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Nutrition for Diabetes Mellitus:

Nutrition for Diabetes Mellitus Chapter 19

LEARNING OBJECTIVES :

LEARNING OBJECTIVES 1. Compare and contrast the types of diabetes with regard to prevalence, symptoms, complications, and treatment. 2. Define nutrition therapy for diabetes mellitus (DM). What are the goals? How are these goals accomplished? 3. Discuss the 2002 revised dietary recommendations established by the American Dietetic Association (ADA) for people with diabetes. 4. Discuss the role of the nurse in the nutrition care of people with diabetes. 5. Provide nutritional advice to patients with diabetes who are experiencing short-term illnesses. 6. Discuss the role of nutrition therapy as it applies to people with diabetes across the life span, with special emphasis on pregnant women. Slide 2

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Diabetes mellitus (DM) Group of conditions characterized by: Relative or complete lack of insulin secretion by beta cells of pancreas or defects of cell insulin receptors Results in disturbances of carbohydrate, protein, and lipid metabolism and hyperglycemia Usually characterized by: Elevated fasting blood glucose (  126 mg/dL if found on at least two occasions) Hyperglycemia Associated with disability and premature death Main goal of treatment maintenance of insulin/glucose homeostasis Slide 3

Diabetes Mellitus, cont’d :

Diabetes Mellitus, cont’d Complications Macrovascular complications increase risk Coronary artery disease Peripheral vascular disease Cerebrovascular accidents Microvascular complications Nephropathy Approximately half of individuals with type 1 diabetes mellitus (T1DM) develop chronic renal failure and chronic kidney disease (CKD) Slide 4

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Neuropathy Decreased sensations in extremities Injury may occur without patient’s awareness Impaired healing may lead to gangrene and amputations Retinopathy Leading cause of blindness in North America Slide 5

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Autonomic effects Orthostatic hypotension Persistent tachycardia Gastroparesis Neurogenic bladder Impotence Impaired visceral pain sensation Symptoms of angina pectoris or myocardial infarction may be obscured Slide 6

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Glucose intolerance Primary categories T1DM: 5% to 10% all cases T2DM: >90% all cases Other types Gestational diabetes mellitus (GDM) Slide 7

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Type 1 diabetes mellitus Symptoms: Onset usually sudden Excess hunger Hyperglycemia Weight loss while consuming large food quantities (polyphagia) Polyuria and polydipsia Usually diagnosed at 20 years of age or less Slide 8

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Autoimmune disease Insulin Type 1 DM insulin required to maintain normal blood glucose levels and to survive Type 2 DM Some individuals may require insulin to optimize blood glucose control Goal of insulin therapy, in conjunction with nutrition therapy and physical activity Mimic physiologic insulin delivery Slide 9

Diabetes Mellitus Management:

Diabetes Mellitus Management Types of insulin Rapid or short acting Intermediate acting Long acting Slide 10

Diabetes Mellitus Management:

Diabetes Mellitus Management Exercise Lowers blood glucose levels Assists in maintaining normal lipid levels Increases circulation Consistent and individualized exercise may reduce therapeutic dose of insulin Slide 11

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Type 2 diabetes mellitus Rarely present with classic diabetes symptoms First symptoms often complications of T2DM: Heart attack Stroke Neuropathic problems Primary metabolic problem Insulin resistance or Failure of cells to respond to insulin produced by body Pancreas loses ability to produce insulin Slide 12

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Oral glucose-lowering medications Used to treat T2DM when diet and physical activity alone cannot control hyperglycemia Blood glucose monitoring Blood glucose levels cornerstone of diabetes management Slide 13

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Blood glucose levels can be monitored several ways Glycosylated hemoglobin (A1C) Amount of A1C reflects average blood glucose level for 100- to 120-day period before test Blood sample can be drawn at any time Not affected by short-term factors such as food intake, exercise, or stress Self-monitoring Performed in individual’s home with blood glucose meters Droplet of blood obtained through fingerstick on regular basis to monitor glucose levels Before and after meals Bedtime Slide 14

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Hypoglycemia Below normal values of blood glucose levels Can result from: Too much insulin Skipping meals Too much exercise without concomitant increase in food intake Onset sudden Fatal if left untreated Hypoglycemia symptoms occur when: Blood glucose drops below 70 mg/dL or less Relatively significant drop in blood glucose Slide 15

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Diabetic ketoacidosis Life-threatening condition caused by insulin deficiency Body breaks down fats and proteins for energy Can cause ketosis, an abnormal accumulation of ketones Hyperglycemia Leads to dehydration Precipitates lactic acidosis Stimulates respiratory center..Produces deep, rapid respirations known as Kussmaul’s respirations Slide 16

Diabetes Mellitus, cont’d:

Diabetes Mellitus, cont’d Large amounts of ketone bodies present Produces fruity or acetone odor on breath If not recognized and treated promptly: Acidosis and dehydration may lead to loss of consciousness Possibly coma and death Slide 17

Diabetes Mellitus, cont’d :

Diabetes Mellitus, cont’d Common conditions that precipitate DKA Insufficient or interrupted insulin therapy Too much food Infection Slide 18

Nutrition Therapy, cont’d:

Nutrition Therapy, cont’d Nutrition recommendations same for individuals with diabetes as for the general population Carbohydrate recommendations Based on eating habits, blood glucose, lipid goals Blood glucose control not impaired by use of sucrose in the meal plan, but sucrose-containing foods should be substituted for other carbohydrates and foods, and should not be eaten in addition to a meal plan Slide 19

Nutrition Therapy, cont’d:

Nutrition Therapy, cont’d Protein intake can range from 15% to 20% of daily kcal from animal and vegetable protein sources If diabetes well controlled, blood glucose levels not affected by moderate alcohol intake Considered as additional kcal Consume with food to reduce risk of hypoglycemia Slide 20

Nutrition Therapy, cont’d:

Nutrition Therapy, cont’d Corn sweeteners, fruit juice or juice concentrate, honey, molasses, dextrose, and maltose Affect glycemic response and caloric content similar to sucrose Sugar alcohols: sorbitol, mannitol , and xylitol Lower glycemic responses than other simple and complex carbohydrates Ingesting large amounts may have laxative effect Nonnutritive sweeteners Approved for use, considered safe for consumption by individuals with diabetes /gestational Saccharin Aspartame Slide 21

Special Considerations:

Special Considerations Illness Blood glucose levels may become elevated and diabetes control may worsen Caused by an increase in hepatic production of glucose stimulated by infection, illness, injury, or stress Specifically, by the release of epinephrine, norepinephrine, glucagon, and cortisol Increases insulin requirements Slide 22

Special Considerations, cont’d:

Special Considerations, cont’d Gastroparesis Delayed gastric emptying can manifest with: Heartburn Nausea Abdominal pain Vomiting Early satiety Weight loss Slide 23

Special Considerations, cont’d:

Special Considerations, cont’d Dietary treatment of gastroparesis Monitor intake carefully Carbohydrates replaced with soft or liquid consistency foods Six small meals may be better tolerated Constipation or diarrhea Fiber intake altered to patient’s needs Slide 24

Special Considerations, cont’d:

Special Considerations, cont’d Dry mouth eased by increasing fluids and moistening food with broth Low-fat (40 g) soft or liquid diet may prevent delay in gastric emptying Metoclopramide (Reglan) may increase gastric contractions and relax pyloric sphincter Insulin should be matched with meals to regulate delayed absorption and glucose changes Slide 25

Management Through the Life Span:

Management Through the Life Span Pregnancy Women with preexisting diabetes Vulnerable to fetal complications Maternal health can be compromised when complications of diabetes occur Ideally excellent glycemic control should be achieved 3 months before conception Slide 26

Management Through the Life Span, cont’d:

Management Through the Life Span, cont’d Gestational diabetes mellitus (GDM) may be induced by stress of pregnancy Form of glucose intolerance Onset during pregnancy Resolves on parturition Risk of fetal abnormalities and mortality increases in presence of hyperglycemia Slide 27

Management Through the Life Span, cont’d:

Management Through the Life Span, cont’d Newborns may also have other problems Respiratory difficulties Hypocalcemia Hypoglycemia Hypokalemia Jaundice Slide 28

Management Through the Life Span, cont’d:

Management Through the Life Span, cont’d Nutrition therapy during pregnancy Individualization of nutrition therapy contingent on maternal weight and height Include provision of adequate kcal and nutrients to meet pregnancy needs consistent with established maternal blood glucose goals Slide 29

Management Through the Life Span, cont’d:

Management Through the Life Span, cont’d Good glucose control usually accomplished by individualization of intake and graphing of weight gain To reduce risks of fetal macrosomia, neonatal hyperglycemia, and perinatal mortality, insulin may be prescribed in addition to nutrition therapy Glucose levels usually revert to normal following delivery 20% to 50% eventually develop T2DM Slide 30

Management Through the Life Span, cont’d:

Management Through the Life Span, cont’d Type 2 DM in children Incidence and prevalence Increased 30-fold over past 20 years, especially ethnic minority populations Obesity most prominent clinical risk factor About 30% children with T2DM, BMI >40, morbid obesity 17% have BMIs >45 Slide 31

Management Through the Life Span, cont’d:

Management Through the Life Span, cont’d Ideal treatment goal normalization of blood glucose values and A 1c Important to successfully control associated comorbidities Hypertension and hyperlipidemia Ultimate goal decrease risk of acute and chronic complications Slide 32

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