DIABETES MELLITUS

THERAPYTHERAPY

Nutrition Therapy

Weight loss frequently is a primary goal of Weight loss frequently is a primary goal of nutrition therapy because 80% to 90% of nutrition therapy because 80% to 90% of people with type II diabetes are obese people with type II diabetes are obese

Diet prescriptions for type II diabetes Diet prescriptions for type II diabetes need to take into account the higher need to take into account the higher prevalence of hyperlipidemia, prevalence of hyperlipidemia, atherosclerosis, and hypertension in this atherosclerosis, and hypertension in this population.population.

Protein Intake

Recommended protein intake for patients Recommended protein intake for patients with type II diabetes: 0.8 g/kg body with type II diabetes: 0.8 g/kg body weight/dayweight/day

Protein allowance amounts 12% to 20% of Protein allowance amounts 12% to 20% of daily calories and should be derived from daily calories and should be derived from both animal and vegetable sources. both animal and vegetable sources.

80% to 90% of daily calories are distributed 80% to 90% of daily calories are distributed between fat and carbohydrate intake, based between fat and carbohydrate intake, based on a patient's nutrition assessment and on a patient's nutrition assessment and treatment goals (glucose, lipid, and weight treatment goals (glucose, lipid, and weight outcomes). outcomes).

Fat Intake Reduce dietary fat to < 35% of total calories Reduce dietary fat to < 35% of total calories Limit saturated fat to < 10% of total calories, and < 7% Limit saturated fat to < 10% of total calories, and < 7%

of calories in patients with elevated LDL cholesterol of calories in patients with elevated LDL cholesterol Limit polyunsaturated fats to 10% of total calories Limit polyunsaturated fats to 10% of total calories Limit daily cholesterol consumption to 300 mg Limit daily cholesterol consumption to 300 mg Moderately increase intake of monounsaturated fats Moderately increase intake of monounsaturated fats

such as canola and olive oil (up to 20% of calories). A such as canola and olive oil (up to 20% of calories). A diet high in monounsaturated fats has been shown to diet high in monounsaturated fats has been shown to improve glucose control, lower triglycerides, and raise improve glucose control, lower triglycerides, and raise HDL levels. HDL levels.

Carbohydrate Intake

Emphasis is placed on whole grains, Emphasis is placed on whole grains, starches, fruits, and vegetables to provide starches, fruits, and vegetables to provide the necessary vitamins, minerals, and fiber the necessary vitamins, minerals, and fiber in the diet. in the diet.

The recommended daily consumption of The recommended daily consumption of fiber is the same for people with diabetes as fiber is the same for people with diabetes as for nondiabetics (20 g to 35 g). for nondiabetics (20 g to 35 g).

Carbohydrate Intake

SucroseSucrose A modest amount of sugar is allowed in the daily diet of A modest amount of sugar is allowed in the daily diet of

patients with type II diabetes. Obese individuals usually patients with type II diabetes. Obese individuals usually are advised to avoid sweets because of the potential of a are advised to avoid sweets because of the potential of a small portion triggering overconsumptionsmall portion triggering overconsumption . .

FructoseFructose A natural source of dietary fructose is fruits and A natural source of dietary fructose is fruits and

vegetables. vegetables. Moderate consumption is recommended, particularly Moderate consumption is recommended, particularly

concerning foods in which fructose is used as a concerning foods in which fructose is used as a sweetening agent.sweetening agent.

Alcohol Intake Moderate consumption will not adversely affect blood Moderate consumption will not adversely affect blood

glucose in patients whose diabetes is well controlled. glucose in patients whose diabetes is well controlled. Calories from alcohol should be included as part of Calories from alcohol should be included as part of the total calorie intake.the total calorie intake.

For patients taking insulin, one or two alcoholic For patients taking insulin, one or two alcoholic beverages per day are acceptable (one alcoholic beverages per day are acceptable (one alcoholic beverage = 12 oz beer, 5 oz wine, or 1[ring] oz beverage = 12 oz beer, 5 oz wine, or 1[ring] oz distilled spirits; sweet drinks should be avoided)distilled spirits; sweet drinks should be avoided)

Patients taking insulin or sulfonylureas are susceptible Patients taking insulin or sulfonylureas are susceptible to hypoglycemia if alcohol is consumed on an empty to hypoglycemia if alcohol is consumed on an empty stomach. stomach.

Oral Antidiabetic Agents

Oral medication is initiated when 3 months Oral medication is initiated when 3 months of diet and exercise alone are unable to of diet and exercise alone are unable to achieve or maintain plasma glucose levels achieve or maintain plasma glucose levels within these glycemic guidelines. within these glycemic guidelines.

If patients are symptomatic, oral If patients are symptomatic, oral antidiabetic agents or insulin should be antidiabetic agents or insulin should be initiated in concert with diet and exercise.initiated in concert with diet and exercise.

Oral Antidiabetic Agents

Current therapy for the treatment of Current therapy for the treatment of hyperglycemia of type II diabetes includes hyperglycemia of type II diabetes includes the following oral antidiabetic agents: the following oral antidiabetic agents: • SSulfonylureas ulfonylureas • BBiguanideiguanides:s: metformin metformin • AAlpha-glucosidase inhibitorlpha-glucosidase inhibitors:s: acarbose acarbose • TThiazoladinedioneshiazoladinediones• MMeglitinideseglitinides

Oral Antidiabetic Agents

In general, oral agents are contraindicated In general, oral agents are contraindicated in patients who: in patients who: • Are pregnant or lactating Are pregnant or lactating • Are seriously ill Are seriously ill • Have significant kidney or liver disease Have significant kidney or liver disease • Have demonstrated allergic reactions. Have demonstrated allergic reactions.

Sulfonylureas

Sulfonylureas work primarily by Sulfonylureas work primarily by stimulating pancreatic insulin secretion, stimulating pancreatic insulin secretion, which in turn reduces hepatic glucose which in turn reduces hepatic glucose output and increases peripheral glucose output and increases peripheral glucose disposal. disposal.

Examples of the compounds are: Examples of the compounds are: • Glimepiride (Amaryl)Glimepiride (Amaryl)• Glipizide Glipizide • GlyburideGlyburide• Gliclazide Gliclazide

Biguanides

Metformin is a biguanide that works mainly Metformin is a biguanide that works mainly by:by: Suppressing excessive hepatic Suppressing excessive hepatic

glucose productionglucose production Increasing glucose utilization in Increasing glucose utilization in

peripheral tissues to a lesser degreeperipheral tissues to a lesser degree It may also improve glucose levels It may also improve glucose levels

by reducing intestinal glucose by reducing intestinal glucose absorptionabsorption

Biguanides

Metformin is effective as monotherapy Metformin is effective as monotherapy or in combination with sulfonylureas, or in combination with sulfonylureas, alpha-glucosidase inhibitors, and alpha-glucosidase inhibitors, and insulininsulin

Treatment with metformin has Treatment with metformin has beneficial effects on plasma lipidsbeneficial effects on plasma lipids

Metformin therapy has been Metformin therapy has been associated with weight loss or no associated with weight loss or no weight gainweight gain

Biguanides

Contraindications:Contraindications: renal failurerenal failure significant hepaticdiseasesignificant hepaticdisease heart failureheart failure alcohol abusealcohol abuse any hypoxic condition or history of any hypoxic condition or history of

lactic acidosislactic acidosis

Biguanides

Lactic acidosis is a rare complication of Lactic acidosis is a rare complication of metformin therapy and has a high metformin therapy and has a high mortality ratemortality rate

In any patient who is hospitalized with In any patient who is hospitalized with an acute severe illness, metformin an acute severe illness, metformin should be temporarily discontinuedshould be temporarily discontinued

Alpha-glucosidase inhibitors

AcarboseAcarbose slows down the breakdown of slows down the breakdown of

disaccharides and polysaccharides and disaccharides and polysaccharides and other complex carbohydrates into other complex carbohydrates into monosaccharidesmonosaccharides

tthe enzymatic generation and subsequent he enzymatic generation and subsequent absorption of glucose is delayed and the absorption of glucose is delayed and the postprandial blood glucose values, which postprandial blood glucose values, which are characteristically high in patients with are characteristically high in patients with type II diabetes, are reducetype II diabetes, are reducedd

Thiazolidinediones(PPAR-agonists)

They They work mainly by improving peripheral work mainly by improving peripheral insulin resistance in skeletal muscle without insulin resistance in skeletal muscle without stimulating insulin secretion.stimulating insulin secretion.

TheyThey works to a lesser degree by reducing works to a lesser degree by reducing excessive hepatic glucose production.excessive hepatic glucose production.

It also results in significant reduction in total It also results in significant reduction in total triglyceride and elevation in HDL levels. triglyceride and elevation in HDL levels.

Meglitinides

Examples: repaglinide, nataglinideExamples: repaglinide, nataglinide It is a It is a benzoic acid derivativebenzoic acid derivative and a short-acting and a short-acting

insulin releaser.insulin releaser. It It stimulates the release of insulin from the stimulates the release of insulin from the

pancreatic beta cells by closing ATP-sensitive pancreatic beta cells by closing ATP-sensitive potassium channels. potassium channels.

ItIt has no significant effect on plasma lipid levels has no significant effect on plasma lipid levels RRapid onset and short duration of action make apid onset and short duration of action make

multiple daily doses necessary (take multiple daily doses necessary (take it it immediately before each meal!). immediately before each meal!).

Monotherapy With Oral Antidiabetic Agents

Obese Patients With Newly Obese Patients With Newly Diagnosed Diabetes Diagnosed Diabetes

With/Without DyslipidemiaWith/Without Dyslipidemia MMetforminetformin or acarbose have the or acarbose have the

advantage of not inducing weight advantage of not inducing weight gain, which can occur with gain, which can occur with sulfonylureas and insulin therapy.sulfonylureas and insulin therapy.

Monotherapy With Oral Antidiabetic Agents

Thin Elderly PatientsThin Elderly Patients Thin patients in general tend to be insulin Thin patients in general tend to be insulin

deficient and more commonly require deficient and more commonly require sulfonylureas as initial oral monotherapysulfonylureas as initial oral monotherapy

Caution should be used when prescribing any Caution should be used when prescribing any medication in the elderly, and starting doses medication in the elderly, and starting doses need to be lower than those in younger need to be lower than those in younger patientspatients

RosiRosiglitazone, acarbose and metformin may glitazone, acarbose and metformin may also be effective as monotherapy also be effective as monotherapy

Monotherapy With Oral Antidiabetic Agents

Patients With Acceptable Fasting Patients With Acceptable Fasting Glucose Values but Elevated Glucose Values but Elevated

Glycohemoglobin LevelsGlycohemoglobin Levels It suggests the likelihood of elevated postprandial It suggests the likelihood of elevated postprandial

glucose levelsglucose levels Acarbose would be an appropriate choice in Acarbose would be an appropriate choice in

these patients ( by reducing the postprandial these patients ( by reducing the postprandial glucose value)glucose value)

If acarbose is not indicated or tolerated, If acarbose is not indicated or tolerated, rosirosiglitazone, metformin, or sulfonylurea may be glitazone, metformin, or sulfonylurea may be effective. effective.

Monotherapy With Oral Antidiabetic Agents

Nonobese Individuals With DiabetesNonobese Individuals With Diabetes Lean patients with mild glucose intolerance Lean patients with mild glucose intolerance

can be given a trial with any of the four can be given a trial with any of the four classes of oral agentsclasses of oral agents

Sulfonylureas are likely to be a better choice Sulfonylureas are likely to be a better choice for patients when blood glucose values are for patients when blood glucose values are consistently in the 200 to 300 mg/dL range consistently in the 200 to 300 mg/dL range (these drugs can be titrated more rapidly to (these drugs can be titrated more rapidly to higher doses, which may be necessary in this higher doses, which may be necessary in this patient group).patient group).

Monotherapy With Oral Antidiabetic Agents

Patients With Prolonged, SeverePatients With Prolonged, Severe Hyperglycemia (Glucose ToxicityHyperglycemia (Glucose Toxicity))

a temporary trial of insulin therapy should be a temporary trial of insulin therapy should be instituted for a few weeks before beginning instituted for a few weeks before beginning an oral agent to reduce insulin resistance and an oral agent to reduce insulin resistance and improve endogenous insulin secretory improve endogenous insulin secretory capacitycapacity

start a sulfonylurea agent at the maximum start a sulfonylurea agent at the maximum dose and follow the patient carefullydose and follow the patient carefully

once metabolic control is achieved the glucose once metabolic control is achieved the glucose toxic state improves. At this point, switching toxic state improves. At this point, switching to other oral agents with less hypoglycemic to other oral agents with less hypoglycemic potential is a reasonable alternativepotential is a reasonable alternative

Monotherapy With Oral Antidiabetic Agents

Patients With Severe Renal or Liver Patients With Severe Renal or Liver DysfunctionDysfunction

Both sulfonylureas and metformin should be Both sulfonylureas and metformin should be used with cautionused with caution

In patients with renal impairment, acarbose or In patients with renal impairment, acarbose or rosirosiglitazone represent an excellent choiceglitazone represent an excellent choice

In patients with significant or progressive liver In patients with significant or progressive liver disease, hyperglycemia is best treated with disease, hyperglycemia is best treated with exogenous insulin alone.exogenous insulin alone.

DIABETES MELLITUSGOALS OF THERAPY (EDPG 1998)

FASTING FASTING PLASMA GLUCOSEPLASMA GLUCOSE: :

< 10< 100 mg/dL0 mg/dL

POSTPRANDIALPOSTPRANDIAL PLASMA GLUCOSE:PLASMA GLUCOSE:

< < 113535 mg/dL mg/dL

HbA1c: HbA1c: < 6,5%< 6,5%

DIABETES MELLITUSGOALS OF THERAPY (EDPG 1998)

Total cholesterol: < 185 mg/dLTotal cholesterol: < 185 mg/dL LDL-cholesterol: < 115 mg/dLLDL-cholesterol: < 115 mg/dL HDL-cholesterol: > 46 mg/dLHDL-cholesterol: > 46 mg/dL Triglycerides: < 150 mg/dLTriglycerides: < 150 mg/dL Blood pressure: < 140/85 mm HgBlood pressure: < 140/85 mm Hg

DIABETES MELLITUSGOALS OF THERAPY

Negative Urine glucoseNegative Urine glucose

Negative Urine KetonesNegative Urine Ketones

Symptomatic ImprovementSymptomatic Improvement

Normalize NutritionNormalize Nutrition

Avoid/Prevent ComplicationsAvoid/Prevent Complications