What is Diabetes Mellitus ?

CH 20 Nutrition and Diabetes Mellitus

What is Diabetes Mellitus? Treatment of Diabetes Mellitus Diabetes Management throughout Life

A group of metabolic disorders of glucose regulation and utilization Characterized by Elevated glucose Altered energy metabolism

2005 Pamela Eccles All Rights Reserved

Caused by
Defective insulin secretion Defective insulin action Or a combination of

Types of Diabetes
Type I Type 2

Type 1 Characteristics

10 million in U.S. diagnosed + 5.5 million more not diagnosed..

Less common 5-10% of cases Pancreas cannot make insulin Blood glucose rises Without insulin Glucose cannot enter cell like it should Insulin must be injected

Type 2 Characteristics
90-95 % of cases Most likely undiagnosed Pancreas does produce insulin Cells not sensitive to (tolerance) Pancreas makes more insulin Cells in pancreas which make insulin exhaust Insulin production falters Associated w/ obesity Abdominal fat especially

Symptoms
Type 1
Frequent urination Unusual thirst Extreme hunger Unusual weight loss Extreme fatigue Irritability

Type 2
Any type 1 symptom(s) Plus Frequent infections Blurred vision Cuts/bruises - slow to heal Tingling/numbness in hands or feet Recurring gum/skin/ bladder infections

People most likely to develop Type 2 diabetes

Are those who are obese have immediate family members w/. are over age 45

are members of high risk ethnic groups African Americans Asian and Pacific Islanders Hispanic Americans Native Americans

Also Women who have given birth to babies weighing over 9 lbs. or have been diagnosed w/ gestational diabetes while pregnant

Diagnosis of Diabetes
Random blood glucose samples Exceed 200mg/100ml Or Blood glucose of 126 mg/100ml w/ 8 hour fast Blood glucose level >200mg/100ml any time during a glucose tolerance test

Nursing Diagnosis
Altered nutrition: more than body requirements and altered nutrition: risk for more than body requirements

These suggest diabetes.

To confirm positive
Second testing Subsequent day

Acute Complications of Diabetes Hyperglycemia, Dehydration, and Glycosuria Blood glucose hyperglycemia Water drawn from tissues into blood Kidneys overwhelmed Glucose excreted w/ fluids and Renal threshold The point at which a electrolytes blood constituent that is Glycosuria normally reabsorbed by the kidneys reaches a level so high the kidneys cannot reabsorb it

The Nursing Diagnosis: Fluid volume deficit or risk for fluid volume deficit Hyperglycemia
May develop in response to Carbohydrate eaten Type Amount Improper use of meds in counterregulatory hormones

Dawn phenomenon Early morning hyperglycemia that develops in response to elevated levels of counterregulatory hormones that act to raise blood glucose after an overnight fast. Without adequate insulin, the glucose cannot enter cells and remains in blood Strenuous exercise Can cause a sharp rise in blood glucose

Use of too much insulin Rebound hyperglycemia Hyperglycemia resulting from excessive secretions of counterregulatory hormones in response to excessive insulin and consequent low blood glucose levels; Somogyi effect Illness/infection

Ketosis and Coma

Undiagnosed Type 1 diabetes Cells deprived of glucose for energy Breakdown of protein and fat energy Liver makes ketone body from fat fragments Build up of ketones in urine and blood acidosis

Fruity breathacetone Diabetic coma may follow Medical emergency Treated in hospital IV fluids Fluid balance Electrolytes Acid imbalance

Nonketotic Coma
(Hyperosmolar hyperglycemic nonketotic coma) Extremely high blood glucose dehydration No ketosis

Weight Loss
Glucose Ketones Energy sources lost In urine

Breakdown of protein for energy Type 1 diabetes Likely to be thinenergy lost Type 2 overweight then gradual weight loss Common in Elderly w/ Type 2 Dont realize thirstdo not drink enough

Nursing Diagnosis: altered nutrition: less than body requirements frequently applies to person w/ Type 1 diabetes

Hypoglycemia
(insulin reaction/insulin shock) Inappropriate management of diabetes Too much insulin Strenuous physical activity Skipped/delayed meals Not enough food Vomiting Severe diarrhea Mental confusion and shakiness Make it difficult for diabetic to take action to correct

The Nursing Diagnosis

Altered nutrition: less than body requirements Symptoms Hunger Headache Sweating Shakiness Nervousness Confusion Disorientation Slurred speech

Chronic Complications of Diabetes

Chronic hyperglycemia Damages blood vessels & nerves even before diagnosis Circulation not good Nerve function Risk of infections The Nursing Diagnosis Risk of infection

Syndrome X
The combination of insulin resistance, hyperinsulinemia, obesity, hypertension, elevated LDL and triglycerides, and reduced HDL that is frequently associated with type 2 diabetes and cardiovascular disease. Also called Insulin-resistance syndrome and metabolic syndrome

Cardiovascular diseases
Atherosclerosis Develops early Progresses rapidly 80% of diabetics die from CVD Especially heart attacks

Neuropathy
Nerve tissue deteriorates Painful prickling Loss of sensation Injuries often go unnoticed infection gangrene amputations of limbs Toes/feet/legs Gastric emptying delayed Nausea Vomiting Weight loss Irregular nutrient control

Small Blood Vessel Disorders

Capillaries Nephropathy (loss of kidney function) Retinopathy (retinal degeneration/ vision loss 85% affected

Treatment of Diabetes Mellitus

Diagnosis
Devastating Overwhelming

Treatment Goals
Maintain blood glucose within fairly normal range, blood lipids optimal blood pressure controlled Reduces risk of onset and progression by 50% Nephropathy Retinopathy Neuropathy

Change Lifestyle
To control blood glucose successfully, the person must master the complex task of coordinating diet, physical activity, and medications.

Treatment Plans
Lifestyle changes Assess and monitor Diet Physical activity Meds Health status Diabetes education

Medical Nutrition Therapy for Diabetes

Diet same as for all healthy people
Controlling Carbohydrates Protein Fats hypo/hyperglycemia

Kidney function CVD

Coordinate diet w/ Meds Physical activity

Energy
Amount Healthy/realistic body weight Growth children/ pregnancy Type 2 diabetics Weight loss 10-20 lbs. Helps w/ Insulin resistance Blood lipids Blood pressure Moderate kcal restriction

Protein
10-20% of total kcal Adequate but not excessive helps delay onset or progression of kidney disease 0.8 g/kg of body weight Same as RDA for healthy people

Carbohydrates
Throughout day Consistent amounts Affect blood glucose most Greatest effect on blood glucose about 1 hour after eaten 45-60% total kcal

Regular physical activity Attention to meds Consistent carbs Too much hyperglycemia Too little hypoglycemia

Safe amount of glucose

Evening snack Sustains glucose through night Frequent hypoglycemia treats w/ carbs weight gain

Complex Carbohydrates Versus Simple Sugars Encourage

Whole-grain breads and cereals Legumes Fruits Vegetables

Provide
Fiber Vitamins Minerals

Concentrated sweets
Excluded In past Now - in moderation

Artificial sweeteners
Minimal calories Can be used in place of sugar

Fat
If blood lipids Ok <30% of kcal from fat <10% from saturated fat Elevated LDL <7% saturated fat

Sodium
Diabetic frequently hypertensive 2400-3000 mg/day Everyone Diabetic w/ hypertension May limit to < 2400 mg/day

Reduced fat products use carefully

May overeat Carbohydrate often replaces fat

Alcohol
If blood glucose wellcontrolled can include Can cause hypoglycemia in alldiabetic especially No more than 2 drinks/day With meals

Alcohol Care w/ oral anitdiabetic agents Skin flushed rapid heartbeat

If Overweight count as fat exchanges Avoid drinks w/ simple sugars Count as part of carb allowance

Avoid if Abuse Pancreatitis Abnormal blood lipids Neuropathy Pregnancy

Micronutrients Requirements same as health population Unless deficient Diabetics using

Some types of diuretics potassium supplements

Missed Meals and Illnesses Illness Blood glucose can rise Increase doses of meds Reduce carb intake If appetite is not good To avoid hypoglycemia Juice Gelatin Soft drink Frozen fruit bar Will try to give of kcal and carb within 3 hours of missed meal

or both

Treating Hypoglycemia
10-15 g carb w/ notice of symptoms If on oral agents that interfere w/ digestion of sucroseneed glucose If notany readily available and easily eaten carb OK See margin p. 473 Avoid foods w/ fat interferes w/ absorption of carb

Check blood glucose within 15-20 min. If risen to acceptable levelOK If not - additional 15-20 g of carb Recheck Continue until blood glucose to acceptable range Advise carrying convenient carb source w/ them

Nocturnal hypoglycemia
People prone to nocturnal hypoglycemia Wake up during night Check blood glucose Snack at bedtime May Plan strenuous activities for earlier in day Reduce insulin dose after evening activity

Hypoglycemia
If severe Disorientation Many dont recognize Unable to swallow IV glucose or Hormone glucagon Without treatment shock and death both

Enteral and Parental Formulas

Indications same as for other people Adjustments for carbs formulas provide Adjust insulin Formula may need to be more lipids and less carbohydrate Specially designed formulas an option

Meal Planning Strategies

Several approaches Individual
Exchange Lists Sorts food into 3 groups Proportions of carb, fat, and protein Carb group Starches Fruit Milk and some milk products Other carbs Vegetables

Fat Group
Butter Margarine Oil salad dressing Nuts Olives Bacon Avocados Coconut Cream cheese Fig. 20-2 p. 475 examples Strict portion sizes All foods in exchange list about same # kcal and nutrients Any food on list exchanged for another HOWTO box p. 477-480

Meat and meat substitutes group

High protein foods

Exchange system a tool

Fat sources and types Fat free milk - milk Whole fat exchange

Carbohydrate counting
Learn to eat consistent amounts of carbohydrates Monitor blood glucose and keep records HOWTO box p. 481

Foods in meat list

Separated into fat categories Low. Medium and High fat

Client must learn to

Plan healthy meals Eat consistent amounts of foods Maintain healthy body weight

Physical Activity
Carefully evaluate Appropriate Type Amount Type 2 diabetes Regular physical activity Improves blood glucose control Helps w/ weight loss Improves blood lipids blood pressure

Physical Activity and Blood Glucose Levels

Check blood glucose Before After Postpone if Too low <100 mg/100ml Hypoglycemia can develop quickly Too high >300 mg/100 ml Can levels even higher

Physical Activity and Food Intake

Adequate hydration Before During On insulin Eat Before During After

Drug Therapy for Diabetes

Type I Need insulin Type 2 Sometimes w/out meds Exercise Diet Oral meds Insulin

Carbs especially important Amount depends on Type exercise Duration Individual responses to Blood testing results

Oral Antidiabetic Agents

Many different ones available Some stimulate release of insulin from beta cells reduce insulin resistance and depress manufacture of glucose reduce rate of complex carbohydrate and sucrose digestion and slow rate of absorption (must use glucose to manage hypoglycemic episodes)

Insulin and Insulin Analogs

Different forms Different timings Rapid (regular) Intermediate NPH and lente Long acting ultra-lente Insulin analog lispro Acts more quickly Short duration risk for hypoglycemia

Insulin and Food Intake

Normally baseline amount w/ more after meals Type I diabetes NHP (intermediate acting) to meet baseline needs Regular (rapid-acting) to process nutrients after a meal Type II diabetes Insulin alone Or Combination of oral and insulin

Insulin and Physical Activity

Insulin taken More than an hour before Exercise and temperature Speed blood flow rate of insulin absorption Hypoglycemia likely Reducing insulin dose 30-50% can prevent [also care w/ injection site and muscles used in exercise]

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Pancreas Transplants
For those who have serious trouble managing Successful Combined w/ kidney transplant Can eliminate need for insulin and dialysis

Monitoring Diabetes Management

Blood glucose meters During medical assessments look at management make suggestions Even when diligent hypoglycemia and hyperglycemia at times Table 10-6 p. 485

Glycated Hemoglobin
Physicians monitor Evaluate % of glycated Hb (GHb) Blood glucose glucose attaches to amino acids on Hb molecules Reflects blood glucose management over past 2-3 months

Urinary Ketones
Monitor Especially during illness Predisposed to ketosis and coma

Other Measures
Weight Blood lipids Blood pressure Reflexes

Diabetes Management throughout Life

Diabetes Management in Childhood Energy and nutrient needs change Difficult w/ children Appetites Activity Teens Difficult when trying to be the same New rules Can manage it themselves

Meal Plans
Flexible, balanced meals Snacks Variety of foods Carb counting Snacks at bedtime Do not force to finish meal Encourage not to skip meals Concentrated sweets allowed within healthy diet Meals at about same time each day Can eat same foods as rest of family

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Family Lifestyles
Incorporate prescribed diet into existing lifestyle Child 3 meals/day 2-3 snacks (between meals and at bedtime) Vary meals and snacks to prevent boredom Avoid labeling good foods/bad foods

Diabetes Management in Pregnancy

Pregnancy
Elevates blood sugar Alters insulin resistance Cells become insulin resistant Levels of hormones antagonize

Health Risks Associated with Diabetes During Pregnancy

Uncontrolled Type I or 2 Risk of spontaneous abortion Macrosomic infant High blood glucose overfeeds Fetus must also make extra insulin to handle After birth hypoglycemic Important to control diabetes during pregnancy

Gestational Diabetes
Most common pregnancy complication Will screen for at 24-28 weeks unless <25 yrs old Normal body weight No first degree relatives w/ diabetes Not of high ethnic risk

High risk requiring cesarean delivery Pregnancy-induced hypertension Infants large w/ possible severe hypoglycemia

Preventive Measures after Pregnancy

Glucose tolerance usually returns to normal after Some w/ gestational diabetes and their infants develop type 2 diabetes later in life Focus on achieving and maintaining healthy body weight

Blood Glucose Monitoring

Pregnant w/ either type 1 or type 2 Control of blood glucose important to health of mother and infant

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Medical Nutrition Therapy

Individualized diet
Additional needs of pregnancy Insulin therapy Adequate but not excessive kcals Carbohydrates moderately restricted 40-45% of total kcal Frequent small meals

Diabetes Management Later in Life

Elderly
Special problems in dealing w/ diabetes Risk for hyper- and hypoglycemia Reduced appetite thirst regulation Altered organ function Depression Mental deterioration Multiple meds Medical conditions that complicate

Blood Glucose Control

Type 2 May advance until insulin necessary Overwhelming Vision loss can affect Drawing meds Giving injections Monitoring blood glucose May make it impossible to live independently

Financial and Social Considerations

Financial Medication Supplies Dr.s visits Health and nutritional status may deteriorate

Social interaction may Depression possible Health care professionals must help elderly find solutions to these problems See Nutrition Assessment Checklist for People with Diabetes

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