DM Ch 31 PPT Edited-1

7/26/2019 DM Ch 31 PPT Edited-1

1/52

Medical Nutrition TherapyMedical Nutrition Therapyfor Diabetes Mellitus andfor Diabetes Mellitus and

Hypoglycemia ofHypoglycemia ofNondiabetic OriginNondiabetic Origin

Chapter 31Chapter 31

Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


2/52

Diabetes Mellitus

A roup of diseases c!aracteri"ed by !i!blood lucose #$%& concentrationsresultin from defects in insulin secretion,

insulin action, or bot!

2Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


3/52

Diabetes and Prediabetes: Types

'ype 1 #formerly I((), type I&

'ype 2 #formerly *I((), type II&

%estational diabetes mellitus #%()& +rediabetes #impaired lucose

!omeostasis&

t!er specific types

-Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


4/52

Prediabetes (Impaired GlucoseHomeostasis

'o forms/ may !ave eit!er or bot!

Impaired fastin lucose #I%& fastin plasmalucose #+%& above normal

Impaired lucose tolerance #I%'& plasmalucose elevated after 734 lucose load

5b A16



5/52

Type ! Diabetes

'o forms

Immune mediated beta cells destroyed byautoimmune process

Idiopat!ic cause of beta cell function lossunnon

Symptoms !yperlycemia, polyuria,polydipsia, ei!t loss, de!ydration,

electrolyte disturbance, and etoacidosis

39 to 109 of all dianosed diabetes



6/52

Type " Diabetes

)ost common form of diabetes,accountin for :09 to :39 of dianosedcases

6ombination of insulin resistance and betacell failure #insulin deficiency&

+roressive disease !yperlycemia

develops radually and may not cause t!eclassic symptoms of type 1 diabetes

;Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


7/52

Gestational Diabetes Mellitus

%lucose intolerance it! onset or firstreconition durin prenancy

ccurs in about 79 of prenancies


8/52

#is$ %actors for Type " Diabetes

$)I >23

+!ysical inactivity

5i!4ris et!nic roups #African American, ?atino,*ative American, Asian America, +acific Islander&

+revious delivery of baby >: lbs or %()

5ypertension

5(? @-3 md? or trilycerides >230 md?

+6S or acant!osis niricans

I%' or I%

5istory of vascular disease



9/52

Methods of Diagnosis

astin plasma lucose #+%&

6asual plasma lucose #any time of day&

ral lucose tolerance test #%''&

:Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


10/52

Diagnosis of Diabetes Mellitus andImpaired Glucose Homeostasis

Diagnosis &riteria

Diabetes +% B12; md? #B7.0 mmol?&

6+% B200 md? #B11.1 mmol?& plus symptoms

2!+% B200 md? #B11.1 mmol?&

+rediabetes

Impaired fastinlucose

+% 100123 md? #3.;7.0 mmol?&

Impaired lucosetolerance

2!+% 101:: md? #7.811.0 mmol?&

*ormal +% @100 md? #@3.; mmol?&

2!+% @10 md? #@7.8 mmol?&

)odified from American (iabetes Association (ianosis and classification of diabetes mellitus #position statement&,)odified from American (iabetes Association (ianosis and classification of diabetes mellitus #position statement&, Diabetes CareDiabetes Care

-0S8, 2007.-0S8, 2007.

6+%, 6asual plasma lucose/ +%, fastin plasma lucose/ 2!+%, 24!our plasma lucose level #measured 2 !ours after an oral6+%, 6asual plasma lucose/ +%, fastin plasma lucose/ 2!+%, 24!our plasma lucose level #measured 2 !ours after an oral

lucose tolerance test it! administration of 73 of lucose&.lucose tolerance test it! administration of 73 of lucose&.



11/52

'lgorithm for Type ! Diabetes



12/52

'lgorithm for Type " Diabetes



13/52

Management of Prediabetes

(iabetes prevention trials

?ifestyle c!ane

Increase p!ysical activity

)oderate ei!t loss

Education

Ceduced fat and enery intae

Ceular participant follo4up

1-Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


14/52

Management of Diabetes

'rials (iabetes and 6ontrol and 6omplications 'rial

#(66'&

Dnited indom +rospective (iabetes Study

#D+(S&

)anaement

)edical nutrition t!erapy

+!ysical activity )onitorin

)edications

Self4manaement education 1Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


15/52

Insulin &ounterregulatoryHormones

%lucaon

Epinep!rine #adrenaline&

*orepinep!rine 6ortisol

%rot! !ormone



16/52

Diabetes: Treatment Goals

Glycemic &ontrol

A16 @7.09F+reprandial capillary plasma lucose :01-0 md? #3.047.2 mmol?&

+ea postprandial capillary plasmalucoseG

@180 md? #@10.0 mmol?&

#ecommendations for Glycemic#ecommendations for Glycemic

&ontrol for 'dults ith Diabetes&ontrol for 'dults ith Diabetes

)odified from American (iabetes Association Standards of medical care in diabetesH2007,)odified from American (iabetes Association Standards of medical care in diabetesH2007, Diabetes CareDiabetes Care-03, 2007.-03, 2007.

FCeferenced to a nondiabetic rane of 94;9 usin a (66'4based assay.FCeferenced to a nondiabetic rane of 94;9 usin a (66'4based assay.GG+ea levels in patients it! diabetes.+ea levels in patients it! diabetes.

1;Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


17/52

)ipid and *lood Pressure Goalsfor Diabetes

)ipids

?(? c!olesterol @100 md? #@2.; mmol?&

5(? c!olesterol )en >0 md? #>1.1 mmol?&

30 md? #>1. mmol?&

'rilycerides @130 md? #@1.7 mmol?&

$lood +ressure @1-080 mm 5

#ecommendations for )ipid and *lood#ecommendations for )ipid and *loodPressure for 'dults ith DiabetesPressure for 'dults ith Diabetes

)odified from American (iabetes Association Standards of medical care in diabetesH2007,)odified from American (iabetes Association Standards of medical care in diabetesH2007, Diabetes CareDiabetes Care-03, 2007.-03, 2007.

5(?, !i!4density lipoprotein/ ?(?, lo4density lipoprotein.5(?, !i!4density lipoprotein/ ?(?, lo4density lipoprotein.



18/52

Medical Nutrition Therapyfor Diabetes

Individuali"e enery needs and nutritioncare based on metabolic profile, treatmentoals, and c!anes person is illin andable to mae



19/52

Goals of Medical NutritionTherapy for Diabetes Mellitus

+rediabetes

(ecrease ris of diabetes and 6( bypromotin !ealt!y food c!oices and p!ysicalactivity leadin to moderate ei!t loss

(iabetes

Ac!ieve and maintain $% levels in normalrane, lo4ris lipid and lipoprotein profile, lo4

ris blood pressure +revent or delay c!ronic complications

Address individual nutrition needs

1:Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


20/52

Goals of Medical NutritionTherapy for Diabetes Mellitus

(cont+d Specific situations

)eet uniJue needs to yout! it! type 1 or type2 diabetes, prenant and lactatin omen, andolder adults it! diabetes

Self4manaement trainin for individuals treatedit! insulin or insulin secretaoues for safee=ercise, prevention and treatment of

!ypolycemia, and treatment of acute illness



21/52

&arbohydrate

?o4carbo!ydrate diets are notrecommended

Suars do not increase lycemia more t!anisocaloric amounts of starc!

actors influencin lycemic response tofoods lycemic inde= #%I& and lycemicload #%?&

6arbo!ydrate countin/ portions of foodcontainin 13 carbo!ydrate

E=c!ane lists



22/52

The Glycemic Inde,


23/52

%iber

23 to -0 of fiber per day it! specialemp!asis on soluble fiber

Cecommend same as eneral public

Cesearc! on !i!er fiber intae for peopleit! diabetes !as been inconclusive

2-Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


24/52

-.eeteners

Sucrose restriction cannot be Kustified based onlycemic response/ it s!ould be substituted in ameal plan for ot!er carbo!ydrate

Ceduces intae of !ealt!y foods or increases

calorie intae ructose !as no benefit over sucrose

Ceduced calorie seeteners suar alco!ols andtaatose

*onnutritive seeteners sacc!arin, aspartame,neotame, acesulfame potassium, and sucralose



25/52

Protein

(oes not affect blood lucose levels in ell4controlled diabetes

(oes not slo absorption of carbo!ydrate

Cecommend usual protein intae #139209 of ilocalories&



26/52

Dietary %at

+eople it! diabetes !ave similar ris tot!ose it! a !istory of 6(

Cecommendations

'otal fat 239 to -39 of total ilocalories Saturated fatty acids @79

)inimi"ed or eliminate transfat

ery lon omea4- polyunsaturated fatty acids +lant sterol and stanol esters/ 2 to - day

2;Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


27/52

'lcohol

Abstain if !istory of abuse, prenancy,medical problems/ moderation for ot!ers

)oderate amounts of alco!ol it! food

!ave minimal effect on lucose and insulin

E=cessive alco!ol #-L drinsday&contributes to !yperlycemia



28/52

Micronutrients

*o clear evidence of benefits ofsupplements

5i!4ris roups

Supplemental antio=idant vitamins !ave notbeen proven beneficial, and some evidenceindicates t!at vitamins E and 6 and

carotene are !armful *o benefit !as been s!on for

supplementation of c!romium



29/52

Physical 'cti/ity and 0,ercise

Interal part of treatment plan for diabetes

Improve insulin sensitivity

Ceduce cardiovascular ris factors


30/52

Potential Problems .ith 0,ercise

5ypolycemia if usin insulin or insulinsecretaoues

6aused by increased insulin sensitivity

5yperlycemia 6aused by a reater t!an normal increase in

counterreulatory !ormones

E=ercise uidelines reJuent blood lucose monitorin before,

durin, and after e=ercise

Ceduce insulin or inest carbo!ydrate-0Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


31/52

&arbohydrate for Insulin or Insulin-ecretagogue 1sers

Add 13 of carbo!ydrate for every -0 to ;0minutes of activity #dependin on intensity&

*o adKustment for e=ercise @-0 min

Add carbo!ydrate if pre4e=ercise lucoselevel @100 md?

*o supplementary carbo!ydrate if notreceivin insulin or secretaoues

65 inestion durin proloned e=erciseimproves performance

-1Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


32/52

Insulin Guidelines for 0,ercise

)oderate to strenuous activity >3 to ;0minutes decrease rapid4 or s!ort4actininsulin #12 D&

+roloned viorous e=ercise may need a139 to 209 decrease in total daily insulindose



33/52

0,ercise Prescription

At least 130 min of moderate4intensityaerobic p!ysical activity or at least :0min of viorous aerobic e=ercise

(istribute over at least - days it! nomore t!an 2 consecutive days it!outactivity

Cesistance e=ercise -M

--Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


34/52

Oral Glucose2)o.eringMedications

*eer lucose4loerin medications used aloneor in combination

Insulin secretaoues sulfonylureas promote insulinsecretion by beta cells

%linides melitinides differ from sulfonylureas in t!at t!ey!ave s!orter metabolic !alf4lives

$iuanides metformin suppresses !epatic lucoseproduction

'!ia"olidinediones 'N(s or liti"ones decrease insulinresistance in perip!eral tissues

a4%lucosidase in!ibitors acarbose in!ibits small boelen"ymes t!at diest carbo!ydrate


Gl ) i M di ti


35/52

Glucose2)o.ering Medications(cont+d

Insulin secretaoues Sulfonylureas and melitinides +romote insulin secretion by beta cells

Insulin sensiti"ers

En!ance insulin action $iuanides #metformin& and 'N(s

CeJuire presence of e=oenous or endoenousinsulin

En"yme in!ibitors #a4lucosidase in!ibitors& In!ibit en"ymes t!at diest carbo!ydrates in t!e

small intestine/ delay carbo!ydrate absorption andloer postprandial lycemia

Acarbose #+recose& and militol #%lyset&-3Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

I 3 t bl Gl ) i


36/52

In3ectable Glucose2)o.eringMedications

E=enatide #$yetta& incretin mimetic orincretin4lie aent

5ormones released durin nutrient absorptiont!at increase lucose4dependent insulinsecretion, slo astric emptyin, decreaselucaon production, and decrease appetite

+ramlintide #Symlin& synt!etic form ofamylin

5ormone normally co4secreted it! insulin inresponse to food intae

-;Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


37/52

Insulin

Essential to survive in type 1 diabetes

)ay be needed to restore lycemia in type2 diabetes

nset, pea, and duration

In!aled insulin

Individuali"e type and timin of insulin

reimen based on eatin and e=ercise!abits and blood lucose levels

Insulin pump


'ction Times of Human Insulin


38/52

'ction Times of Human InsulinPreparations

Type of Insulin Onset of 'ction

Pea$

'ction

1sual 0ffecti/e

Duration

Monitor

0ffect In

#apid 'cting @13 min 12 !r - !r 2 !r

Insulin lispro #5umalo&

Insulin aspart #*ovo?o&

Insulin lulisine #Apidra&

-hort 'cting 0.31 !r 2- !r -; !r O !r

Ceular Intermediate2'cting

*+5 2 !r 10 !r 101; !r 812 !r

)ong 'cting

Insulin larine #?antus& 2 !r +ealess 202 !r 1012 !r

Insulin determir #?evemir& 2 !r +ealess 182 !r 1012 !r

Mi,tures 0.31 !r (ual 101; !r

70-0 #709 neutral protamine 5aedorn P*+5Q,-09 reular&

7323 #739 neutral protamine lispro P*+?Q, 239 lispro&

70-0 #709 neutral protamine aspart P*+AQ, -09 aspart&

Adapted from $ode $


39/52

Monitoring

Self4monitorin of blood lucose #S)$%&up to ei!t times per day

'rainin and record eepin

Dsed to adKust insulin doses and food

6ontinuous ambulatory blood lucosemonitorin

Drine and blood etones

-:Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

M di l N t iti Th f


40/52

Medical Nutrition Therapy forType ! Diabetes

Interate insulin reimen into usual eatin!abits and p!ysical activity sc!edule

)ultiple inKections #R-day& of insulin pump

5alf insulin as basal or bacround/ ot!er!alf before meals

'otal enery intae and 65 intae to

avoid ei!t ain


M di l N t iti Th f


41/52

Medical Nutrition Therapy forType " Diabetes

?ifestyle interventions to improve metabolicabnormalities #lycemia, dyslipidemia,!ypertension&

+roressive usually need to add medication

to )*' $lood lucose control, improve food c!oices,

increase p!ysical activity, moderate eneryrestriction to promote ei!t loss

'eac!in carbo!ydrate sources, servinsi"es, number of servins, meal plannin,limitin fats

S)$% 1Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Medical Nutrition Therapy for


42/52

Medical Nutrition Therapy forType ! Diabetes in 4outh

)aintain normal rot! and development

*utrition prescription based on nutritionassessment

Dse typical food and nutrition !istory

AdKust it! ae, p!ysical activity, and rot! rate

Individuali"e food plans and insulin reimens

Cealistic blood lucose oals Ceduce ris of 6(

)eal plannin approac!es 65 countin




43/52

Medical Nutrition Therapy forType " Diabetes in 4outh

Accompanies c!ild!ood obesity

6essation of e=cessive ei!t ain,promote normal rot! and development

Address 6( ris

'eac!in must include carbo!ydrate foodsand portion si"e

+!ysical activity

$ariatric surery




44/52

Medical Nutrition Therapy forPree,isting Diabetes andPregnancy

+reconception counselin

5ormonal c!anes in first trimester lead to

erratic $% levels/ adKust meal plan Increased need for insulin in second and

t!ird trimesters

AdKust meal plan to provide additionalilocalories

Avoid !ypolycemia and etosis




45/52

Medical Nutrition Therapy forGestational Diabetes Mellitus About 79 of prenancies

5i! ris for type 2 diabetes later in life

Screenin and testin

6arbo!ydrate4controlled meal plan,adeJuate enery, normolycemia, andabsence of etosis

Individuali"e and adKust meal plant!rou!out prenancy

Dse of insulin

6arbo!ydrate distribution

E=ercise3Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.



46/52

Medical Nutrition Therapy forOlder 'dults

Increased prevalence of diabetes and I%'it! ae

Similar recommendations to younerpopulation

6oncern for malnutrition

(ietary restriction is *' arranted inlon4term care communities

5yperlycemia and de!ydration can leadto !yperlycemic !yperosmolar state

;Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


47/52

Nutrition &are Process

*utrition assessment

*utrition dianosis

*utrition intervention (evelopin a food or meal plan

Self4manaement trainin

acilitatin be!avioral c!anes and oal settin

*utrition monitorin and evaluation

ollo4up7Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

'cute &omplications


48/52

'cute &omplications 5ypolycemia

Autonomic or adreneric symptoms s!ainess,

seatin, palpitations, an=iety, !uner

*eurolycopenic symptoms slo performance,difficulty concentratin, confusion anddisorientation, slurred speec!, irrationalbe!avior, e=treme fatiue, sei"ures,unconsciousness

'reatment

5yperlycemia or diabetic etoacidosis

#(A& (A is life t!reatenin but reversible

(an p!enomenon

Somoyi effect


& & f


49/52

&ommon &auses ofHypoglycemia

Inadvertent or deliberate errors in insulin dosesE=cessive insulin or oral secretaoue medications

Improper timin of insulin in relation to food intae

Intensive insulin t!erapy

InadeJuate food intaemitted or inadeJuate meals or snacs

(elayed meals or snacs

Dnplanned or increased p!ysical activities or e=ercise

+roloned duration or increased intensity of e=ercise

Alco!ol intae it!out food

)odified from American (iabetes Association)odified from American (iabetes Association Medical management of type 1 diabetes,Medical management of type 1 diabetes, ed , Ale=andria, A, 200,ed , Ale=andria, A, 200,

American (iabetes Association.American (iabetes Association.

:Elsevier items and derived items 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.


50/52

)ong2Term &omplications

)acrovascular diseases

(yslipidemia

5ypertension

)icrovascular diseases

*ep!ropat!y

Cetinopat!y *europat!y

%astroparesis



51/52

Hypoglycemia of NondiabeticOrigin

Symptoms usually it! $% @;3 md?

+ostprandial #reactive& !ypolycemia

Alimentary !yperinsulinemia Idiopat!ic reactive !ypolycemia

astin #food4deprived& !ypolycemia

actitious !ypolycemia

)anaement five or si= small meals a day


% l P i t


52/52

%ocal Points *utrition t!erapy is a c!allenin but essential aspect of t!e

manaement of diabetes and !ypolycemia of nondiabetic

oriin. Attention to nutrition and food and meal4plannin principles is

essential for metabolic #lucose, lipids, and blood pressure&control and overall ood !ealt!.

An C( !o is noledeable and silled in implementin

current nutrition principles and main recommendations forpatients it! diabetes or !ypolycemia of nondiabetic oriinis t!e medical team member !o s!ould plan, implement,and evaluate )*' and t!e nutrition care process.

Effective education and counselin of a person it! diabetes

ill lead to !is or !er becomin a team player inmanaement of !is or !er blood lucose.

'!e effectiveness of nutrition interventions need to becontinually monitored and documented to promote t!e bestpossible outcomes.

Documents

DM Ch 31 PPT Edited-1