisMay increase satiety between mealsMay increase satiety between meals

DisadvantagesDisadvantagesIncrease intestinal gasIncrease intestinal gasTemporarily may cause abdominal discomfort or gastrointestinalTemporarily may cause abdominal discomfort or gastrointestinaldistressdistressMay alter pharmacokinetics of May alter pharmacokinetics of mineral absorption and mineral absorption and certain certain

drugsdrugs

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• FREQUENCY:FREQUENCY:– Start slow, increase slowStart slow, increase slow– 3 times : breakfast, lunch and dinner3 times : breakfast, lunch and dinner– 2 – 3 times snack (low calorie/low GI: 2 – 3 times snack (low calorie/low GI:

fruits)fruits)

– With low/moderate physical activityWith low/moderate physical activity

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TEE for hypermetabolism

TEE = BEE x TEF x PA x SFTEE = BEE x TEF x PA x SF

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• Use ideal body weight for underweight patientUse ideal body weight for underweight patient• Use adjusted body weight for overweight patientUse adjusted body weight for overweight patient

Ideal body weight = Ideal body weight =

((Body height cm)-100) – (10%x (Body height-100))((Body height cm)-100) – (10%x (Body height-100))

Adjusted body weight = Adjusted body weight =

Actual body weight (ABW) – (25% x (Actual Body Weight- Ideal Actual body weight (ABW) – (25% x (Actual Body Weight- Ideal Body Weight))Body Weight))

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Thermogenic Effect of FoodThermogenic Effect of Food

TEF is the amount of energy used for TEF is the amount of energy used for digestion, absorption and utilization of digestion, absorption and utilization of food consumed. food consumed.

- SDA of protein 30% BEE- SDA of protein 30% BEE

- SDA of carbohydrate < protein- SDA of carbohydrate < protein

- SDA of fat - SDA of fat the lowest the lowest

The average of TEF: 10%The average of TEF: 10%

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Physical Activity (PA)Physical Activity (PA)

• PA very lightPA very light = 10-30% BEE= 10-30% BEE• PA lightPA light = 30-50% BEE= 30-50% BEE• PA moderatePA moderate = 50-80% BEE= 50-80% BEE• PA heavyPA heavy = 80-100% BEE = 80-100% BEE• PAPA very heavy very heavy = > 100% = > 100% BEEBEE

• Bedridden Bedridden 10% BEE 10% BEE• Ambulatory Ambulatory 20% BEE 20% BEE

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Stress Factor (SF)Stress Factor (SF)• Postoperative (without comp.)Postoperative (without comp.) 1.00-1.101.00-1.10• Fracture of long boneFracture of long bone 1.15-1.301.15-1.30• CancerCancer 1.10-1.301.10-1.30• Peritonitis/sepsisPeritonitis/sepsis 1.10-1.301.10-1.30• Serious infection/mult. TraumaSerious infection/mult. Trauma 1.20-1.401.20-1.40• Multiple organ failure syndr. Multiple organ failure syndr. 1.20-1.401.20-1.40• BurnBurn 1.20-2.001.20-2.00

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PROTEIN REQUIREMENT:PROTEIN REQUIREMENT:

• Underweight/normoweight: based on actual Underweight/normoweight: based on actual bodyweightbodyweight

• Overweight/obese: based on adjusted body Overweight/obese: based on adjusted body weightweight

With normal renal function: 0,8 – 1 g/ kgBWWith normal renal function: 0,8 – 1 g/ kgBW

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LIPID REQUIREMENT:LIPID REQUIREMENT:

• < 30% TEE non protein< 30% TEE non protein• SFA/trans fatty acid: < 10% TEE SFA/trans fatty acid: < 10% TEE

non proteinnon protein• MUFA : 10-12% TEE non proteinMUFA : 10-12% TEE non protein• PUFA: 10% TEE non proteinPUFA: 10% TEE non protein• Cholesterol < 200 mg/dayCholesterol < 200 mg/day