Chapter 20 Nutrition and Diabetes Mellitus

Nutrition and
Diabetes
Mellitus
2020
Copyright © 2017 Cengage Learning. All Rights Reserved.

© Cengage Learning 2017
Introduction
• In the United States:
– 12.3% of adults aged 20 and older have
diabetes (about 29 million people)
– Seventh leading cause of death
– Contributes to development of other
life-threatening diseases
• Heart disease and kidney failure

Overview of Diabetes Mellitus
• Elevated blood glucose concentrations
and disordered insulin metabolism
– Inability to produce sufficient insulin and/or
inability to use insulin effectively
• Effects
– Defective glucose uptake and utilization in
muscle and adipose cells
– Unrestrained glucose production in the liver

Overview of Diabetes Mellitus (cont’d.)
• Hyperglycemia
– Marked elevation in blood glucose levels
– Can ultimately cause damage to blood
vessels, nerves, and tissues
• Symptoms of diabetes mellitus
– Related to the degree of hyperglycemia
present
• Above 200 mg/dL: exceeds renal threshold

• Diagnosis of diabetes mellitus
– Based primarily on plasma glucose levels
• Measured under fasting conditions or at random
times during the day
– Oral glucose tolerance test
– Indirect measure: glycated hemoglobin
(HbA1c)

Overview of Diabetes Mellitus:
Diagnosis of Diabetes Mellitus (cont’d.)
• Current diagnosis criteria
– After a fast of at least eight hours
• Plasma glucose concentration: 126 mg/dL or
higher
– Random sample during the day
higher
• Classic symptoms of hyperglycemia present

Diagnosis of Diabetes Mellitus (cont’d.)
• Current diagnosis criteria
– Two hours after a 75-gram glucose load
higher
– HbA1c level: 6.5% or higher
• If people with prediabetes are usually
asymptomatic, why is this condition a
concern?

• Types of diabetes mellitus
– Main types
• Type 1 diabetes
• Type 2 diabetes
– Gestational diabetes: during pregnancy
– Can also result from medical conditions that
damage the pancreas or interfere with insulin
function

Types of Diabetes Mellitus (cont’d.)
• Type 1 diabetes
– Caused by autoimmune destruction of the
pancreatic beta cells
– Insulin must be supplied exogenously
– Usually develops in children or teens
– Classic symptoms: polyuria, polydipsia,
weight loss, and weakness or fatigue

• Type 2 diabetes
– Most prevalent form of diabetes (90-95%)
– Insulin resistance coupled with relative insulin
deficiency
– Hyperinsulinemia: abnormally high blood
insulin
– Obesity substantially increases type 2
diabetes risk (80% of cases obese)

• Type 2 diabetes in children and
adolescents
– Risk factors
• Overweight/obesity
• Family history of diabetes
– Types 1 and 2 may be difficult to distinguish in
children

• Prevention of type 2 diabetes mellitus
– Weight management
• Sustained weight loss of ~7% of body weight
recommended for overweight and obese
individuals
– Dietary modifications
• Increase intake of whole grains and dietary fiber
• Limit intake of sugar-sweetened beverages
• Decrease dietary fat if overweight/obese

• Prevention of type 2 diabetes mellitus
– Active lifestyle
• At least 150 minutes of moderate physical activity
weekly
– Regular monitoring
• Annual monitoring for individuals at risk

Effects of Insulin Insufficiency

• Acute complications of diabetes mellitus
– Diabetic ketoacidosis in type 1 diabetes
• Caused by severe lack of insulin
• Severe ketosis (abnormally high levels of ketone
bodies)
• Acidosis (pH <7.30)
• Hyperglycemia (usually >250 mg/dL)
• Symptoms: acetone breath, marked fatigue,
lethargy, nausea, and vomiting

Acute Complications (cont’d.)
• Diabetic ketoacidosis in type 1 diabetes
– Mental state: alert to diabetic coma
– Treatment:
• Insulin therapy
• Intravenous fluid and electrolyte replacement
• In some cases, bicarbonate therapy

• Hyperosmolar hyperglycemic syndrome in
type 2 diabetes
– Severe hyperglycemia and dehydration that
develop in the absence of significant ketosis
– Symptoms: neurological abnormalities, e.g.,
confusion, speech impairment, seizures, etc.
– Treatment: intravenous fluid and electrolyte
replacement and insulin therapy

• Hypoglycemia: low blood glucose
– Due to inappropriate management of diabetes
– Caused by excessive dosages of insulin or
antidiabetic drugs, prolonged exercise,
skipped or delayed meals, etc.
– Symptoms: sweating, heart palpitations,
shakiness, hunger, weakness, etc.
– Treatment: glucose tablets, juice, or candy

• Chronic complications of diabetes mellitus
– High levels of advanced glycation end
products (AGEs)
• Alter protein structures
• Stimulate metabolic pathways that damage tissues
– Sorbitol
• Increases oxidative stress
• Causes cellular injury

Chronic Complications (cont’d.)
• Macrovascular complications: damage to
large blood vessels
– Accelerates the development of
atherosclerosis in the arteries of the heart,
brain, and limbs
– Peripheral vascular disease: claudication, foot
ulcers, gangrene

• Microvascular complications: damage to
small blood vessels (capillaries)
– Diabetic retinopathy: weakened retinal
capillaries leak fluid, lipids, or blood, causing
local edema or hemorrhaging
– Diabetic nephropathy
• Causes microalbuminuria
• Decreased urine production with accumulation of
nitrogenous wastes

• Diabetic neuropathy: nerve damage
– Extent determined by severity and duration of
hyperglycemia
– Symptoms: deep pain or burning in the legs
and feet, weakness of the arms and legs,
numbness and tingling in hands and feet
– Occurs in about 50% of diabetes cases

Treatment of Diabetes Mellitus
• Requires lifelong treatment
– Balancing meals, medications, exercise
– Frequent adjustments necessary to establish
good glycemic control
• Treatment goals
– Maintain blood glucose levels within a
desirable range
• Prevent or reduce the risk of complications

Treatment of Diabetes Mellitus (cont’d.)
• Treatment goals
– Maintain healthy blood lipid concentrations,
control blood pressure, and manage weight
– Diabetes education
• Certified Diabetes Educator (CDE)
• Patients learn: meal planning, medication
administration, blood glucose monitoring, weight
management, appropriate physical activity,
prevention and treatment of complications

• Evaluating diabetes treatment
– Monitor glycemic status
• Self-monitoring of blood glucose
• Continuous glucose monitoring
– Long-term glycemic control
• Why does the percentage of HbA1c reflect
glycemic control over the preceding two to three
months?
• Fructosamine test: measures nonenzymatic
glycation of serum proteins to determine glycemic
control over the preceding 2-3 weeks

• Evaluating diabetes treatment
– Monitoring for long-term complications
• Blood pressure at each checkup; annual lipid
screening; routine checks for urinary protein, etc.
– Ketone testing
• Checks for ketoacidosis
• Most useful for type 1 diabetes or gestational
diabetes patients

• Nutrition therapy: dietary
recommendations
– Improves glycemic control
– Slows the progression of diabetic
complications
– Macronutrient intakes
• % of kcal distribution depends on food preferences
and metabolic factors
• Maintain consistent day-to-day carbohydrate intake
(unless using intensive insulin therapy)

Treatment of Diabetes Mellitus:
Dietary Recommendations (cont’d.)
• Total carbohydrate intake
– Based on metabolic needs, type of insulin or
other medications, and individual preferences
– Recommended sources: vegetables, fruits,
whole grains, legumes, milk products
• Glycemic index (GI)
– Choosing low- over high-GI foods may
modestly improve glycemic control

• Sugars
– Minimize added sugars
– Sugary foods counted in the daily
carbohydrate allowance
– Fructose as an added sweetener not advised
– Artificial sweeteners can be used safely
• Whole grains and fiber
– Recommendations similar to those for general
public: include fiber-rich foods

• Dietary fat
– Increase omega-3s from fatty fish or plants
– Saturated fat: <10% of total kcalories
– Trans fat: minimized
– Cholesterol: <300 milligrams daily
• Protein: similar to general population
– High intakes may harm kidney function in
patients with nephropathy

• Alcohol use in diabetes
– 1 drink/day for women; 2 drinks/day for men
– Which groups should avoid alcohol?
• Micronutrients
– Same recommendations as general
population
– Supplements not currently recommended for
managing diabetes

• Body weight in type 2 diabetes
– What are the benefits of moderate weight loss
(5% to 10% of body weight) for overweight or
obese patients?

• Nutrition therapy: meal-planning strategies
– Carbohydrate counting
• Widely used for planning diabetes diets
• Dietician:
– Learns about patient’s usual food intake
– Calculates nutrient and energy needs
– Provides patient with daily carbohydrate allowance
divided into a pattern of meals and snacks
• Box 20-8 describes this process for basic
carbohydrate counting

Meal-Planning Strategies (cont’d.)
• Carbohydrate counting
– What is the advantage of advanced
carbohydrate counting?
• Food lists for diabetes (Appendix C)
– Meal plan created by choosing foods with
specified portions from the lists
– Less flexible than carbohydrate counting
– Lists are useful resources for CHO counting

• Insulin therapy
– Required by people with:
• Type 1 diabetes
• Type 2 diabetes who are unable to maintain
glycemic control with medications, diet, and
exercise
– Ideally, insulin treatment should reproduce the
natural pattern of insulin secretion as closely
as possible

Insulin Therapy (cont’d.)
• Insulin preparations (Table 20-6)
– Forms: rapid acting, short acting, intermediate
acting, long acting, and insulin mixtures
• Insulin delivery
– Administered by subcutaneous injection
• Using syringes, insulin pens, or insulin pump
– What prohibits the use of oral delivery?

Effects of Insulin Preparations

• Insulin regimen for type 1 diabetes
– Best managed with intensive insulin therapy
• Multiple daily injections of several types of insulin
or use of an insulin pump
– To learn amounts required for meals:
• Patient keeps records of food intake, insulin doses,
and blood glucose levels
• Carbohydrate-to-insulin ratio calculated
– What is the honeymoon period?

• Insulin regimen for type 2 diabetes
– ~30% of patients can benefit from insulin
therapy
– Different regimens
• Insulin alone or combined with antidiabetic drugs
• One or two daily injections
– Single injection of long-acting insulin at bedtime
– Two or more injections of mixed insulin

• Insulin therapy and hypoglycemia
– Hypoglycemia is the most common
complication of insulin treatment
– Corrected by immediate intake of glucose or
glucose-containing food (15-20 g CHO)
• Insulin therapy and weight gain
– Unintentional side effect
• Particularly with intensive insulin treatment

• Fasting hyperglycemia
– Typically develops in the early morning after
an overnight fast of at least 8 hours
• Insufficient insulin during the night
• Dawn phenomenon
• Rebound hyperglycemia (Somogyi effect)
– Treatment: adjust the dosage or formulation of
insulin administered in the evening

• Antidiabetic drugs (Table 20-7)
– For type 2 treatment
– Oral medications and injectable drugs other
than insulin
– Box 20-10 lists nutrition-related effects of
these drugs

• Physical activity and diabetes
management
– Improves glycemic control considerably
– At least 150 minutes of moderate-intensity
aerobic activity per week over at least 3 days
– Both aerobic and resistance exercise can
improve insulin sensitivity

Treatment of Diabetes Mellitus: Physical
Activity & Diabetes Management (cont’d.)
• Medical evaluation before exercise
– Screen for potential problems
• Aggravated by certain activities
– Exercise safety considerations
• Maintaining glycemic control
– Adjust insulin and/or medication doses
– Check glucose before and after exercise
– Avoid vigorous activity during ketosis

• Sick day management
– During illness: measure blood glucose and
ketone levels several times daily
– Continue drugs or insulin as prescribed
• Adjust doses if diet is altered or persistent
hyperglycemia develops
– Maintain prescribed CHO intakes
– Consume liquids to prevent dehydration

Diabetes Management in Pregnancy
• More difficult to maintain glycemic control
– Due to hormonal changes
• Women with gestational diabetes have a
greater risk of developing type 2 diabetes
later in life
• What are the health risks of uncontrolled
diabetes for mother and fetus?

(cont’d.)
• Pregnancy in type 1 or type 2 diabetes
– Glycemic control at conception and during the
first trimester of pregnancy
• Substantially reduces the risks of birth defects and
spontaneous abortion
– Women with type 1 require intensive insulin
therapy during pregnancy
– Women with type 2 are usually switched to
insulin therapy

(cont’d.)
• Pregnancy in type 1 or type 2 diabetes
– To avoid hypoglycemia and hyperglycemia:
• Carbohydrate intakes must be balanced with
insulin treatment and physical activity
• Gestational diabetes
– What factors increase the risk of gestational
diabetes?

Diabetes Management in Pregnancy:
Gestational Diabetes (cont’d.)
• Overweight women
– Modest kcal reduction (~30% less than
needs) may improve glycemic control
• Limiting CHO intake to 40% to 45% of kcal
may improve blood glucose after meals
• Restricting CHO to ~30 g at breakfast may
help

Diabetes Management in Pregnancy:
Gestational Diabetes (cont’d.)
• Space carbohydrate intake throughout the
day
• Regular aerobic activity can improve
glycemic control
• If glycemic control not achieved by diet
and exercise, insulin or an antidiabetic
drug may be necessary

Nutrition in Practice:
Metabolic Syndrome
• Diagnostic criteria (Table NP20-1)
• Theories regarding obesity and metabolic
abnormalities
• Relationship with cardiovascular disease
• Treatment
– Weight loss
– Dietary modifications
– Physical activity
– Medications

Chapter 20 Nutrition and Diabetes Mellitus

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Chapter 20 Nutrition and Diabetes Mellitus

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